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Aims: To compare the acceptability, reliability and validity of five contemporary diabetes-specific quality of life (QoL) scales. Methods: Adults with type 1 diabetes in the UK (N=1139) and Australia (N=439) completed a cross-sectional, online survey including: ADDQoL, DCP, DIDP, DSQoLS and QoL-Q diabetes (scales randomised to control for order effects). Participants rated each scale for clarity, relevance, ease of completion, length, and comprehensiveness. Scales were compared in terms of acceptability, response patterns, structure, reliability and validity. To assess cross-country reproducibility, analyses conducted on the UK sample were replicated in the Australian sample. Results: Findings (summarized in Table 1) were largely consistent between countries. The strongest scale overall was the DIDP, a brief (7-item), neutrally-worded scale with balanced response options. ADDQoL and QoL-Q diabetes also performed well across most criteria. Conclusions: This is the first empirical study to compare the user acceptability and psychometric properties of five contemporary diabetes-specific QoL scales. These findings may inform assessment of diabetes-specific QoL in routine care and clinical trials, but should be considered in the context of published evidence of the development and responsiveness of the scales. Disclosure J. Speight: Research Support; Self; AstraZeneca, Medtronic, Sanofi. Speaker's Bureau; Self; Novo Nordisk A/S, Roche Diabetes Care. E. Holmes-Truscott: Research Support; Self; Sanofi. Speaker's Bureau; Self; Novo Nordisk Inc. C. Hendrieckx: None. E. Coates: None. S.R. Heller: Advisory Panel; Self; Eli Lilly and Company, Novo Nordisk A/S, Sanofi-Aventis, Takeda Pharmaceutical Company Limited, Zealand Pharma A/S. Consultant; Self; Novo Nordisk A/S. Speaker's Bureau; Self; Eli Lilly and Company, Novo Nordisk A/S. D. Cooke: None. Funding UK National Institute for Health Research (RP-PG-0514-20013 to S.R.H.)

Background\ud \ud Adequate reporting of adaptive designs (ADs) maximises their potential benefits in the conduct of clinical trials. Transparent reporting can help address some obstacles and concerns relating to the use of ADs. Currently, there are deficiencies in the reporting of AD trials. To overcome this, we have developed a consensus-driven extension to the CONSORT statement for randomised trials using an AD. This paper describes the processes and methods used to develop this extension rather than detailed explanation of the guideline.\ud \ud \ud Methods\ud \ud We developed the guideline in seven overlapping stages:1)\ud \ud Building on prior research to inform the need for a guideline;\ud \ud \ud \ud 2)\ud \ud A scoping literature review to inform future stages;\ud \ud \ud \ud 3)\ud \ud Drafting the first checklist version involving an External Expert Panel;\ud \ud \ud \ud 4)\ud \ud A two-round Delphi process involving international, multidisciplinary, and cross-sector key stakeholders;\ud \ud \ud \ud 5)\ud \ud A consensus meeting to advise which reporting items to retain through voting, and to discuss the structure of what to include in the supporting explanation and elaboration (E&E) document;\ud \ud \ud \ud 6)\ud \ud Refining and finalising the checklist; and\ud \ud \ud \ud 7)\ud \ud Writing-up and dissemination of the E&E document.\ud \ud \ud \ud \ud The CONSORT Executive Group oversaw the entire development process.\ud \ud \ud Results\ud \ud Delphi survey response rates were 94/143 (66%), 114/156 (73%), and 79/143 (55%) in rounds 1, 2, and across both rounds, respectively. Twenty-seven delegates from Europe, the USA, and Asia attended the consensus meeting. The main checklist has seven new and nine modified items and six unchanged items with expanded E&E text to clarify further considerations for ADs. The abstract checklist has one new and one modified item together with an unchanged item with expanded E&E text. The E&E document will describe the scope of the guideline, the definition of an AD, and some types of ADs and trial adaptations and explain each reporting item in detail including case studies.\ud \ud \ud Conclusions\ud \ud We hope that making the development processes, methods, and all supporting information that aided decision-making transparent will enhance the acceptability and quick uptake of the guideline. This will also help other groups when developing similar CONSORT extensions. The guideline is applicable to all randomised trials with an AD and contains minimum reporting requirements.

Motor neuron disease (MND), also known as amyotrophic lateral sclerosis, is a neurodegenerative disorder that causes progressive muscle paralysis and typically leads to death within 3 years. As no cure is currently available, symptomatic management is the mainstay of treatment. An important part of this is optimizing nutritional intake with evidence that this may positively affect survival and quality of life. Health care professionals (HCPs) play a pivotal role in nutritional management of people with MND (pwMND) but, to date, their views on the psychological barriers faced by pwMND have not been explored. Such an exploration may identify ways in which the delivery of nutritional care for pwMND can be optimized.Five qualitative focus groups were carried out across the United Kingdom in June 2018 with 51 participants, including 47 HCPs involved with MND care and four service user representatives. Data were analysed through thematic analysis.Four overarching themes were identified: psychological adjustment and patient engagement; nutrition and the need for control; knowledge of nutrition and the complexity of MND; and the psychosocial nature of eating.The findings suggest that the nutritional management of pwMND should be mindful of factors such as the impact of distress at the time of diagnosis, the availability of clear information on nutrition and MND, as well as the importance of illness perceptions and coping strategies. Moreover, tailored psychological interventions should be considered to mitigate the impact on MND on the experience of eating. Statement of contribution What is already known on this subject? Since weight loss and reduced body mass index (BMI) have been identified as independent risk factors for prognosis and survival in motor neuron disease (MND), nutritional management represents an important component of the symptomatic care of people with MND (pwMND) aimed at prolonging survival and maintaining or improving quality of life. However, the current guidelines and quantitative and qualitative literature on the topic are mainly focused on issues around enteral feeding and gastrostomy insertion, and very little is currently known about potential psychological enablers or barriers to earlier nutritional management, especially from the perspectives of health care professionals (HCPs) involved in the delivery of nutritional care in pwMND. What does this study add? First qualitative investigation of enablers or barriers to nutritional care in pwMND from the perspective of HCPs. New insight into psychological factors (e.g., adjustment, avoidance, loss of control) in nutritional care for pwMND. Practical implications and novel clinical suggestions for HCPs involved in nutritional care of pwMND.

Background The optimum treatment for steroid resistant ulcerative colitis (SRUC) is not clear and a range of options can be considered. The aim of this study was to quantify the relative importance of different treatment characteristics to clinicians and understand their preferences for benefit-risk trade-offs. Methods A discrete choice experiment (DCE) was conducted in the UK via online survey of clinicians with expertise in inflammatory bowel disease. This involved 12 tasks where respondents selected a preferred treatment option when presented with two competing, hypothetical treatment profiles for a SRUC scenario. Profiles described five treatment characteristics focusing on clinical outcomes and safety, identified from qualitative interviews with clinicians and evidence from systematic reviews. DCE responses were analysed using conditional logistic regressions. Regression coefficients were used to calculate benefit-risk trade-offs, to find the rate at which clinicians are willing to trade levels of risks in exchange for the preferred levels of clinical outcomes. Regression coefficients were also used to predict uptake rates for selected drugs currently prescribed to patients with SRUC. Results 116 clinicians completed the survey (age 46y; female 42%; consultant 60%; nurse 26%; mean experience 11y). Figure 1 shows the treatment characteristics that make respondents more likely (positive coefficient) or less likely (negative coefficient) to choose a treatment. One unit increase in both lymphoma risk and serious infection risk were strongly considered when clinicians were choosing a treatment compared to one unit increase in the symptom improvement characteristics. Clinicians would accept a higher lymphoma risk of 5 per 10,000 patient years for a 10% improvement in remission rate compared to 4 and 2 cases per 10,000 patient years for 10% better rates of clinical response and mucosal healing respectively. Clinicians at secondary hospitals accepted a lymphoma risk of 4 cases per 10,000 patient years for a 10% improvement in remission vs 7 per 10,000 patient years at tertiary centres. Similar trade-off results were found for serious infection risks. Predicted uptake comparing preferred characteristics to existing treatments was infliximab (62%), tofacitinib (18%), vedolizumab (15%) and adalimumab (5%). Conclusion Clinicians are willing to make difficult trade-offs and tolerate elevated safety risks in exchange for therapeutic benefits. Risk tolerance was highest if the treatment improved long term remission rate, lowest for mucosal healing and higher in clinicians at tertiary centres. The results help to better understand treatment decisions and identify outcomes that might be considered in choosing agents to evaluate in clinical trials.

OBJECTIVE Home telehealth can provide considerable benefits to people diagnosed with chronic obstructive pulmonary disease, yet 20% of patients abandon telehealth. Identifying the factors that affect whether or not a patient decides to continue using telehealth is therefore crucial to the goal of mainstreaming telehealth. However, studies to date have only assessed the perceptions of patients who are not currently using telehealth, have used telehealth in experimental sessions, or are enrolled in a trial. The aim of the present study was to explore the beliefs and perceptions of patients with chronic obstructive pulmonary disease currently using home telehealth and who are not enrolled in a trial. METHOD Semistructured interviews were conducted with 8 patients with chronic obstructive pulmonary disease. Interviews were analyzed using interpretative phenomenological analysis. RESULTS Four superordinate themes are presented: (a) perceiving benefits of "being watched over" as providing peace of mind, (b) learning about the health condition and the impacts on self-management behavior, (c) active engagement in health service provision and better access to health care, and (d) valuing the importance of in-person care. CONCLUSIONS Users generally describe home telehealth in positive terms; however, patients still value face-to-face contact with health care professionals. The positive aspects of home telehealth, such as better access to health care and providing peace of mind, could be communicated to prospective users to improve uptake. Similarly, sustained use of telehealth is likely to be ensured if occasional visits from health care professionals are maintained.

Adaptive designs (ADs) allow pre-planned changes to an ongoing trial without compromising the validity of conclusions and it is essential to distinguish pre-planned from unplanned changes that may also occur. The reporting of ADs in randomised trials is inconsistent and needs improving. Incompletely reported AD randomised trials are difficult to reproduce and are hard to interpret and synthesise. This consequently hampers their ability to inform practice as well as future research and contributes to research waste. Better transparency and adequate reporting will enable the potential benefits of ADs to be realised.This extension to the Consolidated Standards Of Reporting Trials (CONSORT) 2010 statement was developed to enhance the reporting of randomised AD clinical trials. We developed an Adaptive designs CONSORT Extension (ACE) guideline through a two-stage Delphi process with input from multidisciplinary key stakeholders in clinical trials research in the public and private sectors from 21 countries, followed by a consensus meeting. Members of the CONSORT Group were involved during the development process.The paper presents the ACE checklists for AD randomised trial reports and abstracts, as well as an explanation with examples to aid the application of the guideline. The ACE checklist comprises seven new items, nine modified items, six unchanged items for which additional explanatory text clarifies further considerations for ADs, and 20 unchanged items not requiring further explanatory text. The ACE abstract checklist has one new item, one modified item, one unchanged item with additional explanatory text for ADs, and 15 unchanged items not requiring further explanatory text.The intention is to enhance transparency and improve reporting of AD randomised trials to improve the interpretability of their results and reproducibility of their methods, results and inference. We also hope indirectly to facilitate the much-needed knowledge transfer of innovative trial designs to maximise their potential benefits. In order to encourage its wide dissemination this article is freely accessible on the BMJ and Trials journal websites.“To maximise the benefit to society, you need to not just do research but do it well” Douglas G Altman

Background Randomised controlled trials (RCTs) of complex interventions often begin with a pilot phase to test the proposed methods and refine the intervention before it is trialled. Although the Medical Research Council (MRC) recommends regular communication between the practitioners delivering the intervention and the researchers evaluating it during the pilot phase, there is a lack of practical guidance about how to undertake this aspect of pre-trial work. This paper describes a novel structured process for collaborative working, which we developed to iteratively refine a complex intervention prior to an RCT. We also describe an in-built qualitative study to learn lessons about how this approach could be used by future study teams. Methods This work forms part of a broader research programme to develop and trial a complex intervention for people with type 1 diabetes, called DAFNEplus. The intervention is being piloted in three National Health Service (NHS) diabetes centres in two waves, with refinements being incrementally implemented between each wave in response to real-time, collective learning (combining practitioner experience, process evaluation data and patient and public involvement via an advisory group). A structured ‘Collaborative Working Group’ (CWG) process, comprising monthly teleconferences and four strategically timed face-to-face meetings, is being used to identify and respond systematically to emerging implementation challenges and research findings. The group involves 25 members of the study team, including the multi-disciplinary practitioners delivering the intervention, the research teams conducting the process evaluation, the study manager and Chief Investigator. An in-built qualitative study comprising documentary analysis of meeting materials, discourse analysis of meeting transcripts, reflexive note taking, and thematic analysis of focus groups and interviews with CWG members is being undertaken to explore how the CWG works and how its processes and procedures might be improved. Discussion The CWG process offers a potential model for collaborative working in future pre-trial pilot phases and intervention development studies that operationalises MRC guidance to progressively develop a complex intervention and foster shared ownership through genuine collaboration. The findings from the qualitative study will provide insight into how to best support collaborative working to achieve optimal intervention design.

This paper sets out to explore the thinking underpinning young children’s earliest drawings, often regarded as ‘scribbling.’ It questions whether the physical satisfaction of making marks is sufficient reward for this often repeated activity, or whether with each repetition children intend deeper meanings not apparent to the eyes of the adult beholder. The narrative, which frequently accompanies such drawings, indicates that far from being merely a mark-making activity, the scribbled work represents for children a means of communicating a story or an experience. Examination of the dual activity of drawing and talking forms the basis of a research study which highlights the contribution that observation can make towards our understanding of young children’s learning.

BACKGROUND: Interventions designed to help Emergency Department (ED) staff manage frequent attenders are labour-intensive and only benefit a small sample of frequent attenders. We aimed to use the in-depth knowledge of health professionals with experience of working with ED frequent attenders to understand the challenges of managing this group of patients and their opinions on providing more appropriate support. \ud \ud METHODS: Semi-structured interviews were conducted with medical and nursing ED staff, mental health liaison nurses and general practitioners (GPs). Interviews covered the following: definitions and experiences of treating frequent attenders and thoughts on alternative service provision. Vignettes of frequent attenders were used to elicit discussions on these topics. Thematic analysis of transcribed interviews was undertaken. \ud \ud RESULTS: Twelve health professionals were interviewed. Three groups of frequent attenders were identified: people with long-term physical conditions, mental health problems and health-related anxiety. Underlying reasons for attendance differed between the groups, highlighting the need for targeted interventions. Suggested interventions included improving self-management of long-term physical conditions; creating a 'go-to' place away from the ED for patients experiencing a mental health crisis; increasing the provision of mental health liaison services; and for patients with health-related anxiety, the role of the GP in the patients' care pathway was emphasised, as were the benefits of providing additional training for ED staff to help identify and support this group. \ud \ud CONCLUSION: Interventions to address frequent attendance should focus on redirection to and liaison with more appropriate services, located on the hospital site or in the community, tailored to each identified patient group.

IntroductionSocial skills training interventions for children with autism spectrum disorder (ASD) typically focus on a skills deficit model rather than building on existing skills or encouraging the child to seek their own solutions. LEGO-based therapy is a child-oriented intervention to help improve social interactional skills and reduce isolation. The therapy is designed for school-age children with ASD and uses group-based play in a school setting to encourage peer relationships and social learning. Despite the reported potential benefits of LEGO-based therapy in a prior randomised controlled trial (RCT) and its adoption by many schools, the evidence to support its effectiveness on the social and emotional well-being of children with ASD is limited and includes no assessment of cost-effectiveness.Methods and analysisThis multicentre, pragmatic, cluster RCT will randomise 240 participants (aged 7–15 years) with a clinical diagnosis of ASD to receive usual care or LEGO-based therapy with usual care. Cluster randomisation will be conducted on a school level, randomising each school as opposed to each individual child within a school. All prospective participants will be screened for eligibility before assenting to the study (with parents giving informed consent on behalf of their child). All participants will be followed up at 20 and 52 weeks after randomisation to assess for social, emotional and behavioural changes. The primary outcome measure is the social skills subscale of the Social Skills Improvement System completed by a teacher or teaching assistant associated with participating children at the 20-week follow-up time point.Ethics and disseminationEthics approval has been obtained via the University of York Research Ethics Committee. The results of the trial will be submitted for publication in a peer-reviewed journal and will be disseminated to participating families, education practitioners and the third sector including voluntary and community organisations.Trial registration numberISRCTN64852382; Pre-results.

The article presents an introduction to the special September 2013 issue of "International Journal of Early Years Education" addressing research on topics including the impact of Apartheid on education in South Africa, numbers of kindergartens in China, and school readiness.

This article offers a chronological account and critical appraisal of changes to early childhood education and care (ECEC) services in England over the past 20 years. It describes the policy initiatives, educational interventions and research programmes introduced by successive governments that have effected significant changes to ECEC since 1990. The article covers four key areas: policies designed to reduce social inequality; the professionalisation of the children's workforce and changing status of adults employed in preschool education and care settings; changes to early years pedagogy and the early years curriculum and finally how major research programmes such as the Effective Provision of Preschool Education project and the Millennium Cohort Study have informed our understanding of the effects of social disadvantage and the characteristics of ‘high-quality’ preschool provision that can alleviate this. There is now persuasive evidence that investment in state-maintained early education is highly cos...

Background There is currently insufficient evidence for the clinical and cost-effectiveness of psychological therapies for treating post-stroke depression. Methods/Design BEADS is a parallel group feasibility multicentre randomised controlled trial with nested qualitative research and economic evaluation. The aim is to evaluate the feasibility of undertaking a full trial comparing behavioural activation (BA) to usual stroke care for 4 months for patients with post-stroke depression. We aim to recruit 72 patients with post-stroke depression over 12 months at three centres, with patients identified from the National Health Service (NHS) community and acute services and from the voluntary sector. They will be randomly allocated to receive behavioural activation in addition to usual care or usual care alone. Outcomes will be measured at 6 months after randomisation for both participants and their carers, to determine their effectiveness. The primary clinical outcome measure for the full trial will be the Patient Health Questionnaire-9 (PHQ-9). Rates of consent, recruitment and follow-up by centre and randomised group will be reported. The acceptability of the intervention to patients, their carers and therapists will also be assessed using qualitative interviews. The economic evaluation will be undertaken from the National Health Service and personal social service perspective, with a supplementary analysis from the societal perspective. A value of information analysis will be completed to identify the areas in which future research will be most valuable. Discussion The feasibility outcomes from this trial will provide the data needed to inform the design of a definitive multicentre randomised controlled trial evaluating the clinical and cost-effectiveness of behavioural activation for treating post-stroke depression. Trial registration Current controlled trials ISRCTN12715175

The British Psychoanalytic Society (BPAS) is identified with the tradition of psychoanalysis five times a week. The paper discusses the history and evolution of this tradition in the BPAS and how this has been and continues to be supported by various institutional structures including training regulations and subsidies. More recent questioning about frequency is discussed as well as the factors both external and internal that make high frequency analytic work difficult to achieve. Clinical material and illustrations form the basis for discussion of some of the issues involved.

The initial inspiration to develop a special issue of the International Journal of Early Years Education focusing on Creativity and Cultural Innovation in Early Childhood Education came from a symp...

Research related to how young children’s drawings change and develop is well documented and an extensive literature on this area can be traced back to the nineteenth century. Most of this literature, however, focuses on developmental aspects and largely fails to explore what would seem to be an essential ingredient in each drawing’s production—children’s simultaneous utterances which might potentially inform the nature and content of the work and help elucidate their intentions and processes of thinking. In this respect, Kress (1997) suggests that at times it seems as though it is only the end product being interpreted, whilst utterances which could help understanding are ignored; and Jameson (1968) opines that what children want to do is to talk to themselves in pictures, thereby weaving stories around the marks being made as a parallel to active fantasy play. These may or may not be true, but although the end products are something tangible which can be viewed by other than those present, what they cann...

AD101 and SCH-C are two chemically related small molecules that inhibit the entry of human immunodeficiency virus type 1 (HIV-1) via human CCR5. AD101 also inhibits HIV-1 entry via rhesus macaque CCR5, but SCH-C does not. Among the eight residues that differ between the human and macaque versions of the coreceptor, only one, methionine-198, accounts for the insensitivity of macaque CCR5 to inhibition by SCH-C. Thus, the macaque coreceptor engineered to contain the natural human CCR5 residue (isoleucine) at position 198 is sensitive to HIV-1 entry inhibition by SCH-C, whereas a human CCR5 mutant containing the corresponding macaque residue (methionine) is resistant. Position 198 is in CCR5 transmembrane (TM) helix 5 and is not located within the previously defined binding site for AD101 and SCH-C, which involves residues in TM helices 1, 2, 3, and 7. SCH-C binds to human CCR5 whether residue 198 is isoleucine or methionine, and it also binds to macaque CCR5. However, the binding of a conformation-dependent monoclonal antibody to human CCR5 is inhibited by SCH-C only when residue 198 is isoleucine. These observations, taken together, suggest that the antiviral effects of SCH-C and AD101 involve stabilization, or induction, of a CCR5 conformation that is not compatible with HIV-1 infection. However, SCH-C is unable to exert this effect on CCR5 conformation when residue 198 is methionine. The region of CCR5 near residue 198 has, therefore, an important influence on the conformational state of this receptor.

What stories do young children's drawings contain? So often children's free drawings are not held in high regard but are seen as an activity which is undertaken outside lesson time or as an illustration to some prescribed task. However, the concentration and care with which some children undertake a drawing suggests that the content has real significance and has not been undertaken lightly. This small-scale study arose from observations in a school setting of young children talking to themselves as they drew pictures. Often it seemed that this talk was a rehearsal for the drawing and it was this link that the project set out to explore. Children aged from 3 to 7 years were studied in their classrooms where they were participating in a free choice of activities. This paper examines the drawings collected together with transcriptions of the children's descriptions of their drawings. It looks at the symbolism contained within the pictures and the stories woven within each one. The study is intended as a pilo...

Introduction: Telehealth and other technology enabled care services are increasingly aligned with\ud policies promoting self-care and independence in older age, yet there is little evidence that\ud telehealth actually increases self-care behaviour. In fact, emerging evidence suggests that people\ud with long-term health conditions can become fixated on monitoring their health, and dependent on\ud the contact with healthcare staff that telehealth facilitates.\ud Aim: This paper examines the role of telehealth in promoting self-care among people with a longterm\ud health condition. This study is part of a wider research programme, MALT (Overcoming the\ud Barriers to Mainstreaming Assisted Living Technologies), which aims to identify the barriers to and\ud facilitators of delivering telehealth at scale.\ud Methods: Thematic analysis of semi-structured qualitative interviews with 40 older people (12\ud carers contributing), who were using telehealth as part of their condition management. All\ud participants had a diagnosis of chronic obstructive pulmonary disease (COPD) or chronic heart\ud failure (CHF), and had accessed telehealth via a community nurse. Interview data were analysed\ud for emerging themes as well as a priori themes drawn from existing research and conceptual\ud literature about self-care.\ud Results: Managing telehealth in the home was a key theme within the data, with patients adapting\ud their routines and environment to undertake the tasks of monitoring, following up technical issues\ud with equipment, and working in partnership with their nurse in responding to telehealth alerts. The\ud study also found evidence of more informed decision-making among patients as a result of closely\ud monitoring their symptoms with telehealth, which helped to facilitate an increased understanding of\ud their condition, including how to identify and respond to triggers and exacerbations. As a result,\ud patients reported greater confidence in their ability to manage their condition. However, confidence\ud was also derived from the reassurance of knowing that their nurse would respond to a worsening of their symptoms regardless of their own actions. In fact, for many patients, telehealth and the\ud community nurse were viewed as a single entity, and being able to depend on their nurse for\ud support was identified as a key benefit of using telehealth.\ud Conclusions: Telehealth promotes self-care and at the same time encourages dependence. This\ud model of supported self-care was welcomed by people with COPD and CHF, many of whom found\ud it an on-going challenge to be able to predict and detect potential exacerbations and deterioration.\ud Having access to a system that enables people, with the support of a healthcare professional, to\ud better manage the unpredictable nature of their health condition and prevent avoidable hospital\ud admissions as a result, is therefore an important and valued component of long-term condition\ud management.

Aims:\ud To examine frontline staff acceptance of telehealth and identify barriers to and enablers of successful adoption of remote monitoring for patients with Chronic Obstructive Pulmonary Disease and Chronic Heart Failure.\ud \ud Background:\ud The use of telehealth in the UK has not developed at the pace and scale anticipated by policy. Many existing studies report frontline staff acceptance as a key barrier, however data are limited and there is little evidence of the adoption of telehealth in routine practice.\ud \ud Design:\ud Case studies of four community health services in England that use telehealth to monitor patients with Chronic Obstructive Pulmonary Disease and Chronic Heart Failure.\ud \ud Methods:\ud Thematic analysis of qualitative interviews with 84 nursing and other frontline staff; and 21 managers and key stakeholders; data collected May 2012–June 2013.\ud \ud Findings:\ud Staff attitudes ranged from resistance to enthusiasm, with varied opinions about the motives for investing in telehealth and the potential impact on nursing roles. Having reliable and flexible technology and dedicated resources for telehealth work were identified as essential in helping to overcome early barriers to acceptance, along with appropriate staff training and a partnership approach to implementation. Early successes were also important, encouraging staff to use telehealth and facilitating clinical learning and increased adoption.\ud \ud Conclusions:\ud The mainstreaming of telehealth hinges on clinical ‘buy‐in’. Where barriers to successful implementation exist, clinicians can lose faith in using technology to perform tasks traditionally delivered in person. Addressing barriers is therefore crucial if clinicians are to adopt telehealth into routine practice.

Introduction: Telehealth can provide considerable benefits to chronic heart failure (CHF) and chronic obstructive pulmonary disease (COPD) patients. The present study is part of the MALT (Mainstreaming Assisted Living Technologies) project, which is aiming to unlock the major obstacles to mainstreaming Assisted Living Technologies into health and social care services. One of these obstacles is patients refusing to accept telehealth or abandoning its use. Aims: To explore CHF and COPD patients’ beliefs and perceptions regarding telehealth. This paper will identify the barriers and facilitators patients face when deciding to adopt telehealth and the factors that influence sustained use of telehealth. Methods: Semi-structured interviews were conducted with 27 CHF and/or COPD patients (14 females: age range = 53 to 87, mean = 71 years), who had previously been offered and accepted telehealth. Patients had been using telehealth from five months up to three years. All interviews were transcribed verbatim and analysed using interpretative phenomenological analysis. Results: There were few differences in the beliefs and perceptions about telehealth reported by CHF patients, as compared to COPD patients. Patients were positive about telehealth and found it straightforward and simple, even if they had little experience of using other technological devices. Having somebody regularly checking their readings meant that telehealth gave most patients peace of mind over their health. Patients also reported that telehealth increased their access to healthcare, and they reported fewer hospital admissions as a result of healthcare professionals being able to review the results of self-testing immediately. Patients also expressed improvements in their self-management, due to having a greater responsibility for their own health. However, short-term users of telehealth tended to report less improvement in self-management, as compared to long-term users. Despite these positive aspects of telehealth, patients also reported that telehealth was impersonal and that it could never completely replace face-to-face-visits from a healthcare professional. Technical problems, including faulty equipment, inaccurate readings, and delayed data transmission were the main frustrations expressed by patients, although these were not regarded as a barrier as much as a temporary inconvenience. International Congress on Telehealth and Telecare 2013, London, July 01-03, 2013. 2 International Journal of Integrated Care –Volume 13, 20 November –URN:NBN:NL:UI:10-1-115683– http://www.ijic.org/ Conclusions: Users of telehealth are unsurprisingly positive about it and communicating the benefits of “peace of mind” and “increased healthcare” to patients who are unsure whether to take it up might be useful. Similarly, ensuring swift technical support is likely to facilitate sustained use. By facilitating long-term use of telehealth, patients could possibly receive additional benefits, which may not emerge from short-term use only. However, caution should be adopted when interpreting the results, as the research focuses only on current users of telehealth. The findings can now assist in the design of a tool to tailor service recruitment processes.

How should we understand children's creativity? This fascinating collection of international research offers fresh perspectives on children's creative processes and the expression of their creative imagination through dramatic play, stories, artwork, dance, music and conversation. Drawing on a range of research evidence from innovative educational initiatives in a wide variety of countries, Exploring Children's Creative Narratives develops new theoretical and practical insights that challenge traditional thinking about children's creativity. The chapters, written by well-respected international contributors: offer new conceptual and interpretive frameworks for understanding children's creativity contest conventional discourses about the origins and nature of creativity challenge the view that young children's creativity can only be judged in terms of their creative output explore the significance children themselves attribute to their creative activity argue the need for a radical reappraisal of the influence of the sociocultural context on children's creative expression discuss the implications of this research in relation to teacher education and curriculum design. This broad yet coherent compilation of research on creativity in childhood is essential reading for students, researchers and policy makers in early childhood as well as for Early Years professionals with a particular interest in creativity.

This paper sets out to examine the value of talk in the making, understanding and appreciation of Art at Key Stage One of the National Curriculum. First‐hand experience of both artworks and natural and made objects is important to young children's aesthetic awareness and understanding but it also offers a means of developing a spoken and written vocabulary to describe and classify them. The spirit of co‐operation which seems to develop through exploration of objects provides opportunities for talk‐‐helping children to understand more clearly what they are doing and extending their powers of imagination, reasoning and problem‐solving. The use of works produced by artists, both originals and in reproduction, stimulates discussion as the children compare their attempts with the artists’ representations.

This article gives an account of an experience of group work with parents and carers who had children or adolescents with gender identity disorder (GID). The history of this intervention within the context of a service for children with gender identity problems is outlined. The limited literature on the subject is reviewed. Group meetings were held monthly for 6 months, facilitated by two therapists (the authors). Selection criteria for group participants, the aims of the group and the methodology for achieving those aims are described. Some information about the group's composition is provided. The structure and content of the group sessions are outlined together with details of some group interactions. Finally, we present the results of an evaluation of the intervention through feedback questionnaires and discuss the value for the children and young people of running such groups.

The histamine H4 receptor is a novel G-protein-coupled receptor with a unique pharmacological profile. The distribution of H4 mRNA suggests that it may play a role in the regulation of immune function, particularly with respect to allergy and asthma. To define the histamine-binding site of this receptor, molecular modeling and site-directed mutagenesis were used to predict and alter amino acids residing in the histamine-binding pocket. The effects of these alterations on histamine binding and receptor activation were then assessed. Our results indicate that Asp94 (3.32) in transmembrane region (TM) 3 and Glu182 (5.46) in TM5 are critically involved in histamine binding. Asp94 probably serves as a counter-anion to the cationic amino group of histamine, whereas Glu182 (5.46) interacts with the N(tau) nitrogen atom of the histamine imidazole ring via an ion pair. In contrast, Thr178 (5.42) and Ser179 (5.43) in TM5 are not significantly involved in either histamine binding or receptor activation. These results resemble those for the analogous residues in the H1 histamine receptor but contrast with findings regarding the H2 histamine receptor. Our results also demonstrate that Asn147 (4.57) in TM4 and Ser320 (6.52) in TM6 play a role in receptor activation but are not involved in histamine binding. Taken together, these data indicate that although histamine seems to bind to the H4 receptor in a fashion similar to that predicted for the other histamine receptor subtypes, there are also important differences that can probably be exploited for the discovery of novel H4-selective compounds.

Enterococcus faecium strain 9631355 was isolated from animal sources on the basis of its resistance to the growth promotant avilamycin. The strain also exhibited high-level resistance to evernimicin, a drug undergoing evaluation as a therapeutic agent in humans. Ribosomes from strain 9631355 exhibited a dramatic reduction in evernimicin binding, shown by both cell-free translation assays and direct-binding assays. The resistance determinant was cloned from strain 9631355; sequence alignments suggested it was a methyltransferase and therefore it was designated emtA for evernimicin methyltransferase. Evernimicin resistance was transmissible and emtA was localized to a plasmid-borne insertion element. Purified EmtA methylated 50S subunits from an evernimicin-sensitive strain 30-fold more efficiently than those from a resistant strain. Reverse transcription identified a pause site that was unique to the 23S rRNA extracted from resistant ribosomes. The pause corresponded to methylation of residue G2470 (Escherichia coli numbering). RNA footprinting revealed that G2470 is located within the evernimicin-binding site on the ribosome, thus providing an explanation for the reduced binding of the drug to methylated ribosomes.