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Background Patients presenting with chest pain represent a large proportion of attendances to emergency departments. In these patients clinicians often consider the diagnosis of acute myocardial infarction (AMI), the timely recognition and treatment of which is clinically important. Clinical prediction models (CPMs) have been used to enhance early diagnosis of AMI. The Troponin-only Manchester Acute Coronary Syndromes (T-MACS) decision aid is currently in clinical use across Greater Manchester. CPMs have been shown to deteriorate over time through calibration drift. We aim to assess potential calibration drift with T-MACS and compare methods for updating the model. Methods We will use routinely collected electronic data from patients who were treated using TMACS at two large NHS hospitals. This is estimated to include approximately 14,000 patient episodes spanning June 2016 to October 2020. The primary outcome of acute myocardial infarction will be sourced from NHS Digital’s admitted patient care dataset. We will assess the calibration drift of the existing model and the benefit of updating the CPM by model recalibration, model extension and dynamic updating. These models will be validated by bootstrapping and one step ahead prequential testing. We will evaluate predictive performance using calibrations plots and c-statistics. We will also examine the reclassification of predicted probability with the updated TMACS model. Discussion CPMs are widely used in modern medicine, but are vulnerable to deteriorating calibration over time. Ongoing refinement using routinely collected electronic data will inevitably be more efficient than deriving and validating new models. In this analysis we will seek to exemplify methods for updating CPMs to protect the initial investment of time and effort. If successful, the updating methods could be used to continually refine the algorithm used within TMACS, maintaining or even improving predictive performance over time. Trial registration ISRCTN number: ISRCTN41008456

PRECIS In a trio of prospective studies, the iCare rebound tonometer demonstrated significantly lower test-retest variability than Goldmann tonometry with good interoperator and interdevice reproducibility, supporting its value in monitoring intraocular pressure (IOP) changes over time. PURPOSE The purpose of this study was to characterize intraoperator and interoperator and interdevice reliability of IOP measurements with rebound tonometry (RT, ic100). METHODS Three prospective cross-sectional studies were conducted in distinct sample of adult patients with established glaucoma, suspected glaucoma, or no glaucoma at the West Virginia University Eye Institute. Participants in study 1 underwent 5 RT measurements in one randomly selected eye and 5 Goldmann tonometry measurements in the fellow eye by 1 operator; intraoperator variability was compared using the F test. In study 2, 3 operators each obtained 3 RT measurements in participants in randomized operator order. In study 3, a single operator collected 3 measurements each with 3 RTs in randomized device order. Between-operator and between-device reproducibility were characterized using intraclass correlation coefficients (ICCs). RESULTS Overall, 28, 19, and 25 subjects participated in the 3 respective studies. Within-subject variance across subjects was 0.757 in RT measurements and 2.471 in Goldmann measurements (P=0.0035). Interoperator reproducibility of RT measurements was good in both eyes [ICC for right eyes 0.78, 95% confidence interval (CI): 0.60-0.85; ICC for left eyes 0.75, 95% CI: 0.50-0.83]. Interdevice reproducibility of RT measurements was good approaching excellent (ICC for right eyes 0.87, 95% CI: 0.83-0.90; ICC for left eyes 0.89, 95% CI: 0.86-0.91). CONCLUSIONS The RT's lower measurement variability and good interoperator and interdevice reproducibility suggest that it can characterize IOP changes over time more robustly than Goldmann tonometry, aiding clinicians in assessing the effectiveness of glaucoma therapy and the consistency of IOP control.

Introduction People living with multiple long-term conditions (multimorbidity) (MLTC-M) experience an accumulating combination of different symptoms. It has been suggested that these symptoms can be tracked longitudinally using consumer technology, such as smartphones and wearable devices. Aim The aim of this study was to investigate longitudinal user engagement with a smartwatch application, collecting survey questions and active tasks over 90 days, in people living with MLTC-M. Methods ‘Watch Your Steps’ was a prospective observational study, administering multiple questions and active tasks over 90 days. Adults with more than one clinician-diagnosed long-term conditions were loaned Fossil® Sport smartwatches, pre-loaded with the study app. Around 20 questions were prompted per day. Daily completion rates were calculated to describe engagement patterns over time, and to explore how these varied by patient characteristics and question type. Results Fifty three people with MLTC-M took part in the study. Around half were male ( = 26; 49%) and the majority had a white ethnic background ( n = 45; 85%). About a third of participants engaged with the smartwatch app nearly every day. The overall completion rate of symptom questions was 45% inter-quartile range (IQR 23–67%) across all study participants. Older patients and those with greater MLTC-M were more engaged, although engagement was not significantly different between genders. Conclusion It was feasible for people living with MLTC-M to report multiple symptoms per day over 3 months. User engagement appeared as good as other mobile health studies that recruited people with single health conditions, despite the higher daily data entry burden.

Objectives: The objective was to assess the prognostic value of hypertension detected in the emergency department (ED). Methods: The ED presents a unique opportunity to predict long-term cardiovascular disease (CVD) outcomes with its potential for high-footfall, and large-scale routine data collection applied to underserved patient populations. A systematic review and meta-analyses were conducted to assess the prognostic performance and feasibility of ED-measured hypertension as a risk factor for long-term CVD outcomes. We searched MEDLINE and Embase databases and gray literature sources. The target populations were undifferentiated ED patients. The prognostic factor of interest was hypertension. Feasibility outcomes included prevalence, reliability, and follow-up attendance. Meta-analyses were performed for feasibility using a random effect and exact likelihood. Results: The searches identified 1072 studies after title and abstract review, 53 studies had their full text assessed for eligibility, and 26 studies were included. Significant heterogeneity was identified, likely due to the international populations and differing study design. The meta-analyses estimate of prevalence for ED-measured hypertension was 0.31 (95% confidence interval 0.25–0.37). ED hypertension was persistent outside the ED (FE estimate of 0.50). The proportion of patients attending follow-up was low with an exact likelihood estimate of 0.41. Three studies examined the prognostic performance of hypertension and demonstrated an increased risk of long-term CVD outcomes. Conclusion: Hypertension can be measured feasibly in the ED and consequently used in a long-term cardiovascular risk prediction model. There is an opportunity to intervene in targeted individuals, using routinely collected data.

Objective: The purpose of these studies was to (1) determine the effect of a single dose of oral sodium iodide on weaned beef calves and (2) determine the outcome of clinical application of a single dose of oral sodium iodide as an on arrival procedure. Animals: (1) 16 healthy, weaned beef calves and (2) 629, 300 pound high risk beef calves. Procedures: (1) A single dose of oral sodium iodide was administered at 70 mg/kg once. Serum and nasal iodine concentrations were collected. (2) A single dose of oral sodium iodide and/or meloxicam was administered on arrival to a backgrounding operation. Morbidity and mortality results were recorded and analyzed. Results: (1) Serum and nasal fluid iodine concentrations were significantly different from control animals. (2) The control animals had the lowest mortality of the experimental groups. Conclusions: (1) Healthy, weaned beef calves can secrete iodine into their airway surface liquid/secretions to effective antimicrobial concentrations. (2) The administration of oral sodium iodide as an on arrival procedure did not significantly reduce mortality due to BRD. At this time, the use of sodium iodide as a preventative to BRD cannot be advocated.

BackgroundA substantial reduction in GP-recorded self-harm occurred during the first wave of COVID-19 but effects on primary care management of self-harm are unknown.AimTo examine the impact of COVID-19 on clinical management within three months of an episode of self-harm.Design and settingProspective cohort study using data from the UK Clinical Practice Research Datalink.MethodWe compared cohorts of patients with an index self-harm episode recorded during a pre-pandemic period (10th March-10th June, 2010-2019) versus the COVID-19 first-wave period (10th March-10th June 2020). Patients were followed up for three months to capture psychotropic medication prescribing, GP/practice nurse consultation and referral to mental health services.Results48,739 episodes of self-harm were recorded during the pre-pandemic period and 4,238 during the first-wave COVID-19 period. Similar proportions were prescribed psychotropic medication within 3 months in the pre-pandemic (54.0%) and COVID-19 first-wave (54.9%) cohorts. Likelihood of having at least one GP/practice nurse consultation was broadly similar (83.2% vs. 80.3% in the COVID-19 cohort). The proportion of patients referred to mental health services in the COVID-19 cohort (3.4%) was around half of that in the pre-pandemic cohort (6.5%).ConclusionDespite the challenges experienced by primary healthcare teams during the initial COVID-19 wave, prescribing and consultation patterns following self-harm were broadly similar to pre-pandemic levels. However, the reduced likelihood of referral to mental health services warrants attention. Accessible outpatient and community services for people who have self-harmed are required as the COVID-19 crisis recedes and the population faces new challenges to mental health.

ObjectivesPrimary care records have traditionally served the needs and demands of clinicians rather than those of the patient. In England, general practices must promote and offer registered patients online access to their primary care record, and research has shown benefits to both patients and clinicians of doing so. Despite this, we know little about patients’ needs and expectations regarding online access to their record. This study explored what patients and carers want from online access to their electronic primary care health record, their experiences of using it, how they would like to interact with their record and what support they may need.DesignFocus groups and semistructured interviews using purposive sampling to achieve a good sociodemographic spread. Interviews were digitally audiorecorded, transcribed and coded using an established thematic approach.SettingFocus groups and interviews were conducted in community settings in the UK.ParticipantsFifty-four individuals who were either eligible for the National Health Service Health Check, living with more than one long-term condition or caring for someone else.ResultsParticipants views regarding online access were categorised into four main themes: awareness, capabilities, consequences and inevitability. Participants felt online access should be better promoted, and suggested a number of additional functions, such as better integration with other parts of the healthcare system. It was felt that online access could improve quality of care (eg, through increased transparency) but also have potential negative consequences (eg, by replacing face to face contact). A move towards more online records access was considered inevitable, but participants noted a need for additional support and training in using the online record, especially to ensure that health inequalities are not exacerbated.ConclusionsDiscussions with patients and carers about their views of accessing online records have provided useful insights into future directions and potential improvements for this service.

Key Points Question Is the use of accelerometers and/or pedometers associated with increased physical activity in people with cardiometabolic conditions? Findings This systematic review and meta-analysis of 32 randomized clinical trials (4856 participants) found that accelerometer- and pedometer-based interventions were associated with small to medium short-term improvements in physical activity and that consultations with health professionals and pedometers were associated with improved physical activity. Meaning Accelerometer- and pedometer-based interventions for people with cardiometabolic conditions have demonstrated encouraging results, but levels of physical activity remain below the targets set by clinical recommendations., This systematic review and meta-analysis examines the association of accelerometer- and pedometer-based interventions with increases in physical activity among participants with cardiometabolic conditions., Importance Accelerometers and pedometers are accessible technologies that could have a role in encouraging physical activity (PA) in line with current recommendations. However, there is no solid evidence of their association with PA in participants with 1 or more cardiometabolic conditions such as diabetes, prediabetes, obesity, and cardiovascular disease. Objectives To assess the association of accelerometer- and pedometer-based interventions with increased activity and other improved health outcomes in adults with cardiometabolic conditions and to examine characteristics of the studies that could influence the association of both interventions in improving PA. Data Sources Records from MEDLINE, Embase, the Cochrane Central Register of Controlled Trials, the Cumulative Index to Nursing and Allied Health, and PsycINFO were searched from inception until August 2018 with no language restriction. Study Selection Randomized clinical trials or cluster randomized clinical trials evaluating the use of wearable technology devices such as pedometers and accelerometers as motivating and monitoring tools for increasing PA were included. After removing duplicates, the searches retrieved 5762 references. Following abstract and title screening of 1439 references and full-text screening of 107 studies, 36 studies met inclusion criteria. Data Extraction and Synthesis Mean difference in PA was assessed by random-effects meta-analysis. Where the scale was different across studies, the standardized mean difference was used instead. Heterogeneity was quantified using the I2 statistic and explored using mixed-effects metaregression. This study was registered with PROSPERO and followed the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) reporting guideline. Main Outcomes and Measures The primary outcome was objectively measured PA in the short to medium term (postintervention to 8 months’ follow-up). Results Thirty-six randomized clinical trials (20 using accelerometers and 16 using pedometers) involving 5208 participants were eligible for review. Meta-analysis involving 32 of these trials (4856 participants) showed medium improvements in PA: accelerometers and pedometers combined vs comparator showed a small significant increase in PA overall (standardized mean difference, 0.39 [95% CI, 0.28-0.51]; I2 = 60% [95% CI, 41%-73%]) in studies of short to medium follow-up over a mean (SD) of 32 (28.6) weeks. Multivariable metaregression showed improved association with PA for complex interventions that involved face-to-face consultation sessions with facilitators (β = 0.36; 95% CI, 0.17-0.55; P

Reasons to be cautious

ObjectivesPrevious qualitative research investigating the experiences of women diagnosed with gestational diabetes (GD) has provided important insights into the development of behaviour change interventions. However, these studies often lack a theoretical underpinning. This study explored the use of the capability, opportunity, motivation and behaviour (COM-B) framework (which proposes that individuals need the capability, opportunity and motivation to perform a particular behaviour) to code and the socioecological model to contextualise participant responses to better inform intervention development.DesignQualitative semistructured interviews are using purposive sampling. Interviews were audio-recorded, transcribed and coded using the COM-B framework. A socioecological approach was adopted to understand the context of intervention facets.SettingInterviews were conducted in a secondary care setting in South Yorkshire.ParticipantsTwenty-seven postnatal women with a previous diagnosis of GD were interviewed.ResultsApplying the COM-B framework to code participant, responses identified 16 key subthemes which reflected either: capability, opportunity or motivation components of the model. Four domains adapted from the socioecological model: individual, family life, community and healthcare provision; contextualised factors are important for these women in terms of behaviour change. Emotional response at the individual level was highly motivating or demotivating. Factors related to family life and community were particularly dominant and had the potential to either facilitate or impede change. We found many participants relied on healthcare provision during the prenatal and postnatal periods with timing and positive relationships being key to good care.ConclusionsOur study provides further insight into the factors crucial for behaviour change in women diagnosed with GD. By innovatively applying the COM-B framework in a socioecological context, it is clear intervention facets need to target microlevel through the macrolevel to engage this population in behaviour change. Future work should consider family-level intervention as this could allow for sustained behaviour change and consequently prevent the development of type 2 diabetes mellitus.

Vounzoulaki and colleagues’ finding that women with a history of gestational diabetes are almost 10 times more likely to develop type 2 diabetes starkly underscores the importance of providing ongoing postnatal support to this high risk group.1 Postnatal and annual HbA1c screening alone, however, is unlikely to achieve reduction in the risk of incident type 2 diabetes without access to interventions that support sustained lifestyle change in …

To report a case of toxic optic neuropathy caused by an ocular bee sting. Case report and literature review. A 44-year-old female presented with no light perception vision 2 days after a corneal bee sting in her right eye. She was found to have diffuse cornea edema with overlying epithelial defect and a pinpoint penetrating laceration at 6 o’clock. There was an intense green color to the cornea. The pupil was fixed and dilated with an afferent pupillary defect. A small hyphema was seen, and a dense white cataract had formed. A diagnosis of toxic endophthalmitis with associated toxic optic neuropathy was made. The patient underwent pars plana vitrectomy and lensectomy with anterior chamber washout. She was also placed on systemic broad-spectrum antibiotics. She had noted clinical improvement over the course of her hospitalization and was discharged with light perception vision. A corneal opacity precluded viewing of the fundus. We utilized ganzfeld electroretinography and flash visual evoked potentials (2 and 10 Hz) to assess the visual function. Both tests were normal and predicted improvement following restorative surgery. She underwent a secondary lens implantation with penetrating keratoplasty 7 months later. This was followed by an epiretinal membrane peel 1 year after the bee sting. Her best corrected visual acuity improved to 20/80. Toxic endophthalmitis and toxic optic neuropathy can be complications of ocular bee sting. We discuss the management of this rare occurrence and the role of electroretinographic testing and visual evoked potentials in predicting visual outcome.

Purpose To evaluate the intraocular pressure (IOP)-lowering efficacy and safety of 10- and 15-μg bimatoprost implant in subjects with open-angle glaucoma (OAG) and ocular hypertension (OHT) after initial and repeated administrations. Design Randomized, 20-month, multicenter, subject- and efficacy evaluator-masked, parallel-group, phase 3 clinical study. Participants Adults with OAG or OHT in each eye, open iridocorneal angle inferiorly in the study eye, and study eye baseline IOP (hour 0; 8 am ) of 22–32 mmHg after washout. Methods Study eyes received bimatoprost implant 10 μg (n = 198) or 15 μg (n = 198) on day 1 with readministration at weeks 16 and 32, or twice-daily topical timolol maleate 0.5% (n = 198). Intraocular pressure was measured at hours 0 and 2 at each visit. Main Outcome Measures Primary end points were IOP and change from baseline IOP through week 12. Safety measures included treatment-emergent adverse events (TEAEs) and corneal endothelial cell density (CECD). Results Both dose strengths of bimatoprost implant were noninferior to timolol in IOP lowering after each administration. Mean diurnal IOP was 24.0, 24.2, and 23.9 mmHg at baseline and from 16.5–17.2, 16.5–17.0, and 17.1–17.5 mmHg through week 12 in the 10-μg implant, 15-μg implant, and timolol groups, respectively. The incidence of corneal and inflammatory TEAEs of interest (e.g., corneal endothelial cell loss, iritis) was higher with bimatoprost implant than timolol and highest with the 15-μg dose strength. Incidence of corneal TEAEs increased after repeated treatment; with 3 administrations at fixed 16-week intervals, incidence of ≥20% CECD loss was 10.2% (10-μg implant) and 21.8% (15-μg implant). Mean best-corrected visual acuity (BCVA) was stable; 3 implant-treated subjects with corneal TEAEs had >2-line BCVA loss at their last visit. Conclusions Both dose strengths of bimatoprost implant met the primary end point of noninferiority to timolol through week 12. One year after 3 administrations, IOP was controlled in most subjects without additional treatment. The risk-benefit assessment favored the 10-μg implant over the 15-μg implant. Ongoing studies are evaluating other administration regimens to reduce the potential for CECD loss. The bimatoprost implant has potential to improve adherence and reduce treatment burden in glaucoma.

Importance - Accelerometers and pedometers are accessible technologies that could have a role in encouraging physical activity (PA) in line with current recommendations. However, there is no solid evidence of their association with PA in participants with 1 or more cardiometabolic conditions such as diabetes, prediabetes, obesity, and cardiovascular disease.\ud \ud Objectives - To assess the association of accelerometer- and pedometer-based interventions with increased activity and other improved health outcomes in adults with cardiometabolic conditions and to examine characteristics of the studies that could influence the association of both interventions in improving PA.\ud \ud Data Sources - Records from MEDLINE, Embase, the Cochrane Central Register of Controlled Trials, the Cumulative Index to Nursing and Allied Health, and PsycINFO were searched from inception until August 2018 with no language restriction.\ud \ud Study Selection - Randomized clinical trials or cluster randomized clinical trials evaluating the use of wearable technology devices such as pedometers and accelerometers as motivating and monitoring tools for increasing PA were included. After removing duplicates, the searches retrieved 5762 references. Following abstract and title screening of 1439 references and full-text screening of 107 studies, 36 studies met inclusion criteria.\ud \ud Data Extraction and Synthesis - Mean difference in PA was assessed by random-effects meta-analysis. Where the scale was different across studies, the standardized mean difference was used instead. Heterogeneity was quantified using the I2 statistic and explored using mixed-effects metaregression. This study was registered with PROSPERO and followed the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) reporting guideline.\ud \ud Main Outcomes and Measures - The primary outcome was objectively measured PA in the short to medium term (postintervention to 8 months’ follow-up).\ud \ud Results - Thirty-six randomized clinical trials (20 using accelerometers and 16 using pedometers) involving 5208 participants were eligible for review. Meta-analysis involving 32 of these trials (4856 participants) showed medium improvements in PA: accelerometers and pedometers combined vs comparator showed a small significant increase in PA overall (standardized mean difference, 0.39 [95% CI, 0.28-0.51]; I2 = 60% [95% CI, 41%-73%]) in studies of short to medium follow-up over a mean (SD) of 32 (28.6) weeks. Multivariable metaregression showed improved association with PA for complex interventions that involved face-to-face consultation sessions with facilitators (β = 0.36; 95% CI, 0.17-0.55; P

Introduction We estimated the cost effectiveness of different cognitive screening tests for use by General Practitioners (GPs) to detect cognitive impairment in England. Methods A patient-level cost-effectiveness model was developed using a simulated cohort that represents the elderly population in England (65 years and older). Each patient was followed over a lifetime period. Data from published sources were used to populate the model. The costs include government funded health and social care, private social care and informal care. Patient health benefit was measured and valued in Quality Adjusted Life Years (QALYs). Results Base-case analyses found that adopting any of the three cognitive tests (Mini-Mental State Examination, 6-Item Cognitive Impairment Test or GPCOG (General Practitioner Assessment of Cognition)) delivered more QALYs for patients over their lifetime and made savings across sectors including healthcare, social care and informal care compared with GP unassisted judgement. The benefits were due to early access to medications. Among the three cognitive tests, adopting the GPCOG was considered the most cost-effective option with the highest Incremental Net Benefit (INB) at the threshold of £30 000 per QALY from both the National Health Service and Personal Social Service (NHS PSS) perspective (£195 034 per 1000 patients) and the broader perspective that includes private social care and informal care (£196 251 per 1000 patients). Uncertainty was assessed in both deterministic and probabilistic sensitivity analyses. Conclusions Our analyses indicate that the use of any of the three cognitive tests could be considered a cost-effective strategy compared with GP unassisted judgement. The most cost-effective option in the base-case was the GPCOG. Copyright © 2016 John Wiley & Sons, Ltd.

Purpose This reports a case using fibrin glue to secure a glaucoma drainage device plate to the sclera where there is a concern with the use of suture. Observations A 13-year-old patient with congenital aniridia and associated glaucoma refractory to topical medications underwent implantation of a glaucoma drainage device (GDD) for improved intraocular pressure (IOP) control. The patient had substantial scleral thinning with staphyloma formation, potentially making the use of traditional suturing techniques problematic. Fibrin glue was used to attach the GDD plate, as well the tube and patch graft which has been previously described, without sutures. The patient tolerated the procedure well with a 41% reduction in IOP at six months follow-up with no migration of the GDD from its original position. Conclusions and importance The use of fibrin glue in ophthalmology can be expanded to include attachment of the GDD plate to the sclera in patients with suturing contraindications.

This thesis examines how day-to-day physical activity can influence the health of our bones throughout ageing. This thesis has used a range of wearable devices and analysis techniques to calculate a range of metrics relevant to our daily activity levels, from the intensity of activity, to the impact forces experienced by the body. This thesis culminates in a now patented prototype wearable device able to calculate the forces experienced by bones, during various forms of physical activity and exercise.

BackgroundDespite the seven-fold increased risk of type 2 diabetes mellitus (T2DM) among females previously diagnosed with gestational diabetes (GD), annual rates of follow-up in primary care are low. There is a need to consider how to reduce the incidence of progression to T2DM among this high-risk group.AimTo examine the views of females diagnosed with GD to ascertain how to improve primary care support postnatally, and the potential role of technology in reducing the risk of progression to T2DM.Design and settingA qualitative study of a purposive sample of 27 postnatal females leaving secondary care with a recent diagnosis of GD.MethodSemi-structured interviews were conducted with 27 females, who had been previously diagnosed with GD, at around 6–12 weeks postnatally. Interviews were audiotaped, transcribed, and analysed thematically.ResultsFacilitators and barriers to engaging in a healthy postnatal lifestyle were identified, the most dominant being competing demands on time. Although females were generally satisfied with the secondary care they received antenatally, they felt abandoned postnatally and were uncertain what to expect from their GP in terms of follow-up and support. Females felt postnatal care could be improved by greater clarity regarding this, and enhanced by peer support, multidisciplinary input, and subsidised facilities. Technology was seen as a potential adjunct by providing information, enabling flexible and personalised self-management, and facilitating social support.ConclusionA more tailored approach for females previously diagnosed with GD may help reduce the risk of progression to T2DM. A need for future research to test the efficacy of using technology as an adjunct to current care was identified.

Objective To investigate the relationship between numeracy and the accuracy of side effect risk estimation following the presentation of information about a medicine via the Cancer Research UK (CR-UK) patient information website. Methods 591 website users were presented with information in different formats about the risks of side effects from taking tamoxifen. Participants estimated the risk of each side effect, provided other subjective ratings about the information and completed a numeracy task. Results Regardless of presentation format, numeracy was correlated with the accuracy of three side effect risk estimates. People with cancer and tamoxifen users showed stronger correlations for all side effect estimates. In addition, numeracy was positively related to the perceived influence of the information on the decision to take the medicine and was negatively related to ratings of satisfaction with the information. Conclusion People with a lower numeracy level make larger errors in interpreting medicines side effect risk information. Practice implications Pharmacists, other health professionals and patient information websites should ensure they provide clear explanations of risk, particularly to people with low numeracy, and assess their understanding of those explanations. Future research into risk communication should take account of numeracy level, to investigate the impact of different formats.

PurposeResearch has shown that mycoprotein, a vegetable protein ingredient, can lower blood cholesterol. This paper aims to test this in a consumer setting.Design/methodology/approachIn total, 21 healthy, free‐living adults, who were not usually mycoprotein consumers, were asked to eat mycoprotein, as Quorn™ products, daily for six weeks. Ten control group participants followed their habitual diets. Fasting lipids, blood pressure, blood glucose, weight, body mass index and waist circumference were measured at baseline and after six weeks.FindingsA significant reducing effect of the intervention on total cholesterol levels was found among those participants with higher baseline blood cholesterol level. No significant differences were seen between the intervention and control groups for the sample as a whole, although there were compliance issues in the control group that may have reduced its validity. Good compliance with the mycoprotein‐rich diet also appeared to have a significant lowering effect on total blood cholesterol and LDL cholesterol. The findings confirm that mycoprotein may be a useful food ingredient for helping to manage blood cholesterol levels.Research limitations/implicationsThere was no randomisation or blinding, which may have influenced compliance with a habitual diet in the control group. The sample size was small and so further work in a larger population is warranted, particularly to determine optimal mycoprotein intakes and likely mechanisms of action.Originality/valueThe paper focuses on a trial that used commercially available products in a free‐living sample.

Background: The importance of breastfeeding-related health outcomes in reducing inequalities in health has been recognized as a National Health Service target to increase initiation rates especially among disadvantaged groups in England. This study examined the psychosocial factors influencing infant feeding intention among pregnant teenagers expecting their first baby and living in deprived urban areas in England. Methods: A mixed methods study, using a quantitative questionnaire based on the Theory of Planned Behaviour, was conducted in four English regions with predominantly white and Asian teenagers (n = 71). This method identified which of all known Theory of Planned Behaviour variables were the most important in influencing feeding intentions. Focus groups provided contextual insight into the meaning of these variables for white pregnant teenagers living in a northern English inner city (n = 17). Results: Moral norms were identified as the most predictive variable influencing teenage intention to formula feed or breastfeed. The likelihood that breastfeeding “will be embarrassing” was the only attitudinal belief rated as significantly important in influencing teenage intention to breastfeed. Three overarching themes emerged from the focus group data: “moral norms,”“sexuality of the breast,” and “self-esteem,” with concerns relating to breastfeeding in public cutting across all themes. Conclusions: Breastfeeding was viewed as a morally inappropriate behavior by most of these teenagers, with formula feeding being perceived as the appropriate behavior. Existing breastfeeding promotion activities are likely to continue to fail to reach teenagers experiencing deprivation in England in the absence of effective strategies to change the underlying negative moral norms toward breastfeeding. (BIRTH 37:2 June 2010)

Background: All licensed medicines in the European Union must be provided with a Patient Information Leaflet that includes a list of all known side effects. Among patients who read the leaflet, the side effects section is the most often read. A UK government regulatory publication recommends providing medicine side effect risk information in a combined format, using verbal descriptors accompanied by numerical information. Objectives: This study, with users of an existing popular patient information website, investigates the effectiveness of presenting medicine side effect risk information in different forms. Design: Participants were randomly allocated to one of the three formats for representing risk information (verbal descriptors, e.g. ‘common’; absolute frequencies, e.g. ‘less than 1 in 10 people’; and a combination of verbal descriptors and frequency bands, e.g. ‘common (affects less than 1 in 10 people)’. Methods: Participants (n= 187) were recruited from users of the Cancer Research UK patient information website. They were asked to imagine that they had to take a cancer treatment (tamoxifen), estimate the risks of four side effects occurring, and complete Likert scales relating to their satisfaction with the information supplied and perceived likelihood of various outcomes. Results: Those in the absolute frequency format demonstrated greater accuracy in estimating the likelihood of having two of four side effects than the other two formats. They were also more accurate at estimating the likelihood of themselves or the average person having any side effect from taking tamoxifen. Participants in the absolute frequency format rated the risk to health from tamoxifen as lower than those in the other two formats, were more satisfied with the information they received than those in the verbal format, and felt there would be less impact of the information on tamoxifen use than those in the combined format. Conclusions: These findings fail to confirm that the recommended use of combined descriptors for medicine side effects is unequivocally superior to absolute frequency alone. They also add weight to the growing body of research highlighting the deficiencies in using verbal descriptors for conveying side effect risk, and the strength of using absolute frequency descriptors.

PurposeFruit and vegetable (F&V) intakes amongst Scottish schoolchildren are lower than recommended. The purpose of this paper is to describe an intervention which combined F&V with peer‐modelling and rewards to influence consumption of F&V.Design/methodology/approachA school‐based initiative was implemented in 19 primary schools. The evaluation of 8 schools (n = 1,477 pupils aged 4.5‐12 years) is reported. The three‐week intervention included free F&V (80 g portions), a peer‐modelling video and a series of small rewards followed by a four to six week maintenance phase during which time free F&V continued. Questionnaires were completed at baseline (T1) and up to two months after the end of the maintenance phase (T2) to assess changes in F&V consumption.FindingsAt T2, children in years 1 and 2 consumed F&V at school more often compared with T1, and ate a greater number of portions each time. There were no significant differences in home consumption. The picture was similar for children in years 3‐7 with no change in the reported number of portions.Originality/valueFew behavioural interventions have been carried out in the public health arena to increase F&V consumption. This paper shows that a peer‐modelling intervention significantly increased consumption of F&V at school, while home consumption remained stable.

Background Hospital malnutrition (undernutrition) continues to attract concern. The implementation of standards for food and fluids in Scotland provided the stimulus for an audit of current practices in NHS Fife hospitals in order to provide baseline data with which to evaluate progress. Methods One hundred and fifty in-patients were recruited from wards likely to yield those with a high risk of malnutrition. Using patient records and anthropometry, data were collected on weight, weight change, body mass index (BMI), mid-upper-arm circumference (MUAC), dietetic referral, therapeutic diets and patients’ perceptions of nutritional status. Malnutrition was estimated by comparing BMI, weight change and MUAC with the Malnutrition Universal Screening Tool (MUST) and standards published by the Scottish Intercollegiate Guidelines Network (SIGN). Results Depending upon the standard used, the minimum risk of malnutrition varied from 14 to 25%. The prevalence was lower than that reported previously, although methods were not directly comparable. Obesity was also evident with 42% of patients having a BMI > 25. Mean weight change from admission to audit was +0.4 kg, with a wide range (−11 kg to +13 kg). Most patients identified as malnourished were referred to the dietitian or given nutritional support. Conclusions Fewer patients were at risk of malnutrition than expected. However, improving the provision of food and fluids remains a priority in Fife as malnutrition and eating problems can occur across the entire BMI spectrum.

PurposeThere are many herbal supplements on the market claiming to aid weight loss but few are evidence‐based. This study aims to test one such formulation.Design/methodology/approachAn over‐the‐counter herbal supplement containing yerba maté, guarana and damiana (YGD) was tested in 73 overweight health professionals for six weeks. Subjects were not asked to make any lifestyle changes.FindingsSelf‐reported weight, waist circumference and hip circumference reduced significantly, while 22 per cent of subjects experienced a clinically significant weight loss. The anthropometric changes were in line with other commercial diet and exercise programmes. Reported between‐meal hunger, and consumption of snacks reduced across the six weeks. Reported satiety after meals increased and subjects claimed to be more in control of snacking, emotional eating and portion sizes. A follow‐up at week ten, when 82 per cent of subjects had stopped taking YGD, revealed no additional reductions in weight or hip circumference. Fullness ratings had stabilised, while hunger ratings had increased. There were no consistent adverse effects that could reasonably be related to YGD.Research limitations/implicationsTaken alongside a 2001 randomised, placebo‐controlled trial, this study provides evidence that a YGD supplement can aid weight loss and reduce waist and hip circumference, probably by increasing satiety.Originality/valueThe growing market in weight management products brings with it a responsibility for manufacturers to provide evidence that their products work. This paper adds to the evidence base.

There is clinical and research consensus that significant cognitive, social, emotional development and adjustment to physical changes occurs during young adulthood, in the period between ages 18 and 24 years.1 While three–quarters of psychiatric disorders in adults emerge before the age of 25 years, a European study, comparing access to mental health care by age bands, reported that 18–24-year-old participants were least likely to get care for mental health problems.2 In the 2016 UK National Confidential Enquiry into Suicide in Children and Young People, 43% of people aged

Differences in the drug use characteristics and psychosocial variables in the use and non-use of ecstasy within 845 16–25 year-olds in the UK was examined. Based on levels of ecstasy use and intentions, two groups of non-users (resistant and vulnerable), three groups of users (light, moderate and heavy) and an ex-user group were identified. It was found that there is predictive utility in this way of expanding the widely employed ‘user versus non-user’ dichotomy. Resistant non-users were more likely to be younger, female, and were characterized by lower levels of use of four other drugs (amphetamine, cannabis, cocaine and LSD). Those ‘at risk’ of using ecstasy reported more frequent use of amphetamine, LSD, and cannabis than resistant non-users. Heavy user groups reported using amphetamine, cocaine and LSD more frequently than all the other groups. Having ecstasy using friends increased the odds of being an ‘at risk’ non-user or an ecstasy user. Normative influence also differentiated between the three user groups (light, moderate, and heavy). Beliefs about ecstasy use being immoral, ecstasy offers being difficult to resist, ecstasy use making one feel guilty and ecstasy being readily available differentiated between user and non-user groups. These factors could usefully inform the content of health education materials designed to change ecstasy use. Copyright © 2003 John Wiley & Sons, Ltd.

This study examined the hypothesis that students would exhibit changes in their levels of, and cognitions about, drug use throughout their university career. Three hundred and eighty undergraduates from Years 1, 2, and 3 (174 male, 206 female) initially participated in the study (response rate 63%). Questionnaires were distributed at 6-month intervals over a period of 2 years, resulting in 4 time points. The questionnaires contained items relating to the use of, and cognitions about the use of, alcohol, amphetamine, cannabis, ecstasy, LSD, and tobacco. No evidence was found to suggest an increase in the percentage of respondents using drugs over their university career. However, a significant increase in the frequency of ecstasy use between Years 1 and 2 was found. Various cognitive measures also exhibited changes between Years 1 and 2, associated with increasingly “liberal” views toward drug use. No evidence was found to suggest that drug use tailed off toward the end of the university career. The findings point to the need for increased drugs education for students, and the need for more research to aid in the understanding of how university life affects drug use levels.

Venous thromboembolism (VTE) risk assessment for adults admitted to hospital is commonplace, but the utility of assessment tools in patients admitted to hospices or palliative care units and prediction of symptomatic VTE is unknown.To investigate the relationship between risk of VTE and development of symptoms.Retrospective consecutive admission, case-note data from seven U.K. hospices were collected during an evaluation of a VTE risk assessment protocol using the Pan Birmingham Cancer Network palliative-modified Thromboembolic Risk Factors (THRIFT) Consensus Group criteria and presence/absence of a temporary elevated risk (TER) of VTE. Symptoms/signs during admission consistent with possible VTE were documented.A total of 1164 case-notes were analyzed (age range 23-99; men 627). THRIFT risk was high in 13%, medium in 83%, and low in 4%; a TER was identified in 24%. In the "clinically relevant group" (no contraindication, not anticoagulated), where primary thromboprophylaxis could have been prescribed (n = 528), TER and symptoms were associated (21% symptoms with TER vs. 9% symptoms without TER: Chi-squared, P0.001). A high/moderate THRIFT score had a sensitivity of 98.4% (95% CI 91.3%-99.9%) and specificity of 5.8% (95% CI 3.9%-8.3%). The TER assessment had a more evenly balanced sensitivity (41.9%; 95% CI 29.5%-55.2%) and specificity (79%; 95% CI 75.0%-82.6%).Hospice inpatients are at risk for VTE. TER alone is simpler to use and may be more useful in this population than the THRIFT but still has limitations regarding ability to predict symptoms.

Objectives The study evaluated the interpretation of, and preferences for, numerical information on side-effect incidence when presented in three different formats. Methods It used a controlled design, with participants allocated at random to receive one of the three formats. Participants were recruited via a pop-up window on the CancerHelp UK website. The sample comprised 129 website users, of whom 96% were women and 86% had cancer, who received frequency information on four side effects of tamoxifen, using one of three risk expressions (percentages, e.g. ‘affects 25% of people’; frequencies, e.g. ‘affects 1 in 4 people’; combined, e.g. ‘affects 1 in 4 people (25%)’). They then interpreted information on tamoxifen and its effect on health, and estimates of side-effect frequency, and then stated a preference from the three risk expression formats. Key findings The results showed that the three formats did not influence participants’ ratings of the information or their side-effect estimates. However, more than half (53%) the participants preferred the combined (frequency and percentage) format. In conclusion, a combined risk expression format performed no worse than percentages or frequencies alone and was preferred by a majority. Conclusions The three risk expression formats did not differ in their effect on participants’ interpretations. However, the preferred format was the combined (frequency and percentage) risk expression.

To report an unusual case of endogenous fungal endophthalmitis due to Candida dubliniensis. Interventional case report of a 27-year-old immunocompetent male with loss of vision, dense vitritis, and chorioretinal infiltrates, who underwent a diagnostic pars plana vitrectomy. Microbiology cultures obtained by a diagnostic vitrectomy were positive for the growth of C. dubliniensis. This infectious process was then appropriately treated with intravitreal amphotericin B and systemic fluconazole with resolution of the endophthalmitis. Endogenous fungal endophthalmitis is a condition that can masquerade other more common causes of endophthalmitis. Atypical cases of endophthalmitis may benefit from diagnostic pars plana vitrectomy for prompt diagnosis and treatment.

Advances in regional anesthesia, specifically continuous peripheral nerve blocks (CPNBs), have greatly improved pain outcomes for wounded soldiers in Iraq and Afghanistan. pain management practice variations, however, do exist, depending on the availability of pain-trained military professionals deployed to combat support hospitals. an exploratory study was undertaken to examine pain and other outcomes during evacuation and at landstuhl regional medical center (lrmc), germany.a mixed-methods, semistructured interview survey design was conducted on a convenience sample of wounded u.s. soldiers evacuated from iraq and afghanistan to lrmc. setting and patients. a total of 110 wounded soldiers evacuated from IRAQ and Afghanistan from July 2007 to February 2008 completed a pain survey at LRMC. Data were collected on demographics, injury mechanism, last 24-hour average, least, and worst, and pain now by using a 0-10 scale, and percent pain relief (from 0% [No relief] to 100% [Complete relief]). Similar items and measures of anxiety, distress, and worry during flight transport were measured (from 0 [None] to 10 [Extreme]). Responses were analyzed by using descriptive and correlational statistics, multiple linear regression, Mann-Whitney U-tests, and t-tests. The Walter Reed Army Medical Center, Human Use Committee approved this investigation.Participants were typically male (99.1%), Caucasian (80%), and injured from improvised explosive devices (60%) and gunshots (21.8%). Average and worst pain scores were inversely correlated with pain relief during transport (r = -0.58 and r = -0.46, respectively; P0.001), and low to moderately positively correlated with increased anxiety, distress, and worry during transport (P0.05). Average percent pain relief achieved was 45.2% +/- 26.6% during transport and 64.5% +/- 23.5% while at LRMC (P0.001). Participants with CPNB catheters placed at LRMC reported significantly less pain right now (P = 0.031) and better pain relief (P = 0.029) than soldiers without CPNBs.Our findings underscore the value of early aggressive pain management after major combat injuries. Increased pain was associated with increased anxiety, distress, and worry during transport, suggesting the need for psychological management along with analgesia. Regional anesthesia techniques while at LRMC contributed to better pain outcomes.

Objective To investigate the effectiveness of presenting medicine side effect risk information in different forms, including that proposed by UK guidelines [ [1] Medicines and Healthcare products Regulatory Agency. Always read the leaflet—Getting the best information with every medicine. (Report of the Committee on Safety of Medicines Working Group on Patient Information). London: The Stationery Office, 2005.]. Methods 134 Cancer Research UK (CRUK) website users were recruited via a ‘pop-up’. Using a 2 × 2 factorial design, participants were randomly allocated to one of four conditions and asked to: imagine they had to take tamoxifen, estimate the risks of 4 side effects, and indicate a presentation mode preference. Results Those presented with absolute frequencies demonstrated greater accuracy in estimating 2 of 4 side effects, and of any side effect occurring, than those presented with frequency bands. Those presented with combined descriptors were more accurate at estimating the risk of pulmonary embolism than those presented with numeric descriptors only. Conclusion Absolute frequencies outperform frequency bands when presenting side effect risk information. However, presenting such exact frequencies for every side effect may be much less digestible than all side effects listed under 5 frequency bands. Combined numerical and verbal descriptors may be better than numeric only descriptors when describing infrequent side effects. Practice implications Information about side effects should be presented in ways that patients prefer, and which result in most accurate risk estimates.

Objective This study investigated the daily hassles-eating behavior relationship and its moderators in a naturalistic setting. Design A multilevel diary design was used to examine day-to-day within-person effects of daily hassles on eating behavior (N = 422), together with the individual and simultaneous influence of potential moderating variables. Main outcome measures Daily diary reports of between-meal snacking, fruit and vegetable consumption and perceived variations in daily food intake. Results The results showed daily hassles were associated with increased consumption of high fat/sugar snacks and with a reduction in main meals and vegetable consumption. Ego-threatening, interpersonal and work-related hassles were associated with increased snacking, whereas, physical stressors were associated with decreased snacking. The overall hassles-snacking relationship was significantly stronger and more positive at high compared to low levels of restraint, emotional eating, disinhibition, external eating and in females and obese participants. Simultaneous consideration of these moderators indicated that emotional eating was the pre-eminent moderator of the hassles-snacking relationship. Conclusion Daily hassles were associated with an increase in unhealthy eating behavior. These changes may indicate an important indirect pathway through which stress influences health risk.

Four hundred and twenty-two employees completed daily diaries measuring positive affect, negative affect, work hours, and health behaviors (snacking, smoking, exercise, alcohol, caffeine consumption) on work days over a 4-week period. In addition, measures of job demands, job control, and social support (iso-strain variables) were completed on 1 occasion. Multilevel random coefficient modeling was used to examine relationships between the job characteristics, daily work variables, and self-reported health behaviors. Results indicated a more important role for within-person daily fluctuations than for between-persons variations in predicting health behaviors. Whereas negative affect was negatively related to health behavior for both men and women, work hours had negative impacts for women only. Iso-strain variables showed few main effects and a modest number of interactions with daily variables (mainly for men). Findings point to the limited impact of stable features of work design compared to the effects of daily work stressors on health behaviors.

The Looking at Infant Feeding Today (LIFT) study examined the factors underlying the infant feeding choices of first-time mothers in the Leeds and Bradford areas of England experiencing material hardship, with a view to informing interventions aimed at increasing breastfeeding uptake amongst this group. This short report describes the novel methodology used to obtain data from a sample of pregnant women who are traditionally ‘hard-to-reach’ in deprived areas. This involved the use of trusted individuals such as midwives and multilingual health workers. A total of 449 women were approached; 441 (91.5%) agreed to participate and 303 returned completed questionnaires. Whilst 285 participants self-completed, 18 opted for interviewer assistance provided by a trained multilingual health worker. Feeding method up to 10 days after birth was obtained from the hospital records of 248 women (82.4% of eligible returns), and self-reported feeding method at six weeks was obtained from 273 women (90.7% of eligible returns). The study succeeded in obtaining data from a relatively deprived and hard-to-reach sample, with adequate numbers of participants in the subgroups of interest (teenage, left full time education age 16 or younger, household receiving income support or job seekers allowance, Asian or African-Caribbean).