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Synopses of a selection of recently published research articles of relevance to palliative care [ABSTRACT FROM AUTHOR]

Background and Objectives: D‐negative red cells are transfused to D‐negative females of childbearing potential (CBP) to prevent haemolytic disease of the foetus and newborn (HDFN). Transfusion of low‐titre group O whole blood (LTOWB) prehospital is gaining interest, to potentially improve clinical outcomes and for logistical benefits compared to standard of care. Enhanced donor selection requirements and reduced shelf‐life of LTOWB compared to red cells makes the provision of this product challenging. Materials and Methods: A universal policy change to the use of D‐positive LTOWB across England was modelled in terms of risk of three specific harms occurring: risk of haemolytic transfusion reaction now or in the future, and the risk of HDFN in future pregnancies for all recipients or D‐negative females of CBP. Results: The risk of any of the three harms occurring for all recipients was 1:14 × 103 transfusions (credibility interval [CI] 56 × 102–42 × 103) while for females of CBP it was 1:520 transfusions (CI 250–1700). The latter was dominated by HDFN risk, which would be expected to occur once every 5.7 years (CI 2.6–22.5). We estimated that a survival benefit of ≥1% using LTOWB would result in more life‐years gained than lost if D‐positive units were transfused exclusively. These risks would be lower, if D‐positive blood were only transfused when D‐negative units are unavailable. Conclusion: These data suggest that the risk of transfusing RhD‐positive blood is low in the prehospital setting and must be balanced against its potential benefits. [ABSTRACT FROM AUTHOR]

Summary: The emerging COVID‐19 pandemic has overwhelmed healthcare resources worldwide, and for transfusion services this could potentially result in rapid imbalance between supply and demand due to a severe shortage of blood donors. This may result in insufficient blood components to meet every patient's needs resulting in difficult decisions about which patients with major bleeding do and do not receive active transfusion support. This document, which was prepared on behalf of the National Blood Transfusion Committee in England, provides a framework and triage tool to guide the allocation of blood for patients with massive haemorrhage during severe blood shortage. Its goal is to provide blood transfusions in an ethical, fair, and transparent way to ensure that the greatest number of life years are saved. It is based on an evidence‐ and ethics‐based Canadian framework, and would become operational where demand for blood greatly exceeds supply, and where all measures to manage supply and demand have been exhausted. The guidance complements existing national shortage plans for red cells and platelets. [ABSTRACT FROM AUTHOR]

We use the concepts of trust and knowledge to explore translation of scientific evidence about treatment of ovine footrot to students studying at agricultural colleges. We explore the role of different forms of trust (companion, competence and commitment) in facilitating relationships between students and informants. We also investigate how students acquire knowledge, and how this influences their practices for treating footrot. We find that despite being taught evidence-based practice (antibiotic treatment and no foot trimming) at college, most students would still use traditional farm practice (foot trimming) to treat footrot. Students develop tacit knowledge of traditional practices from farmers whilst working on sheep farms and these farmers have a strong influence on students' practices; students have high levels of companion trust for "known farmers". College lecturers who demonstrate competence gain students' trust, but where this does not occur there is a failure in communication between lecturer and student. Students acquire explicit classroom knowledge of evidence-based practice at college because there is limited practical experiential learning. This explicit knowledge is typically insufficient to change behaviour, unless students trust their lecturer. Our findings indicate that farming experience dominates over classroom experience and so college education alone will not ensure uptake of evidence-based practice. • Lecturers are aware of evidence-based practice for management of lameness in sheep. • Trust is essential for the implementation of knowledge by agricultural students. • Students develop tacit knowledge of management of lameness whilst working on farms. • Farmers are trusted informants of students' beliefs, lecturers are often mistrusted. • Students have trust for lecturers who demonstrate competence. [ABSTRACT FROM AUTHOR]

Background: The involvement of two nurses to dispense and administer controlled drugs is routine practice in most clinical areas despite there being no legal or evidence-based rationale. Indeed, evidence suggests this practice enhances neither safety nor care. Registered nurses at two hospices agreed to change practice to single nurse dispensing and administration of controlled drugs (SNAD). Participants' views on SNAD were evaluated before and after implementation. The aim of this study was to explore the views and experiences of nurses who had implemented SNAD and to identify the views and concerns of those who had not yet experienced SNAD. Method: Data was obtained through semi-structured interviews. Results: Qualitative thematic analysis of interview transcripts identified three key themes: practice to enhance patient benefit and care; practice to enhance nursing care and satisfaction; and practice to enhance organisational safety. Conclusion: The findings have implications for the understanding of influences on medicines safety in clinical practice and for hospice policy makers. [ABSTRACT FROM AUTHOR]

Background: Neosporosis caused by the protozoan parasite Neospora caninum, is an economically important cause of abortion, stillbirth, low milk yield, reduced weight gain and premature culling in cattle. Consequently, a seroepidemiological study of N. caninum antibodies was conducted in England with 29,782 samples of blood taken from 15,736 cattle from 114 herds visited on three occasions at yearly intervals. Herds were categorised into lower (< 10%) and higher (≥ 10%) median herd seroprevalence. Hierarchical models were run to investigate associations between the sample to positive (S/P) ratio and herd and cattle factors. Results: Ninety-four percent of herds had at least one seropositive cow; 12.9% of adult cattle had at least one seropositive test. Approximately 90% of herds were seropositive at all visits; 9 herds (8%) changed serological status between visits. The median N. caninum seroprevalence in positive herds was 10% (range 0.4% to 58.8%). There was a positive association between the serostatus of offspring and dams that were ever seropositive. In the hierarchical model of low seroprevalence herds there was no significant association between S/P ratio and cattle age. There was a significantly lower S/P ratio in cattle in herds that were totally restocked after the foot-and-mouth epidemic of 2001 compared with those from continuously stocked herds and cattle purchased into these herds had a higher S/P ratio than homebred cattle. In the model of high seroprevalence herds the S/P ratio increased with cattle age, but was not associated with restocking or cattle origin. Conclusion: There were no strong temporal changes in herd seroprevalence of N. caninum but 90% of herds had some seropositive cattle over this time period. Vertical transmission from seropositive dams appeared to occur in all herds. In herds with a high seroprevalence the increasing S/P ratio in 2-4 year old cattle is suggestive of exposure to N. caninum: horizontal transmission between adult cattle, infection from a local source or recrudescence and abortions. Between-herd movements of infected cattle enhance the spread of N. caninum, particularly into low seroprevalence herds. Some restocked herds had little exposure to N. caninum, while in others infection had spread in the time since restocking. [ABSTRACT FROM AUTHOR]

Objectives The aim of this study is to review gender differences in elderly suicide in relation to specific social aspects of the suicidal process and health care contact before death. Such information may have practical value in identifying and targeting vulnerable elderly in whom suicide may be potentially preventable. Methods Data were extracted from the records of coroner's inquests into all reported suicide of persons aged 60 and over, in Cheshire over a period of 13 years 1989–2001. The Coroner's office covers the whole county of Cheshire (population 1 000 000). Results Men were less likely to have been known to psychiatric services (Odds Ratio [OR] 0.4 95% 0.2–0.6) and with less frequently reported history of previous attempted suicide compared to women (OR 0.5 95% Confidence Intervals [CI] 0.2–1). All deceased from ethnic minorities were men, none of whom had been known to psychiatric services. There was no significant difference between women and men in relation to, physical or psychiatric morbidity, GP contact prior to suicide, intimation of intent or living alone. Of suicide victims not known to services a surprisingly high proportion of 38% and 16% were found to have psychiatric morbidity in men and women respectively. Conclusion Suicide is an important problem in the elderly with gender playing an important part in their social behaviour but a high proportion of the deceased were not known to local services. Primary Care professionals have an important role to play in reducing elderly suicide as most contact with the health service in elderly suicide seem to be with GPs. Copyright © 2003 John Wiley & Sons, Ltd. [ABSTRACT FROM AUTHOR]

We present the largest and most representative study of the serological diversity of Dichelobacter nodosus in England. D. nodosus causes footrot and is one of the top five globally important diseases of sheep. The commercial vaccine, containing nine serogroups, has low efficacy compared with bivalent vaccines. Our aim was to investigate the prevalence and distribution of serogroups of D. nodosus in England to elucidate whether a bivalent vaccine could protect the national flock. Farmers from 164 flocks submitted eight interdigital swabs from eight, preferably diseased, sheep. All serogroups, A–I, were detected by PCR in 687/1150 D. nodosus positive swabs, with a prevalence of 2.6–69.3% of positive swabs per serogroup. There was a median of two serogroups per flock (range 0–6). Serogroups were randomly distributed between, but clustered within, flocks, with 50 combinations of serogroups across flocks. H and B were the most prevalent serogroups, present in > 60% of flocks separately but in only 27% flocks together. Consequently, a bivalent vaccine targeting these two serogroups would protect 27% of flocks fully (if only H and B present) and partially, if more serogroups were present in the flock. We conclude that one bivalent vaccine would not protect the national flock against footrot and, with 50 combinations of serogroups in flocks, flock-specific vaccines are necessary. [ABSTRACT FROM AUTHOR]

Abstract: Between December 2002 and April 2006, 114 cattle farms in the south west of England were visited at least once, with 100 farms visited three times. A total of 29,782 serum samples were collected from 15,736 individually identified cattle. The sera were tested for the presence of antibodies against Mycobacterium avium subsp. paratuberculosis (MAP) using an indirect enzyme-linked immunosorbent assay (ELISA). The mean seroprevalence in herds sampled three times was 7.1%; 10.1% of cattle had at least one positive result. There were 78%, 75% and 75% dairy herds with at least one positive bovine at the first, second and third routine visits, respectively. In comparison, 44%, 42% and 46% suckler herds had at least one positive bovine for the first, second and third routine visits, respectively. In most herds (>90%), within herd seroprevalence of MAP remained stable over time. Markov chain Monte Carlo (MCMC) simulation methods were used to re-estimate the test sensitivity and specificity. The sensitivity results were 33.3% (95% CI, 28.8–37.8%), 34.5% (95% CI, 30.3–38.8%) and 34.8% (95% CI, 30.8–38.9%) for the first, second and third routine visits and the specificity results were 99.7% (95% CI, 99.3–99.9%), 99.8% (95% CI, 99.4–99.9%) and 99.7% (95% CI, 99.3–99.9%) for the first, second and third routine visits, respectively. The expected true prevalence was also estimated, 11 (21.1%) suckler herds and 1 (2.1%) dairy herd were predicted to be truly free from infection during the study period. The seroprevalence of antibodies against MAP increased with cattle age. There was a significantly higher seroprevalence of MAP in dairy breeds of cattle compared with suckler breeds of cattle. This was more pronounced in Channel Island breeds. Smaller dairy herds (<100 cattle) had a relatively lower seroprevalence of MAP than dairy herds with ≥100 cattle. In 8 (42%) of the 19 herds with ≥100 cattle born into the same herd, seropositive cattle were clustered by birth month whilst in the remaining herds clustering was not apparent. Daughters were significantly more likely to be MAP seropositive when born to a seropositive dam. [Copyright &y& Elsevier]

Since 2006, farmers in England have received new recommendations on best practice to manage lameness in sheep through a range of knowledge exchange activities. The adoption of each recommendation varied, but in 2013 approximately 50% of farmers reported treating all lame sheep within 3 days of onset of lameness (prompt treatment), 41% did not practice routine foot trimming, 50% culled sheep that had been lame and 14% vaccinated against footrot; all recommended best practices. The aim of this study was to investigate the prevalence of lameness in ewes in England from 2013 to 2015 and to identify changes in practice to manage lameness between 2013 and 2015 and the population attributable fraction for these managements. A longitudinal study with a cohort of 154 English sheep farmers was run for three years, farmers completed questionnaires on lameness in their flock for the previous 12 months in 2013, 2014 and 2015. The geometric mean prevalence of lameness in ewes was 4.1% in 2015, significantly higher than 3.3% and 3.2% for the same 128 farmers who provided data in both 2013 and 2014. Between 2013 and 2015 there was a significant reduction in farmers practising prompt treatment (50.6%–28.6%) but an increase in not practising routine foot trimming (40.9%–79.2%), culling sheep that had been lame (49.4%–81.8%), and vaccinating against footrot (14.3%–29.2%). Not practising prompt treatment, ≥5% of sheep feet bleeding during routine foot trimming, vaccinating ewes for <6 years or not vaccinating at all, and other flocks mixing with the flock, were associated with a significantly higher flock prevalence of lameness. Culling sheep that had been lame was not associated with prevalence of lameness. The population attributable fractions (PAFs) for not vaccinating for>5 years, not treating lame sheep promptly, ≥5% of sheep feet bleeding during routine foot trimming, and mixing of flocks were 34.5%, 25.3%, 2.9% and 2.4%. In 2013, when 50% of farmers used prompt treatment, the PAF for not using prompt treatment was only 13.3%. We conclude that the change in practice by these farmers towards flock-level managements and a reduction in individual prompt treatment of lame sheep negatively impacted the prevalence of lameness in sheep. This change occurred despite the evidence that prompt treatment of lame sheep is highly effective at reducing the prevalence of lameness in sheep flocks and is an example of cognitive dissonance. [ABSTRACT FROM AUTHOR]

Background: Group AB plasma does not contain anti-A or anti-B antibodies and is therefore considered universal but is in limited supply (4% of the population). There is currently no licensed universal plasma available, and therefore current clinical guidelines for transfusion require the donor and recipient to be blood group compatible. We sought to understand the benefits of universal plasma to hospitals in England, to inform R&D priorities going forward., Study Design and Methods: To understand the benefits of universal plasma (cryoprecipitate included), we distributed two surveys to hospitals (267 in total) in England., Results: Safety was the perceived top benefit of universal plasma (95%), with cost identified as the main barrier to adoption (82%), although the majority of respondents were willing to pay more for universal components. Ninety-five respondents felt they would replace all or part of their stock holding with universal plasma, with 91% anticipating that their overall stock holding of plasma would reduce as well as there will be a reduction in their plasma wastage (by up to 25%). Hospitals (56%) thought that the availability of universal plasma would support more rapid provision of plasma for transfusion, particularly in emergency situations, with the emergency/trauma department deemed to be the area that would see the greatest benefit from these universal blood components., Discussion: The response to both the potential clinical and operational benefits of a universal plasma and cryoprecipitate was positive., (© 2024 The Author(s). Transfusion published by Wiley Periodicals LLC on behalf of AABB.)

Background: In-hospital acute resuscitation in trauma has evolved toward early and balanced transfusion resuscitation with red blood cells (RBC) and plasma being transfused in equal ratios. Being able to deliver this ratio in prehospital environments is a challenge. A combined component, like leukocyte-depleted red cell and plasma (RCP), could facilitate early prehospital resuscitation with RBC and plasma, while at the same time improving logistics for the team. However, there is limited evidence on the clinical benefits of RCP., Objective: To compare prehospital transfusion of combined RCP versus RBC alone or RBC and plasma separately (RBC + P) on mortality in trauma bleeding patients., Methods: Data were collected prospectively on patients who received prehospital transfusion (RBC + thawed plasma/Lyoplas or RCP) for traumatic hemorrhage from six prehospital services in England (2018-2020). Retrospective data on patients who transfused RBC from 2015 to 2018 were included for comparison. The association between transfusion arms and 24-h and 30-day mortality, adjusting for age, injury mechanism, age, prehospital heart rate and blood pressure, was evaluated using generalized estimating equations., Results: Out of 970 recruited patients, 909 fulfilled the study criteria (RBC + P = 391, RCP = 295, RBC = 223). RBC + P patients were older (mean age 42 vs 35 years for RCP and RBC), and 80% had a blunt injury (RCP = 52%, RBC = 56%). RCP and RBC + P were associated with lower odds of death at 24-h, compared to RBC alone (adjusted odds ratio [aOR] 0.69 [95%CI: 0.52; 0.92] and 0.60 [95%CI: 0.32; 1.13], respectively). The lower odds of death for RBC + P and RCP vs RBC were driven by penetrating injury (aOR 0.22 [95%CI: 0.10; 0.53] and 0.39 [95%CI: 0.20; 0.76], respectively). There was no association between RCP or RBC + P with 30-day survival vs RBC., Conclusion: Prehospital plasma transfusion for penetrating injury was associated with lower odds of death at 24-h compared to RBC alone. Large trials are needed to confirm these findings., (© 2023. The Author(s).)

Objectives: To evaluate the End-of-Life and Bereavement Care model (SWAN) from conception to current use., Design: A realist evaluation was conducted to understand what works for whom and in what circumstances. The programme theory, derived from a scoping review, comprised: person and family centred care, institutional approaches and infrastructure. Data were collected across three stages (May 2021 to December 2021): semi-structured, online interviews and analysis of routinely collected local and national data., Setting: Stage 1: Greater Manchester area of England where the SWAN model was developed and implemented. Stage 2: Midlands. Stage 3: National data., Participants: Twenty-three participants were interviewed: Trust SWAN leads, end-of-life care nurses, board members, bereavement services, faith leadership, quality improvement, medicine, nursing, patient transport, mortuary, police and coroners., Results: Results from all three stages were integrated within themes, linked to the mechanisms, context and outcomes for the SWAN model. The mechanisms are: SWAN is a values-based model, promoting person/family-centred care and emphasising personhood after death. Key features are: memory-making, normalisation of death and 'one chance' to get things right. SWAN is an enablement and empowerment model for all involved. The branding is recognisable and raises the profile of end-of-life and bereavement care. The contextual factors for successful implementation and sustainability include leadership, organisational support, teamwork and integrated working, education and engagement and investment in resources and facilities. The outcomes are perceived to be: a consistent approach to end-of-life and bereavement care; a person/family-centred approach to care; empowered and creative staff; an organisational culture that prioritises end-of-life and bereavement care., Conclusion: The SWAN model is agile and has transferred to different settings and circumstances. This realist evaluation revealed the mechanisms of the SWAN model, the contextual factors supporting implementation and perceived outcomes for patients, families, staff and the organisation., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2022. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Competing Interests: Competing interests: We have read and understood BMJ policy on declaration of interests and have no relevant interests to declare.

Recent independent UK government reports and studies have highlighted the importance, but lack, of flock health services provided by veterinarians. Qualitative interviews were analysed by thematic analysis to construct belief statements to understand veterinarians' opinions on preventative advice and drivers for current services to sheep farmers. A postal questionnaire was sent to 515 sheep practices registered with the Royal College of Veterinary Surgeon (RCVS) in England and Wales in 2012 to gather quantitative data on these belief statements and to gather demographic information and current services provided by the veterinarian. Exploratory factor analysis with heuristic approaches was conducted on the respondents' belief statements to identify common factors of veterinarian beliefs. Three main factors were identified: motivation for proactiveness, perceived capability to offer preventative services and perceived opportunity to deliver these services. A beta regression model was built to identify the factors significantly associated with the time veterinarians spent in an advisory role. The relative proportion of time increased by 10% (1.01-1.19), 16% (1.03-1.30) and 29% (CI: 1.09-1.53) for each unit increase in score for factor 1 motivation, factor 2 capability and factor 3 opportunity respectively, indicating that these latent factors explained time veterinarians spent in an advisory role with sheep clients. There was a significant correlation between these factors suggesting influence of the associated beliefs between factors. This study provides insight into the nature and drivers of veterinarians' current behaviour and beliefs. These results could be further tested in behaviour intervention studies and help in designing efficient strategies aiming at promoting proactive health services offered by veterinarians on sheep farms in England and Wales., (Copyright © 2015 Elsevier B.V. All rights reserved.)

The aims of this study were to update the prevalence of lameness in sheep in England and identify novel risk factors. A total of 1260 sheep farmers responded to a postal survey. The survey captured detailed information on the period prevalence of lameness from May 2012-April 2013 and the prevalence and farmer naming of lesions attributable to interdigital dermatitis (ID), severe footrot (SFR), contagious ovine digital dermatitis (CODD) and shelly hoof (SH), management and treatment of lameness, and farm and flock details. The global mean period prevalence of lameness fell between 2004 and 2013 from 10.6% to 4.9% and the geometric mean period prevalence of lameness fell from 5.4% (95% CL: 4.7%-6.0%) to 3.5% (95% CI: 3.3%-3.7%). In 2013, more farmers were using vaccination and antibiotic treatment for ID and SFR and fewer farmers were using foot trimming as a routine or therapeutic treatment than in 2004. Two over-dispersed Poisson regression models were developed with the outcome the period prevalence of lameness, one investigated associations with farmer estimates of prevalence of the four foot lesions and one investigated associations with management practices to control and treat lameness and footrot. A prevalence of ID>10%, SFR>2.5% and CODD>2.5% were associated with a higher prevalence of lameness compared with those lesions being absent, however, the prevalence of SH was not associated with a change in risk of lameness. A key novel management risk associated with higher prevalence of lameness was the rate of feet bleeding/100 ewes trimmed/year. In addition, vaccination of ewes once per year and selecting breeding replacements from never-lame ewes were associated with a decreased risk of lameness. Other factors associated with a lower risk of lameness for the first time in a random sample of farmers and a full risk model were: recognising lameness in sheep at locomotion score 1 compared with higher scores, treatment of the first lame sheep in a group compared with waiting until >5 were lame, treatment of lame sheep within 3 days, ease of catching lame sheep and quarantine for >21 days. A previously known factor associated with a lower risk of lameness was footbathing to prevent ID. We conclude that the prevalence of lameness in sheep in England has fallen and that this might be in part because of increased uptake of managements recently reported as beneficial to control lameness. Routine foot trimming should be avoided., (Copyright © 2015 Elsevier B.V. All rights reserved.)

Footrot, including interdigital dermatitis, is caused by Dichelobacter nodosus cause the majority of lameness in sheep in the UK. Lame sheep often have overgrown hoof horn but recent evidence has indicated that trimming overgrown hoof horn increases recovery time, and that routine foot trimming of the flock does not reduce the prevalence or incidence of lameness. The objectives of this study were to investigate the temporal associations between hoof horn length, footrot and climate. Fifty multiparous ewes were monitored for 10 months. On eight occasions hoof horn length, foot lesions and body condition were recorded. At the first examination, ewes were assigned to one of two treatment groups. All ewes that became lame with footrot were treated at one time point per week, either by trimming hoof horn and applying a topical antibiotic spray or with parenteral antibiotic and topical antibiotic spray. Hoof horn length in ewes at pasture varied over the year and was associated with temperature and rainfall. New cases of footrot occurred all year round and were associated with prior prevalence of footrot in the flock and prior temperature and rainfall. Overgrown hoof horn did not precede lameness but occurred once the sheep were lame. One year of prompt treatment of footrot reduced the range in hoof horn length in the sheep in both treatment groups. At the end of the study the hoof lengths of ewes in both groups were not significantly different. On this farm, hoof horn length was self-regulating in both non-lame and treated lame sheep whether trimming was part of the treatment or not and there would have been no benefit from routine foot trimming of this flock., (Copyright © 2014 The Authors. Published by Elsevier Ltd.. All rights reserved.)

Footrot is an infectious bacterial disease of sheep that causes lameness. The causal agent is Dichelobacter nodosus. There is debate regarding the role of Fusobacterium necrophorum in disease initiation. This research used an observational longitudinal study of footrot, together with quantitative PCR (qPCR) of bacterial load of D. nodosus and F. necrophorum, to elucidate the roles of each species in the development of disease. All feet of 18 a priori selected sheep were monitored for five weeks assessing disease severity (healthy, interdigital dermatitis (ID) and severe footrot (SFR)) and bacterial load. A multinomial model was used to analyse these data. Key unadjusted results were that D. nodosus was detected more frequently on feet with ID, whereas F. necrophorum was detected more frequently on feet with SFR. In the multinomial model, ID was associated with increasing log10 load of D. nodosus the week of observation (OR=1.28 (95% CI=1.08-1.53)) and the week prior to development of ID (OR=1.20 (95% CI=1.01-1.42). There was no association between log10 load(2) of F. necrophorum and presence of ID (OR=0.99 (95% CI=0.96-1.02))). SFR was associated with increasing log10 load of D. nodosus the week before disease onset (OR=1.42 (95% CI=1.02-1.96)) but not once SFR had occurred. SFR was positively associated with log10 load(2) of F. necrophorum once disease was present (OR=1.06 (95% CI=1.01-1.11)). In summary, there was an increased risk of increasing D. nodosus load the week prior to development of ID and SFR and during an episode of ID. In contrast, F. necrophorum load was not associated with ID before or during an episode, and was only associated with SFR once present. These results contribute to our understanding of the epidemiology of footrot and highlight that D. nodosus load plays the primary role in disease initiation and progression, with F. necrophorum load playing a secondary role. Further studies in more flocks and climates would be useful to confirm these findings. This study identifies that D. nodosus load is highest during ID. This supports previous epidemiological findings, which demonstrate that controlling ID is the most effective management strategy to prevent new cases of ID and SFR., (Copyright © 2014. Published by Elsevier B.V.)

This article presents a review of key issues around caring for people in the last hours and days of life. The aim is that community nurses will be able to support patients and families, and to provide and explain decisions and interventions to promote comfort and dignity based on current evidence.

The incidence of herd breakdown (HBD) with bovine tuberculosis (bTB) has continued to increase year on year since the 1980s in Great Britain. The management of bTB constitutes a major challenge for government and the cattle industry. Whilst various factors have been implicated with the risk of HBD with bTB, factors involved in recovery are less well described. In this paper, we used a multilevel multistate model to identify the factors affecting the probability of a herd being placed under restriction following a bTB outbreak and the factors involved in those restrictions being lifted. By modelling both transitions within the same model, we control for unobserved herd-specific characteristics, and investigate the frequency of change between the restricted and derestricted states. There were two patterns of herd breakdown: transient (characterised by fast cycling between restricted and derestricted states) and continuous (characterised by rare changes between the two states). The risk of a herd being placed under restriction was dominated by predictors related to cattle movements. The probability of derestriction increased with more regular testing. Some risks affected both transitions, namely loge mean size of neighbouring herds in the test-year, whether the herd bred its own replacements and the foot and mouth disease indicator of whether a bTB test was done between February 2002 and January 2003, possibly because the underlying true state of the herd, as infected or not, meant that these factors increased or reduced the risk of HBD. These results highlight that management of bTB is dependent on the true underlying herd status of bTB infection and that some confusion of the benefits or otherwise of some management practices, e.g. using home bred replacements can be explained by this underlying status., (Copyright © 2013 Elsevier B.V. All rights reserved.)

Background: Imperfect diagnostic testing reduces the power to detect significant predictors in classical cross-sectional studies. Assuming that the misclassification in diagnosis is random this can be dealt with by increasing the sample size of a study. However, the effects of imperfect tests in longitudinal data analyses are not as straightforward to anticipate, especially if the outcome of the test influences behaviour. The aim of this paper is to investigate the impact of imperfect test sensitivity on the determination of predictor variables in a longitudinal study., Methodology/principal Findings: To deal with imperfect test sensitivity affecting the response variable, we transformed the observed response variable into a set of possible temporal patterns of true disease status, whose prior probability was a function of the test sensitivity. We fitted a Bayesian discrete time survival model using an MCMC algorithm that treats the true response patterns as unknown parameters in the model. We applied our approach to epidemiological data of bovine tuberculosis outbreaks in England and investigated the effect of reduced test sensitivity in the determination of risk factors for the disease. We found that reduced test sensitivity led to changes to the collection of risk factors associated with the probability of an outbreak that were chosen in the 'best' model and to an increase in the uncertainty surrounding the parameter estimates for a model with a fixed set of risk factors that were associated with the response variable., Conclusions/significance: We propose a novel algorithm to fit discrete survival models for longitudinal data where values of the response variable are uncertain. When analysing longitudinal data, uncertainty surrounding the response variable will affect the significance of the predictors and should therefore be accounted for either at the design stage by increasing the sample size or at the post analysis stage by conducting appropriate sensitivity analyses.

Background: Lesions on sows' limbs and bodies are an abnormality that might impact on their welfare. The prevalence of and risks for limb and body lesions on lactating sows on commercial English pig farms were investigated using direct observation of the sows and their housing., Results: The prevalence of lesions on the limbs and body were 93% (260/279) and 20% (57/288) respectively. The prevalence of limb and body lesions was significantly lower in outdoor-housed sows compared with indoor-housed sows. Indoor-housed sows had an increased risk of wounds (OR 6.8), calluses (OR 8.8) and capped hock (OR 3.8) on their limbs when housed on fully slatted floors compared with solid concrete floors. In addition, there was an increased risk of bursitis (OR 2.7), capped hock (OR 2.3) and shoulder lesions (OR 4.8) in sows that were unwilling to rise to their feet. There was a decreased risk of shoulder lesions (OR 0.3) and lesions elsewhere on the body (OR 0.2) in sows with more than 20 cm between their tail and the back of the crate compared with sows with less than 10 cm., Conclusion: The sample of outdoor housed sows in this study had the lowest prevalence of limb and body lesions. In lactating sows housed indoors there was a general trend for an increased risk of limb and body lesions in sows housed on slatted floors compared with those housed on solid concrete floors with bedding. Sows that were less responsive to human presence and sows that had the least space to move within their crates had an additional increased risk of lesions.

Background: In a cross sectional study of 88 indoor and outdoor English pig farms, the prevalence of foot and limb lesions in 2843 preweaning piglets aged 1-4 weeks from 304 litters was recorded. The environmental risks for the prevalence of lesions and population attributable fractions were calculated. The risks for lesions in piglets were compared with those for limb and body lesions in their mothers. A small number of piglets with each type of lesion were examined post mortem to elucidate the pathology of the clinical lesions observed., Results: The prevalence of sole bruising, sole erosion, skin abrasion and swollen joints or claws in 2843 piglets was 49.4% (1404), 15.5% (441), 43.6% (1240) and 4.7% (143) respectively. The prevalence of all foot and limb lesions was higher in indoor housed piglets than in outdoor housed piglets. The prevalence of sole bruising (OR 0.3) and skin abrasion (OR 0.6) decreased with each week of age from 1-4 weeks, but there was no significant association between piglet age and the prevalence of sole erosion or swollen joints and claws. There was an increased prevalence of sole bruising (OR 3.0) and swollen joints or claws (OR 3.0) and a decreased prevalence of skin abrasion (OR 0.3, piglets

Background: Bovine herpesvirus type-1 (BHV-1) is an important pathogen of cattle that presents with a variety of clinical signs, including the upper respiratory tract infection infectious bovine rhinotracheitis (IBR). A seroepidemiological study of BHV-1 antibodies was conducted in England from 2002 - 2004: 29,782 blood samples were taken from 15,736 cattle from 114 herds which were visited on up to three occasions. Antibody concentration was measured using a commercial ELISA. Farm management information was collected using an interview questionnaire, and herd size and cattle movements were obtained from the cattle tuberculosis testing database and the British Cattle Movement Service. Hierarchical statistical models were used to investigate associations between cattle and herd variables and the continuous outcome percentage positive (PP) values from the ELISA test in unvaccinated herds., Results: There were 7 vaccinated herds, all with at least one seropositive bovine. In unvaccinated herds 83.2% had at least one BHV-1 seropositive bovine, and the mean cattle and herd BHV-1 seroprevalence were 42.5% and 43.1% respectively. There were positive associations between PP value, age, herd size, presence of dairy cattle. Adult cattle in herds with grower cattle had lower PP values than those in herds without grower cattle. Purchased cattle had significantly lower PP values than homebred cattle, whereas cattle in herds that were totally restocked after the foot-and-mouth epidemic in 2001 had significantly higher PP values than those in continuously stocked herds. Samples taken in spring and summer had significantly lower PP values than those taken in winter, whereas those taken in autumn had significantly higher PP values than those taken in winter. The risks estimated from a logistic regression model with a binary outcome (seropositive yes/no) were similar., Conclusion: The prevalence of BHV-1 seropositivity in cattle and herds has increased since the 1970s. Although the study population prevalence of BHV-1 was temporally stable during study period, the associations between serological status and cattle age, herd size, herd type, presence of young stock and restocked versus continuously stocked herds indicate that there is heterogeneity between herds and so potential for further spread of BHV-1 within and between herds.