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The remarkable archaeological record of Neolithic Orkney has ensured that these islands play a prominent role in narratives of European late prehistory, yet knowledge of the subsequent Bronze Age is comparatively poor. The Bronze Age settlement and cemetery at the Links of Noltland, on the island of Westray, offers new evidence, including aDNA, that points to a substantial population replacement between the Late Neolithic and Bronze Age. Focusing on funerary practice, the authors argue for interconnecting identities centred on household and community, patrilocality and inheritance. The findings prompt a reconsideration of the Orcadian Bronze Age, with wider implications for population movement and the uptake of cultural innovations more widely across prehistoric north-western Europe.

Defining categories of musical actions in improvisation with young children is challenging due to the spontaneous, creative and emergent nature of interactions. Following a literature review, two new constructs were proposed to circumscribe and classify different types of events in improvisation, Creative Musical Agency (CMA) and Socio-Musical Aptitude (S-MA). These were refined and tested through eight phases of mixed-methods research. Two cycles of improvisation workshops were video-recorded. Multimodal Video Analysis of musical, gaze and gestural Modes of Communication contextualized with field notes was used to refine constructs. Two raters independently observed and rated children’s improvisations as showing CMA, S-MA or neither, giving reasons for difficulty or ambiguity in using constructs in separate interviews. Raters demonstrated fair agreement for CMA (Κappa 0.21) and moderate agreement for S-MA (Kappa 0.5). Development of these constructs offers a valuable way of understanding the complexity of young children’s musical actions and mental processes in improvisation.

Raw sequencing reads of ancient samples produced for this study have been deposited in the European Nucleotide Archive under accession no. PRJEB46830. Modern mitochondrial genomes generated as part of this study have been deposited in GenBank, accession nos. MZ846240 to MZ848095., Orkney was a major cultural center during the Neolithic, 3800 to 2500 BC. Farming flourished, permanent stone settlements and chambered tombs were constructed, and long-range contacts were sustained. From ∼3200 BC, the number, density, and extravagance of settlements increased, and new ceremonial monuments and ceramic styles, possibly originating in Orkney, spread across Britain and Ireland. By ∼2800 BC, this phenomenon was waning, although Neolithic traditions persisted to at least 2500 BC. Unlike elsewhere in Britain, there is little material evidence to suggest a Beaker presence, suggesting that Orkney may have developed along an insular trajectory during the second millennium BC. We tested this by comparing new genomic evidence from 22 Bronze Age and 3 Iron Age burials in northwest Orkney with Neolithic burials from across the archipelago. We identified signals of inward migration on a scale unsuspected from the archaeological record: As elsewhere in Bronze Age Britain, much of the population displayed significant genome-wide ancestry deriving ultimately from the Pontic-Caspian Steppe. However, uniquely in northern and central Europe, most of the male lineages were inherited from the local Neolithic. This suggests that some male descendants of Neolithic Orkney may have remained distinct well into the Bronze Age, although there are signs that this had dwindled by the Iron Age. Furthermore, although the majority of mitochondrial DNA lineages evidently arrived afresh with the Bronze Age, we also find evidence for continuity in the female line of descent from Mesolithic Britain into the Bronze Age and even to the present day., We thank Steve Birch, Jenny Murray, and Sue Black for help with samples; Harald Ringbauer for advice on hapROH; and Joyce Richards for comments on an early draft. Excavations at LoN and KoS are directed by H.M. and G.W., EASE (Environment and Archaeology Services), grant funded by Historic Environment Scotland. M. Ni Challanain, M. McCormick, and D. Gooney undertook osteological identifications and sample selection. K.D., M.G.B.F, P.J., M.S., G.O.-G, A.F., and S.R. were supported by a Leverhulme Trust Doctoral Scholarship program awarded to M.B.R. and M.P. DNA sequencing was also supported by the UK Natural Environment Research Council Biomolecular Analysis Facility (NBAF) at the University of Liverpool, under NBAF Pilot Scheme NBAF685, awarded to C.J.E. whilst at the University of Oxford. P.S., M.P., and M.B.R. acknowledge FCT (Fundação para a Ciência e a Tecnologia) support through project PTDC/EPH-ARQ/4164/2014, partially funded by FEDER (Fundo Europeu de Desenvolvimento Regional) funds (COMPETE 2020 project 016899). PS was supported by FCT, European Social Fund, Programa Operacional Potencial Humano, and the FCT Investigator Programme and acknowledges FCT/MEC (Ministério da Educação e Ciência) for support to CBMA through Portuguese funds (PIDDAC: Programa de Investimentos e Despesas de Desenvolvimento da Administração Central)—PEst-OE/BIA/UI4050/2014. V.M. and D.G.B. acknowledge the Science Foundation Ireland/Health Research Board/Wellcome Trust Biomedical Research Partnership Investigator Award No. 205072 to D.G.B., “Ancient Genomics and the Atlantic Burden.” The ORCADES was supported by the Chief Scientist Office of the Scottish Government (CZB/4/276, CZB/4/710), a Royal Society University Research Fellowship to J.F.W., the MRC (Medical Research Council) Human Genetics Unit quinquennial programme “QTL in Health and Disease,” Arthritis Research UK, and the EU FP6 EUROSPAN project (contract no. LSHG-CT-2006-018947). The Edinburgh Clinical Research Facility, University of Edinburgh, performed DNA extractions and the Sanger Institute performed whole-genome sequencing. The Viking Health Study–Shetland (VIKING) was supported by the MRC Human Genetics Unit quinquennial programme grant “QTL in Health and Disease.” DNA extractions were performed at the Edinburgh Clinical Research Facility, University of Edinburgh. Whole genome sequencing was supported by the Scottish Genomes Partnership award from the Chief Scientist Office of the Scottish Government and the MRC (grant reference SGP/1) and the MRC Whole Genome Sequencing for Health and Wealth Initiative (MC/PC/15080). We acknowledge Wellcome Trust funding (098051) for the ORCADES whole-genome sequencing. J.F.W. acknowledges support from the MRC Human Genetics Unit programme grant, “Quantitative traits in health and disease” (U. MC_UU_00007/10). We also acknowledge the invaluable contributions of the research nurses in Orkney and Shetland, the administrative team in Edinburgh, and the people of Orkney and Shetland.

There has been a recent expansion of school curricula and extra-curricular activities emphasizing musical creativity and collaboration. Parents have a crucial role in providing children with access to such experiences; their views on music and the nature of creativity influence the types of musical engagement their children will access. Teachers also have an important role, yet can have difficulties when supporting children in open-ended tasks. A qualitative study investigated parents’ and teachers’ constructions of creativity and music. Interviews were held with 11 parents and 4 teachers of preschool children who took part in improvisation workshops. Data were analyzed with thematic analysis, resulting in identification of three themes. Creativity and musicality were described as fundamental to children’s “human nature” but positioned as a non-fundamental part of their own adult identities. “Values” explored conceptualizations of creativity through artistic products; musicality was appreciated demonstration of technical skill. “Frames for engaging” identified adults engaging with their children in creative tasks mainly through child-led narratives; in contrast, parents took on the role of “teacher” in musical tasks. Understanding these influential views offers insight into the types of activities and guidance offered to pre-schoolers and how they can be built on to foster children’s musical creativity.

Introduction Undiagnosed obstructive sleep apnoea (OSA) is increasingly recognized as a serious post-operative risk with bariatric surgery, hence increasing demand for pre-operative screening and a need for simpler ways for screening than the clinical standard, respiratory polygraphy, to mitigate strain on sleep services. WatchPAT 300 (WP) is a finger-mounted sensor that uses peripheral arterial tonometry to estimate the apnoea hyponoea index (AHI). While its use is increasing it has not yet been validated in patients with a BMI >35, the target population in bariatric surgery. Aims To validate WP against polygraphy in pre-bariatric surgery patients with clinically suspected OSA and a BMI>35 and to assess patient acceptability of WP. Methods AHI was measured simultaneously with WP and Embletta. Outcome measures were 1) autoscored AHI from WP and 2) manually re-scored AHI from Embletta. Agreement between AHI from Embletta and WP was assessed using intra-class correlation coefficient (ICC), bland Altman and ROC plots. Results 28 patients (22 female/6 male, mean ± SD age 44.1 ± 11.6, BMI 45.7 ± 7.5) participated. One study failed due to the patient removing the WP probe prematurely. AHI was higher in WP than Embletta (28.1± 17.9 versus 15.0 ±13.4; p 15 (Area under the curve 0.917; p Discussion WP accurately estimates the AHI in pre bariatric surgery patients, has a low failure rate and is clinically acceptable in this group. Further larger scale studies are needed to confirm these findings before incorporating into clinical guidelines.

Older adults undergoing emergency abdominal surgery have significantly poorer outcomes than younger adults. For those who survive, the level of care required on discharge from hospital is unknown and such information could guide decision-making. The ELF (Emergency Laparotomy and Frailty) study aimed to determine whether preoperative frailty in older adults was associated with increased dependence at the time of discharge.The ELF study was a UK-wide multicentre prospective cohort study of older patients (65 years or more) undergoing emergency laparotomy during March and June 2017. The objective was to establish whether preoperative frailty was associated with increased care level at discharge compared with preoperative care level. The analysis used a multilevel logistic regression adjusted for preadmission frailty, patient age, sex and care level.A total of 934 patients were included from 49 hospitals. Mean(s.d.) age was 76·2(6·8) years, with 57·6 per cent women; 20·2 per cent were frail. Some 37·4 per cent of older adults had an increased care level at discharge. Increasing frailty was associated with increased discharge care level, with greater predictive power than age. The adjusted odds ratio for an increase in care level was 4·48 (95 per cent c.i. 2·03 to 9·91) for apparently vulnerable patients (Clinical Frailty Score (CFS) 4), 5·94 (2·54 to 13·90) for those mildly frail (CFS 5) and 7·88 (2·97 to 20·79) for those moderately or severely frail (CFS 6 or 7), compared with patients who were fit.Over 37 per cent of older adults undergoing emergency laparotomy required increased care at discharge. Frailty scoring was a significant predictor, and should be integrated into all acute surgical units to aid shared decision-making and discharge planning.Los adultos mayores sometidos a cirugía abdominal de urgencia tienen resultados significativamente peores que los adultos jóvenes. Para aquellos pacientes que sobreviven, el nivel de atención que requieren tras el alta hospitalaria se desconoce y esta información podría servir de guía en la toma de decisiones. El estudio ELF (Emergency Laparotomy and Frailty) tenía como objetivo determinar si la fragilidad preoperatoria en adultos mayores se asociaba con un aumento de la dependencia en el momento del alta. MÉTODOS: El estudio ELF era un estudio multicéntrico extenso efectuado en el Reino Unido (n = 49) que incluyó una cohorte prospectiva de 934 pacientes mayores ( 65 años) sometidos a laparotomía de urgencia durante marzo-junio de 2017. El objetivo fue establecer si la fragilidad preoperatoria aumentaba el nivel de asistencia en el momento del alta en comparación con el nivel de asistencia preoperatorio. Para el análisis se utilizó una regresión logística multinivel ajustada a características previas al ingreso: fragilidad, edad del paciente, género, y nivel de asistencia.La edad media de los pacientes fue 76,2 años (DE = 6,83), con un 57% de mujeres, un 20,2% de pacientes frágiles y un 37,4% de adultos mayores que presentaron un aumento en el nivel de asistencia en el momento del alta. Un aumento de la fragilidad se asoció con un incremento en el nivel de asistencia en el momento del alta (y mayor poder predictivo que la edad). La razón de oportunidades (odds ratio, OR) ajustada por el aumento del nivel de asistencia fue 4,48 (i.c. del 95% 2,03-9,91) para pacientes aparentemente vulnerables (Clinical Frailty Scale, CFS 4); 5,94 (i.c. del 95% 2,54-13,90) para aquellos ligeramente frágiles (CFS 5); y 7,88 (i.c. del 95% 2,97-20,79) para aquellos con fragilidad moderada o grave (CFS 6 and 7) en comparación con pacientes en buenas condiciones. CONCLUSIÓN: Este es el primer estudio que documenta que más del 37% de adultos mayores sometidos a laparotomía de urgencia precisaron un aumento en el nivel de asistencia en el momento del alta. La evaluación de la fragilidad debería integrarse en todas las unidades quirúrgicas de agudos para ayudar a compartir la toma de decisiones y los planes de tratamiento.

People with disabilities face inequalities in mental wellbeing, for which social exclusion is a contributing factor. Musical activities offer a promising but complex intervention, making impacts on a population with highly varied characteristics and needs challenging to capture. This paper reports on a mixed methods, person-centered study investigating a community music intervention for such a population. Three groups of adult service users with varied disabilities (either physical, learning, or both), took part in weekly music workshops in different locations. Music staff, housing and resource center staff, as well as participants and members of their families, took part in semi-structured interviews. A quantitative measure administered by service staff was used to rate service users’ social development. Two lay researchers, both individuals with a disability contributed to all aspects of the study. Interviews were analyzed through thematic analysis. Improvements in individuals’ self-expression, confidence, mood, and social skills were consistent with previous findings. Differences in effect between centers included: Group 1, some of whom had previous experience of workshops, showed an improvement in musical skills; Group 2 showed a mixed response, some participated with enthusiasm but others chose art activities over music workshops; Group 3 had lasting positive impact, this group had very limited opportunities for music due to their rural location. Quantitative analysis showed significant increase over all groups in communication, interaction with others, and joint attention. The intervention was beneficial for participants in separate locations in similar ways, but also highlighted that context and prior experience mediated effects in distinct ways. The lay researchers enhanced the qualitative analysis by emphasizing (1) the importance of recognizing participants’ self-expression in non-verbal modes of communication and (2) the importance of having music staff with a disability to provide a positive role model. This paper proposes that mixed methods person-centered research is the most suitable approach to capture and understand the multiple and varied effects of this complex intervention for a diverse group of participants.

Improvisation represents a unique process of social creativity in real time, practiced in widely varying musical contexts with different levels of experience. Yet psychologist have mostly studied the practices of individual jazz soloists with an expectation that shared understanding, knowledge and technical abilities are a prerequisite for group improvising. A qualitative study interviewed six trios of free improvisers (n=18) to illuminate the processes of shared musical improvisation across a range of contemporary artistic practice. Comparison of different members' accounts of events during recorded free improvisations indicated that their understandings of who did what and why converged at some points, notably during relative stasis, and diverged at others. Improvisers anticipated and interpreted musical behaviors of their collaborators with reference to previous shared social or musical experience, but considered that such expectations could, and should, be confounded. Familiarity between improvisers could be seen as helpful in building trust within dynamic and highly uncertain musical contexts, and in allowing a less conscious approach to interaction. Improvisers individually assumed that their group shared certain tastes and asserted that others recognized certain musical material as connected to previous practice together. These ideas of shared tastes and practices could best be understood as constructions within this particular social context, since they were not necessarily consistent across the ensemble. The findings emphasize the fundamentally social nature of improvising: shared understanding is not a prerequisite for participation, but shared experience over time enriches the resources of meaning an individual can bring to their interaction in an improvising group.

There is evidence that music interventions can offer opportunities for creative, psychological and social developments for individuals with mild to profound learning disabilities, addressing the disadvantages they face in respect of social outcomes. This paper reports on a qualitative study investigating a community music intervention for such a population. Thirty-seven adult service users (12 female, 25 male) took part in weekly music workshops for ten weeks. Their learning difficulties ranged from mild to profound, and their levels of independence ranged from requiring constant one-to-one care to living alone in sheltered accommodation. Interviews were conducted at multiple time points with music and resource centre staff as well as participants and members of their families and other centre users; researchers also observed all workshops, taking field notes. Thematic analysis of the data informed understanding of the disadvantages facing participants, their experience of the workshop programme and its immediate and wider social outcomes, as well as suggesting key mechanisms for effects. Disadvantages and barriers facing participants included: limited access to enjoying or learning music; boredom, isolation and limited networks; lack of experience of new social contexts; and an associated lack of confidence, low mood or self-esteem. Participants were found to enjoy and sustain engagement with a programme of dedicated group music workshops delivered by staff trained in an empathic and inclusive approach. Impacts included an ongoing enthusiasm to engage in music; wider recognition of musicality; increased self-confidence; being happier, more relaxed and/or enthusiastic after the workshops; better ability to interact with unfamiliar situations and people; and participation in social activities for an unprecedented length of time. Key factors in achieving those impacts are that participants: had fun and interacted socially; felt secure, welcomed and involved at all times; exercised choice; worked with others in non-verbal tasks; and encountered challenge while engaging and progressing at their own rate.

Background: cancellation of planned surgery impacts substantially on patients and health systems. This study describes the incidence and reasons for cancellation of inpatient surgery in the UK NHS. Methods: we conducted a prospective observational cohort study over 7 consecutive days in March 2017 in 245 NHS hospitals. Occurrences and reasons for previous surgical cancellations were recorded. Using multilevel logistic regression, we identified patient- and hospital-level factors associated with cancellation due to inadequate bed capacity. Results: we analysed data from 14 936 patients undergoing planned surgery. A total of 1499 patients (10.0%) reported previous cancellation for the same procedure; contemporaneous hospital census data indicated that 13.9% patients attending inpatient operations were cancelled on the day of surgery. Non-clinical reasons, predominantly inadequate bed capacity, accounted for a large proportion of previous cancellations. Independent risk factors for cancellation due to inadequate bed capacity included requirement for postoperative critical care [odds ratio (OR)=2.92; 95% confidence interval (CI), 2.12–4.02; PConclusions: a significant proportion of patients presenting for surgery have experienced a previous cancellation for the same procedure. Cancer surgery is relatively protected, but bed capacity, including postoperative critical care requirements, are significant risk factors for previous cancellations.

SummaryBackground Endoscopic balloon dilatation (EBD) is recognised treatment for symptomatic Crohn's strictures. Several case series report its efficacy. A systematic analysis for overall efficacy can inform the design of future studies. Aim To examine symptomatic (SR) and technical response (TR) and adverse events (AE) of EBD. Stricture characteristics were also explored. Methods A systematic search strategy of COCHRANE, MEDLINE and EMBASE was performed. All original studies reporting outcomes of EBD for Crohn's strictures were included. SR was defined as obstructive symptom-free outcome at the end of follow-up, TR as post-dilatation passage of the endoscope through a stricture, and adverse event as the presence of complication (perforation and/or bleeding). Pooled event rates across studies were expressed with summative statistics. Results Twenty-five studies included 1089 patients and 2664 dilatations. Pooled event rates for SR, TR, complications and perforations were 70.2% (95% CI: 60–78.8%), 90.6% (95% CI: 87.8–92.8%), 6.4% (95% CI: 5.0–8.2) and 3% (95% CI: 2.2–4.0%) respectively. Cumulative surgery rate at 5 year follow-up was 75%. Pooled unweighted TR, SR, complication, perforation and surgery rates were 84%, 45%, 15%, 9% and 21% for de novo and 84%, 58%, 22%, 5% and 32% for anastomotic strictures. Outcomes between two stricture types were no different on subgroup meta-analysis. Conclusions Efficacy and complication rates for endoscopic balloon dilatation were higher than previously reported. From the few studies with 5 year follow-up the majority required surgery. Future studies are needed to determine whether endoscopic balloon dilatation has significant long-term benefits.

The authors describe an unusual cause of ventriculoperitoneal shunt malfunction presenting as acute hydrocephalus.

Background and aims Key performance indicators [KPIs] exist across a range of areas in medicine. They help to monitor outcomes, reduce variation, and drive up standards across services. KPIs exist for inflammatory bowel disease [IBD] care, but none specifically cover inflammatory bowel disease [IBD] surgical service provision. Methods This was a consensus-based study using a panel of expert IBD clinicians from across Europe. Items were developed and fed through a Delphi process to achieve consensus. Items were ranked on a Likert scale from 1 [not important] to 5 [very important]. Consensus was defined when the inter quartile range was ≤ 1, and items with a median score > 3 were considered for inclusion. Results A panel of 21 experts [14 surgeons and 7 gastroenterologists] was recruited. Consensus was achieved on procedure-specific KPIs for ileocaecal and perianal surgery for Crohn's disease, [N = 10] with themes relating to morbidity [N = 7], multidisciplinary input [N = 2], and quality of life [N = 1]; and for subtotal colectomy, proctocolectomy and ileoanal pouch surgery for ulcerative colitis [N = 11], with themes relating to mortality [N = 2], morbidity [N = 8], and service provision [N = 1]. Consensus was also achieved for measures of the quality of IBD surgical service provision and quality assurance in IBD surgery. Conclusions This study has provided measurable KPIs for the provision of surgical services in IBD. These indicators cover IBD surgery in general, the governance and structures of the surgical services, and separate indicators for specific subareas of surgery. Monitoring of IBD services with these KPIs may reduce variation across services and improve quality.

There is evidence that alcohol consumption among those in middle-class occupations consistently exceeds safe levels, yet there has been little research into why this occurs. This article explores the meanings associated with alcohol use among professional, managerial and clerical workers. Qualitative data were collected from five focus groups of male and female employees aged 21–55 (N =49: 32 male, 17 female). Each focus group was conducted on the premises of a medium-scale or large-scale employer, four public sector and one private sector, in the north-east of England. Using Bourdieu's concepts of ‘habitus’, ‘capitals’ and ‘fields’ we found that, among these middle-class occupational groups, alcohol use was associated with two habitus: a ‘home drinking’ habitus and a ‘traditional drinking’ habitus. Those of the home drinking habitus particularly used wine as a source of cultural capital and a means of distinction, whereas those in the traditional habitus consumed lager, beer and spirits to have fun in social settings. A small minority appeared to belong to a third, omnivorous, habitus where a wide range of alcoholic drinks were consumed in a variety of contexts. Existing public health initiatives to reduce alcohol consumption may require modification to accommodate a range of drinking cultures.

Anti-CD154mAb is a powerful co-stimulation blockade agent that is efficacious in preventing rejection, even in xenogeneic settings. It has been used in the majority of successful long-term pig-to-non-human primate islet transplantation models. However, its clinical use was halted as a result of thromboembolic complications that were also observed in preclinical and clinical organ transplantation models. An anti-CD154mAb was administered to 14 streptozotocin-induced diabetic cynomolgus monkey recipients of porcine islets, some of which received the agent for many months. Monkeys were monitored for complications, and blood monitoring was carried out frequently. After euthanasia, multiple biopsies of all organs were examined for histological features of thromboembolism. Anti-CD154mAb prevented rejection of genetically engineered pig islets in all monkeys. No significant complications were attributable specifically to anti-CD154mAb. There was no evidence of thromboembolism in multiple histological sections from all major organs, including the brain. Our data suggest that in diabetic monkeys with pig islet grafts, anti-CD154mAb would appear to be an effective and safe therapy, and is not associated with thromboembolic complications.

Background: UK society is ageing. Older people who drink alcohol, drink more than those from previous generations, drink more frequently than other age groups and are more likely to drink at home and alone. Alcohol problems in later life however are often under-detected and under-reported meaning older people experiencing alcohol problems have high levels of unmet need. Methods: This study sought to identify existing services within South of Tyne, North East England to capture the extent of service provision for older drinkers and identify any gaps. The Age UK definition of ‘older people’ (aged 50 and over) was used. Services were contacted by telephone, managers or their deputy took part in semi-structured interviews. Findings: Forty six service providers were identified. Only one provided a specific intervention for older drinkers. Others typically provided services for age 18+. Among providers, there was no definitive definition of an older person. Data collection procedures within many organisations did not enable them to confirm whether older people were accessing services. Where alcohol was used alongside other drugs, alcohol use could remain unrecorded. Conclusion: To enable alcohol services to meet the needs of older people, greater understanding is needed of the patterns of drinking in later life, the experiences of older people, the scale and scope of the issue and guidance as to the most appropriate action to take. An awareness of the issues related to alcohol use in later life also needs to be integrated into commissioning of other services that impact upon older people.

The delivery of brief interventions (BIs) in health care settings to reduce problematic alcohol consumption is a key preventive strategy for public health. However, evidence of effectiveness beyond primary care is inconsistent. Patient populations and intervention components are heterogeneous. Also, evidence for successful implementation strategies is limited. In this article, recent literature is reviewed covering BI effectiveness for patient populations and subgroups, and design and implementation of BIs. Support is evident for short-term effectiveness in hospital settings, but long-term effects may be confounded by changes in control groups. Limited evidence suggests effectiveness with young patients not admitted as a consequence of alcohol, dependent patients, and binge drinkers. Influential BI components include high-quality change plans and provider characteristics. Health professionals endorse BI and feel confident in delivering it, but training and support initiatives continue to show no significant effects on uptake, prompting calls for systematic approaches to implementing BI in health care.

Background\ud Concurrent alcohol and medication use can result in significant problems especially in mid to later life. Alcohol is often used instead of medication for a number of health-related conditions. This novel qualitative study explored concurrent alcohol and medication use, as well as the use of alcohol for medicinal purposes, in a sample of individuals in mid to later life.\ud \ud Methods\ud Twenty-four interviews (12 men/12 women, ages 51–90 years) and three focus groups (n = 27, 6 men/21 women, ages 50–95 years) from three branches of Age UK and two services for alcohol problems in North East England.\ud \ud Results\ud Older people in this study often combined alcohol and medication, frequently without discussing this with their family doctor. However, being prescribed medication could act as a motivating factor to stop or reduce alcohol consumption. Participants also used alcohol to self-medicate, to numb pain, aid sleep or cope with stress and anxiety. Some participants used alcohol to deal with depression although alcohol was also reported as a cause of depression. Women in this study reported using alcohol to cope with mental health problems while men were more likely to describe reducing their alcohol consumption as a consequence of being prescribed medication.\ud \ud Conclusions\ud As older people often combine alcohol and medication, health professionals such as family doctors, community nurses, and pharmacists should consider older patients’ alcohol consumption prior to prescribing or dispensing medication and should monitor subsequent drinking. In particular, older people should be informed of the dangers of concurrent alcohol and medication use.

This article reports on a study of the views of Scottish teachers concerning the delivery of arts subjects within the 5–14 curriculum. Data were gathered through focus group interviews with primary, secondary and primary head teachers, and a questionnaire survey of 232 teachers in 10 Scottish LEAs. Research issues included the balance of the curriculum; assessment; the specialist knowledge required to teach each subject with confidence; how the arts were valued by parents and schools; and the benefits which may accrue to pupils and the school through participation in the arts. This article compares findings from primary teachers with those from secondary teachers. While differences were apparent in terms of confidence with teaching and assessing the arts, and how they felt arts subjects were valued, all participants strongly endorsed the benefits of arts education, particularly in terms of pupils' personal development. The implications of these findings are discussed in relation to current literature.

Group musical improvisation is a unique psychological phenomenon. Cognitive literature on jazz musicians argues that creativity in improvisation is constrained by stylistic conventions and facility with existing musical elements. However the expanding field of free improvisation is predicated on avoiding idiomatic expectations and familiar material. To model musical improvisation in its widest sense, 15 diverse free improvisers were video recorded performing in trios, and interviewed in-depth while reviewing the recording. Improvisers chose on an iterative basis whether to maintain what they were doing or change, either to initiate a new direction or to respond to another improviser. Responses were subjectively understood to adopt, augment or contrast the contributions of others. These choices were based on evaluative dimensions of texture, rate of initiatives, and degrees of novelty and diversity, as well as structural and practical concerns and experience of enjoyment. Improvisers did not perceive consistent agency for themselves while improvising, and their evaluations were influenced by constructions of the social context. Results highlight that new material is generated at a variable rate by any one individual during this collaborative creativity, and indicate that constraints on choices to cope with high cognitive demands are subjective and situation-specific rather than objective.

Purpose – The purpose of this paper is to examine the prevalence of alcohol use disorders (AUDs) amongst young people in the criminal justice system (CJS) in the North East of England and to compare the ability of the Alcohol Use Disorders Identification Test (AUDIT) to the Youth Justice Board ASSET tool in identifying alcohol-related need in Youth Offending Team (YOT) clients. Design/methodology/approach – A validated screening tool (AUDIT) was used to identify alcohol-related health risk or harm. Findings from AUDIT were compared with those of the standard criminogenic risk screening tool used in CJS (ASSET). An anonymous cross-sectional questionnaire was administered during a one-month period in 2008. The questionnaires were completed by 11-17-year-old offenders who were in contact with three YOTs, one Youth Offending Institution and one Secure Training Estate. Findings – In total, 429 questionnaires were completed out of a possible 639 (67 per cent). The majority (81 per cent) of the young offenders were identified as experiencing alcohol-related health risk or harm and 77 per cent scored within a possibly alcohol-dependent range. In total, 77 (30 per cent) of young people completing both assessments were identified as having an AUD by AUDIT but not identified as needing alcohol-related treatment using ASSET. Research limitations/implications – This research was confined to one geographical area of England, however, the results show that even in this area of high drinking by young people the levels of AUDs amongst young people in the CJS are very high. Social implications – There are major social implications to this research. It is imperative for changes to be made to the care pathways in place in the UK for young people coming through the CJS with alcohol-related issues. Originality/value – This paper adds to the evidence base by using well-validated tools to measure alcohol use amongst young people in the CJS in the UK.

Purpose: To determine whether apoptosis contributes to regeneration of the corneal epithelium following erosion and following ultraviolet irradiation. Methods: Central corneal erosions were made on one eye of 16 rats. One eye of another set of 16 rats was exposed to UVB irradiation. The rats were killed at time intervals varying from 12 hours to 7 days after treatment. Enucleated eyes were fixed in buffered formaldehyde and evaluated by terminal deoxynucleotidyl transferase-mediated deoxyuridinetriphosphate (dUTP) nick-end labelling (TUNEL) and morphology. The total number of cells and the number of TUNEL positive cells were counted in perpendicular sections using light microscopy. Results: Following central erosion the total epithelial cell number was restored by day 3. During the first 5 days, TUNEL positive cells were observed only in small numbers, but an increase occurred by days 6 and 7. After UVB, an increase in TUNEL positive cells was noted for at least 3 days, and by day 7 there was a small increase of TUNEL positive cells. This differed from the results seen in control animals. Conclusions: The present study indicates that after injury, apoptosis occurs in two distinct phases. There is an initial early phase of apoptosis which subsides at about the time the cell mass is being restored and after damaged cells have been removed. A later phase of apoptosis occurs suggests it has a homeostatic role which contributes to the regulation of the cell population.

With quadrotor use seeing extensive growth in recent years, the autonomous control of these Unmanned Aerial Vehicles (UAVs) is an increasing relevant and intersting field. In this paper a linear state-space approach at designing a stable hover controller in the presence of disturbances is presented along with simulation of control system performance. Additionally the design of a tracking system, for linear inertial position and yaw, is presented with simulation results. The gain matrix developed for this control system is independent of the specific quadrotor parameters, meaning that this same gain matrix can be used on a wide variety of quadrotors without modification. The hover and tracking controllers designed in this paper proved to perform well in simulation under perturbation disturbances and normally distributed disturbances on the UAVs linear speeds and angular speeds., 8 pages, 10 figures

Background Return to employment is one of the key goals of joint replacement surgery in the working-age population. There is limited quantitative and qualitative research focusing on return to work after hip and knee replacement. It remains unclear why certain groups of patients are not able to achieve sufficient functional improvement to allow productive return to work while others can. Very little is known about the individual patient and employer perspectives in this regard.Aims To review current evidence for the factors influencing employment outcomes in patients undergoing hip and knee replacement.Methods Original articles and reviews in Medline, Embase and PsycINFO from 1987 to 2013 were included in the analysis.Results Age, patient motivation, employment before surgery and type of job were found to be important factors in determining return to work following hip and knee replacement.Conclusions There is a need for further qualitative work on how and why these factors influence employment outcomes.

A group of burnt mounds vulnerable to coastal erosion in Shetland was surveyed in Spring 1996. Rescue excavation conducted at one of these sites, Tangwick, uncovered a burnt mound in close association with a specialized, non-domestic structure of Bronze Age date. It is concluded that Tangwick represents a distinct site type, previously little recognized, and it is proposed that such sites may have been used for feasting, possibly on a seasonal basis. More broadly, the results of survey work indicate that burnt mounds in Shetland are not a homogenous class of site and this variety has not been adequately accounted for within the prevailing models. This project was funded by Historic Scotland and practical assistance was provided by Shetland Amenity Trust.

It is important that the impact of the offshore environment on wind turbine reliability is reduced significantly due to the importance of offshore wind deployment to global energy targets. Future development may otherwise be compromised by unsustainable operation and maintenance (O&M) costs. This paper aims to improve the accuracy of offshore O&M models by accounting for any relationship between certain weather characteristics and wind turbine failure modes. This is done using maintenance data from a UK onshore wind farm and weather data from a weather station located nearby. Non-parametric Mixture Models are estimated from the data and they are used to calculate a more accurate, weather dependent, failure rate which will be used in future research for Markov Chain Monte Carlo Simulation. This research will be of particular interest to wind turbine operators and manufacturers

Increasing alcohol consumption among older individuals is a public health concern. Lay understandings of health risks and stigma around alcohol problems may explain why public health messages have not reduced rates of heavy drinking in this sector. A qualitative study aimed to elucidate older people's reasoning about drinking in later life and how this interacted with health concerns, in order to inform future, targeted, prevention in this group. In 2010 a diverse sample of older adults in North East England (ages 50-95) participated in interviews (n = 24, 12 male, 12 female) and three focus groups (participants n = 27, 6 male, 21 female). Data were analysed using grounded theory and discursive psychology methods. When talking about alcohol use older people oriented strongly towards opposed identities of normal or problematic drinker, defined by propriety rather than health considerations. Each of these identities could be applied in older people's accounts of either moderate or heavy drinking. Older adults portrayed drinking less alcohol as an appropriate response if one experienced impaired health. However continued heavy drinking was also presented as normal behaviour for someone experiencing relative wellbeing in later life, or if ill health was construed as unrelated to alcohol consumption. Older people displayed scepticism about health advice on alcohol when avoiding stigmatised identity as a drinker. Drinking patterns did not appear to be strongly defined by gender, although some gendered expectations of drinking were described. Identities offer a useful theoretical concept to explain the rises in heavy drinking among older populations, and can inform preventive approaches to tackle this. Interventions should engage and foster positive identities to sustain healthier drinking and encourage at the community level the identification of heavy drinking as neither healthy nor synonymous with dependence. Future research should test and assess such approaches.

Health outcomes are key to patients and clinicians, but trials of alcohol brief intervention (BI) tend to focus on behavioral outcomes, while those finding positive effects on physical- or mental-health outcomes generally lack power to show robust effects. To test the feasibility of a randomized controlled trial of BI for either hypertensive or depressed primary-care patients who drink alcohol above recommended levels, records at 25 English primary-care practices were searched for adult patients with risky drinking and comorbid hypertension or depression. Eligible patients were randomized to either a hypertension or depression arm, then to a control or intervention condition. They were screened for at-risk drinking using the Alcohol Use Disorders Identification Test (AUDIT). Consenting respondents scoring >7 on the AUDIT completed the Patient Health Questionnaire-9 (PHQ-9) (depression arm) or blood pressure measurement (hypertension arm) and received either BI or standard advice. At six-month follow-up, participants are again screened for alcohol use and comorbid condition. Seventeen practices (median adult patients, 7181; quartile 1, 5195, quartile 3, 8050) searched their databases. Fourteen percent of adult patients (median; quartile 1, 8.4%, quartile 3, 16.5%) drank above guidelines. Twenty percent of adult patients (median; quartile 1, 18.5%, quartile 3, 23.2%) were hypertensive, of which 5% (median; quartile 1, 3.9%, quartile 3, 5.3%) also drank heavily. Fourteen percent of adult patients had mild to moderate depression (median; quartile 1, 8.9%, quartile 3, 16.9%), of which 2% (median; quartile 1, 1.9%, quartile 3, 2.9%) also drank heavily. Of 2590 eligible patients, 633 (24%) completed the AUDIT. Thirty-five percent scored positively on the AUDIT in the hypertension arm, and 50% scored positively in the depression arm. Eighty patients were recruited to the hypertension arm, and recruitment to the depression arm is ongoing. Patients eligible for an RCT of BI for comorbid heavy drinking and hypertension or mild/moderate depression are identifiable in primary care records, though with variation among practices. Almost a quarter of these patients can be screened by mail for current alcohol use; more screen positively in the depression arm than in the hypertension arm. A trial in the hypertension arm seems most feasible.

Group musical improvisation, as a spontaneous process of collaborative creativity effected through non-verbal social interaction, is a unique psychological phenomenon and universal capacity. Existing studies focus on improvisation among professional jazz musicians, often using qualitative methods. However, improvisation transcends genres and levels of training or experience, and existing qualitative data are rarely analyzed as discourse. We compare findings from studies of jazz musicians’ improvising with interview data from free improvisers from varied backgrounds focused on their improvising together ( n = 10). The ways jazz musicians construct improvising in talk were distinct from the constructions of this more diverse group, suggesting a specifically professional discourse. By focusing on accounts of deciding whether to play, the ambiguity of musical contributions in the non-verbal context of playing is highlighted. Analysis indicates that musical acts within improvisation are interpreted by the musicians involved in ways that inherently support or resist particular identities. The unique creative, communicative and social process of musical improvising in groups can therefore best be understood when the entirety of improvisational practice and its various contexts are acknowledged. Future research can best recognize the diversity of, and change in, what improvisation can encompass with continued discursive investigation of group improvising.

Background Recent evidence shows that workers in white collar roles consume more alcohol than other groups within the workforce, yet little is known about their views of drinking. Methods Focus groups were conducted in five workplaces to examine the views of white collar workers regarding the effect of alcohol use on personal and professional lives, drinking patterns and perceived norms. Analysis followed the method of constant comparison. Results Alcohol use was part of everyday routine. Acceptable consumption and ‘excess’ were framed around personal experience and ability to function rather than quantity of alcohol consumed. Public health messages or the risk of adverse health consequences had little impact on views of alcohol consumption or reported drinking. Conclusions When developing public health alcohol interventions it is important to consider the views of differing groups within the population. Our sample considered public health messages to be of no relevance to them, rather they reinforced perceptions that their own alcohol use was controlled and acceptable. To develop effective public health alcohol interventions the views of this group should be examined in more detail.

Aims: To ascertain the views of general practitioners (GPs) regarding the prevention and management of alcohol- related problems in practice, together with perceived barriers and incentives for this work; to compare our findings with a comparable survey conducted 10 years earlier. Methods: In total, 282 (73%) of 419 GPs surveyed in East Midlands, UK, completed a postal questionnaire, measuring practices and attitudes, including the Shortened Alcohol and Alcohol Problems Perception Questionnaire (SAAPPQ). Results: GPs reported lower levels of post-graduate education or training on alcohol-related issues (

AIMS: To assess whether information in general practitioner (GP) referral letters provides a basis for selection of diagnostic tests in patients referred for specialist respiratory advice. METHODS: We undertook a prospective study within a respiratory outpatients department to compare the diagnostic tests planned at three stages of the referral/specialist consultation process: i) using the GP referral letter alone; ii) using the referral letter and patient history; iii) using the referral letter, patient history, and clinical examination. RESULTS: Analysis of the content of GP referral letters revealed wide variations in referral information. A high proportion of tests selected using the referral letter alone were altered after specialist history-taking and examination. Far fewer changes were recorded between history-taking and examination. CONCLUSIONS: Neither literature review nor our study support a system which bases diagnostic test selection on GP referral letters alone. However, our findings suggest that approaches which include specialist history-taking in advance of face-to-face consultation merit further investigation.

The aggregation of data from disparate sources offers clear benefits for healthcare researchers and practitioners. Such aggregation, however, must satisfy ethical, legal and social requirements: data ownership must be respected; patient privacy must not be compromised; data storage and transfer must be secure; etc. In this paper we describe the query aspects of sif (for service-oriented interoperability framework), a system which has been developed to support healthcare-related applications that depend upon the secure aggregation of data from multiple legacy databases. Importantly, the system allows the federation of data stored in varying database management systems utilising varying schemas.

Scots law constructs a co-parental role for nonresident fathers without clarifying how this should operate in practice. Personal Construct Theory (PCT) offers a useful approach to understanding such fathers’ distinct and changing conceptions of their role. Findings are presented from a study of 17 nonresident Scottish fathers maintaining contact with nonresident children. Idiographic analysis of data from repertory grid interviews administered three times over the course of a year shows that participants perceive family situations in terms of paternal involvement, impact, emotion, or antagonism. Changes in construing following family events support the PCT understanding of hostility; implications for family services are discussed.

To determine whether apoptosis contributes to regeneration of the corneal epithelium following erosion and following ultraviolet irradiation.Central corneal erosions were made on one eye of 16 rats. One eye of another set of 16 rats was exposed to UVB irradiation. The rats were killed at time intervals varying from 12 hours to 7 days after treatment. Enucleated eyes were fixed in buffered formaldehyde and evaluated by terminal deoxynucleotidyl transferase-mediated deoxyuridinetriphosphate (dUTP) nick-end labelling (TUNEL) and morphology. The total number of cells and the number of TUNEL positive cells were counted in perpendicular sections using light microscopy.Following central erosion the total epithelial cell number was restored by day 3. During the first 5 days, TUNEL positive cells were observed only in small numbers, but an increase occurred by days 6 and 7. After UVB, an increase in TUNEL positive cells was noted for at least 3 days, and by day 7 there was a small increase of TUNEL positive cells. This differed from the results seen in control animals.The present study indicates that after injury, apoptosis occurs in two distinct phases. There is an initial early phase of apoptosis which subsides at about the time the cell mass is being restored and after damaged cells have been removed. A later phase of apoptosis occurs suggests it has a homeostatic role which contributes to the regulation of the cell population.

Using reliability data comprising of two modern, large scale wind farm sites and wind data from two onsite met masts, a model is developed which calculates wind speed dependant failure rates which are used to populate a Markov Chain. Monte Carlo simulation is then exercised to simulate three wind farms which are subjected to controlled wind speed conditions from three separate potential UK sites. The model then calculates and compares wind farm reliability due to corrective maintenance and component failure rates influenced by the wind speed of each of the sites. Results show that the components affected most by changes in average daily wind speed are the control system and the yaw system. A comparison between this model and a more simple estimation of site yield is undertaken. The model takes into account the effects of the wind speed on the cost of operation and maintenance and also includes the impact of longer periods of downtime in the winter months and shorter periods in the summer. By taking these factors into account a more detailed site assessment can be undertaken. There is significant value to this model for operators and manufacturers.

Purpose: During blinking the lids apply a shear force to the corneal epithelium. The aim of this study was to determine if a shear force applied to the epithelial surface increases the rate at which cells shed. Methods: The shedding rate was studied in perfused whole rabbit eyes, and the effect of a shear force examined by exposing the corneas to a stirred solution. Control corneas were exposed to a static solution. The shedding rate and size of shed cells were measured, and the number of terminally differentiated cells on the corneal surface determined after 6 h of perfusion using ethidium bromide. Results: Compared with controls, the shear force increased the cell shedding rate from the corneal surface significantly (p

Training the Trainers of Tomorrow Today (T4) is a new way to deliver “Training for Trainers”. Responding to local dissatisfaction with existing arrangements, T4 builds on 3 essential requirements for a future shape of training: 1. Clinical Leadership and a Collaborative Approach 2. Cross-Specialty Design and Participation 3. Local Delivery and Governance Networks Design principles also included: 3 levels of training to reflect differing needs of clinical supervisors, educational supervisors and medical education leader, mapping to GMC requirements and the London Deanery's Professional Development Framework; alignment of service, educational theory and research; recognition of challenges in delivering and ensuring attendance in busy acute and mental health settings, and the development of a faculty network. The delivery plan took into account census of professional development uptake and GMC Trainee Surveys. Strong engagement and uptake from the 11 Trusts in NW London has been achieved, with powerful penetration into all specialties. Attendance has exceeded expectations. Against an initial 12 month target of 350 attendances, 693 were achieved in the first 8 months. Evaluation of content demonstrates modules are pitched appropriately to attendees needs, with positive feedback from trainers new to the role. Delivery style has attracted high ratings of satisfaction: 87% attendees rating delivery as “good\excellent”. External evaluation of impact demonstrated improved training experiences through changes in supervision, the learning environment and understanding of learning styles. We have addressed sustainability of the programme by advertising and recruiting Local Faculty Development Trainers. Volunteer consultants and higher trainees are trained to deliver the programme on a cascade model, supported by the Specialty Tutors, individual coaching and educational bursaries. The Trainers are local champions for excellence in training, provide a communication between the programme and local providers, are a repository of expertise in their service, and trouble shoot local barriers to engagement.

Background Risky drinking in pregnancy by UK women is likely to result in many alcohol-exposed pregnancies. Studies from the USA suggest that brief intervention has promise for alcohol risk reduction in antenatal care. However, further research is needed to establish whether this evidence from the USA is applicable to the UK. This pilot study aims to investigate whether pregnant women can be recruited and retained in a randomized controlled trial of brief intervention aimed at reducing risky drinking in women receiving antenatal care. Methods The trial will rehearse the parallel-group, non-blinded design and procedures of a subsequent definitive trial. Over 8 months, women aged 18 years and over (target number 2,742) attending their booking appointment with a community midwife (n = 31) in north-east England will be screened for alcohol consumption using the consumption questions of the Alcohol Use Disorders Identification Test (AUDIT-C). Those screening positive, without a history of substance use or alcohol dependence, with no pregnancy complication, and able to give informed consent, will be invited to participate in the trial (target number 120). Midwives will be randomized in a 1:1 ratio to deliver either treatment as usual (control) or structured brief advice and referral for a 20-minute motivational interviewing session with an alcohol health worker (intervention). As well as demographic and health information, baseline measures will include two 7-day time line follow-back questionnaires and the EuroQoL EQ-5D-3 L questionnaire. Measures will be repeated in telephone follow-ups in the third trimester and at 6 months post-partum, when a questionnaire on use of National Health Service and social care resources will also be completed. Information on pregnancy outcomes and stillbirths will be accessed from central health service records before the follow-ups. Primary outcomes will be rates of eligibility, recruitment, intervention delivery, and retention in the study population, to inform power calculations for a definitive trial. The health-economics component will establish how cost-effectiveness will be assessed, and examine which data on health service resource use should be collected in a main trial. Participants’ views on instruments and procedures will be sought to confirm their acceptability. Discussion The study will produce a full trial protocol with robust sample-size calculations to extend evidence on effectiveness of screening and brief intervention. Trial Registration Current Controlled Trials ISRCTN43218782

PURPOSE. Phosphorylation of myosin light chain (MLC) is essential for the contractility of the actin cytoskeleton, which regulates barrier integrity, adhesion, and migration. This study was conducted to investigate the effect of benzalkonium chloride (BAK), a preservative in topical ophthalmic formulations, on MLC phosphorylation in primary cultures of bovine corneal epithelial cells (BCECs). METHODS. MLC phosphorylation was assessed by urea-glycerol gel electrophoresis followed by Western blot analysis. Activation of RhoA, which inhibits MLC phosphatase through Rho kinase, was examined by immunoprecipitation. The release of adenosine triphosphate (ATP) was measured by the luciferase-luciferin bioluminescence technique. RESULTS. Positive expression of MLC kinase (MLCK) was found at the mRNA and protein levels by RT-PCR and Western blot analysis, respectively. Exposure to BAK for 10 to 20 minutes at concentrations of 0.0005%, 0.001%, and 0.003% reduced MLC phosphorylation by more than 30%. In addition, BAK led to thinning of the cortical actin and a decrease in cell adhesion. However, RhoA activity was found to increase with BAK treatment. Similar to BAK, ATP-depletion (induced by both antimycin-A and hypoxia) led to MLC dephosphorylation. BAK exposure also showed acute ATP release. CONCLUSIONS. BAK induces acute ATP release and concomitant MLC dephosphorylation in bovine corneal epithelial cells. The dephosphorylation, presumably due to ATP loss, is indicative of a loss of contractility of the actin cytoskeleton that could affect cellular functions contributing to the maintenance of epithelial barrier integrity.

For offshore wind turbines to become an economical energy generation option it is vital that the impact of the offshore environment on reliability is understood. This paper aims to model the impact of the wind speed and the external humidity and temperature. This is achieved using reliability data comprising of two modern, large scale wind farm sites consisting of approximately 380 wind turbine years of data. Weather data comes from a nearby weather station and an onsite met mast. A model is developed, using the reliability data, which calculates weather dependant failure rates and downtimes which are used to populate a Markov Chain. Monte Carlo simulation is then exercised to simulate the lifetime of a large scale wind farm which is subjected to controlled weather conditions. The model then calculates wind farm availability and component seasonal failure rates. Results show that offshore, the wind speed will have the biggest impact on component reliability, increasing the wind turbine failure rate by approximately 61%. The components affected most by this are the control system and the drive train. The higher offshore wind speeds appear to cause a higher proportion of major failures than experienced onshore. Research from this paper will be of interest to operators and wind turbine manufacturers who are interested in maintenance costs and logistics.

There is an expanding field of research into how making or listening to music can improve wellbeing. As a spontaneous, social, creative nonverbal process unfolding in real time, musical improvisation between individuals is a unique psychological phenomenon distinct from other areas of musical activity. It may therefore have an influence on health or wellbeing distinct from other musical behaviours, and from other components of a musical intervention. Given the psychological complexity of this behaviour it is important to establish the parameters of improvisation, the effects on health or wellbeing that are perceived or claimed for it, and any mechanisms understood to bring about these effects. To establish this, literature was reviewed that explicitly investigates or theorises about the capacity of musical improvisation to influence health or wellbeing. Only work examining its application within music therapy was identified. The behaviours and interactions that constitute improvisation during music therapy are clearly defined. Improvisation in music therapy is seen to have specific benefits for particular populations including the amelioration of neurological damage, improvements in mental health conditions, reductions in stress and anxiety, and improved communication and joint attention behaviours in children with autistic spectrum disorders. Four unique characteristics of musical improvisation are identified as underlying these effects: its potential to link conscious with unconscious processes, the demands on attention of absorption in a creative process, the non-verbal social and creative interaction experienced, and the capacity for expressing difficult or repressed emotions without having to articulate these verbally. Although improvisation is undertaken in music therapy for a purpose distinct from that of improvisation in other contexts, its processes can be seen as substantively similar, suggesting that improvising in itself may offer intrinsic benefits to health or wellbeing to broader populations and outwith the therapeutic context. Based on this review, a model is proposed for how improvisation in music can influence the health or wellbeing of those involved.