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PG 1448+273 is a luminous, nearby ( z = 0.0645), narrow-line Seyfert 1 galaxy, which likely accretes close to the Eddington limit. XMM-Newton observations of PG 1448+273 in 2017 revealed the presence of an ultrafast outflow, as seen through its blueshifted iron K absorption profile, with an outflow velocity of about 0.1 c . Here, the first NuSTAR observation of PG 1448+273, performed in 2022 and coordinated with XMM-Newton, is presented, which shows remarkable variability of its ultrafast outflow. The average count rate is a factor of 2 lower during the last 60 ks of the NuSTAR observation, where a much faster component of the ultrafast outflow was detected with a terminal velocity of 0.26 ± 0.04 c . This is significantly faster than the outflow component that was initially detected in 2017, when overall PG 1448+273 was observed at a lower X-ray flux, and which implies an order of magnitude increase in the wind kinetic power between the 2017 and 2022 epochs. Furthermore, the rapid variability of the ultrafast outflow in 2022, on timescales down to 10 ks, suggests we are viewing through a highly inhomogeneous disk wind in PG 1448+273, where the passage of a denser wind clump could account for the increase in obscuration in the last 60 ks of the NuSTAR observation.

Objectives As awareness of bipolar disorder (BD) increases and the world experiences a rapid ageing of the population, the number of people living with BD in later life is expected to rise substantially. There is no current evidence base for the effectiveness of psychological interventions for older adults with BD. This focus group study explored a number of topics to inform the development and delivery of a recovery-focused therapy (RfT) for older adults with BD.Design A qualitative focus group study.Setting Three focus groups were conducted at a university in the North West of England.Participants Eight people took part in the focus groups; six older adults with BD, one carer and one friend.Results Participant’s responses clustered into six themes: (1) health-related and age-related changes in later life, (2) the experience of BD in later life, (3) managing and coping with BD in later life, (4) recovery in later life, (5) seeking helping in the future and (6) adapting RfT for older people.Conclusions Participants reported a range of health-related and age-related changes and strategies to manage their BD. Participants held mixed views about using the term ‘recovery’ in later life. Participants were in agreement that certain adaptations were needed for delivering RfT for older adults, based on their experience of living with BD in later life. The data collected as part of the focus groups have led to a number of recommendations for delivering RfT for older adults with BD in a randomised controlled trial (Clinical Trial Registration: ISRCTN13875321).

We describe a research-based mentoring program for new full-time faculty at a small residential college, which emphasizes the empowerment of the new faculty themselves to identify and obtain the resources they need for success. In our model, the mentor takes on a role of primarily providing accountability, easing the burden on mentors, thereby making for a more sustainable program. Our mixed methods assessment of the program suggests that, paradoxically, these lessened expectations foster closer personal relationships between mentor and protégé than might have occurred if that were a programmatic expectation.

Background: Recovery focused therapy has been shown to improve recovery outcomes in individuals with recent onset bipolar disorder. However the process by which this is achieved is unclear. This paper therefore examines potential mediators of this effect using data from a randomised controlled trial comparing recovery focused therapy with treatment as usual (ISRCTN43062149). Methods: A single-blind randomised controlled trial compared treatment as usual (TAU) with recovery-focused therapy (RfT) plus TAU (n = 67) in participants diagnosed with bipolar disorder with onset within 5 years. Impact of treatment at six and twelve months post baseline on potential mediators (mood appraisal, growth and self-concept) for changes in personal recovery, social functioning and quality of life outcomes were first assessed. Mediation effects were evaluated on each outcome for mediators significantly impacted by treatment. Results: RfT had a significant impact on positive self-appraisal and stigma at 12 months and self-esteem and post-trauma growth at six months. Both self-esteem and post-trauma growth significantly mediated the effect of RfT on personal recovery at six months follow-up. Limitations: This is a relatively small study which was not originally powered to test for exploratory mediation effects. Conclusions: Improvements in personal recovery following RfT are linked to improvements in personal growth and self-esteem. This mediation relationship was not apparent for functioning or quality of life.

Objective To explore the attitudes towards implantable cardioverter defibrillator (ICD) deactivation and initiation of deactivation discussions among patients, relatives and clinicians.Design A multiphase qualitative study consisting of in situ hospital ICD clinic observations, and semistructured interviews of clinicians, patients and relatives. Data were analysed using a constant comparative approach.Setting One tertiary and two district general hospitals in England.Participants We completed 38 observations of hospital consultations prior to ICD implantation, and 80 interviews with patients, family members and clinicians between 2013 and 2015. Patients were recruited from preimplantation to postdeactivation. Clinicians included cardiologists, cardiac physiologists, heart failure nurses and palliative care professionals.Results Four key themes were identified from the data: the current status of deactivation discussions; patients’ perceptions of deactivation; who should take responsibility for deactivation discussions and decisions; and timing of deactivation discussions. We found that although patients and doctors recognised the importance of advance care planning, including ICD deactivation at an early stage in the patient journey, this was often not reflected in practice. The most appropriate clinician to take the lead was thought to be dependent on the context, but could include any appropriately trained member of the healthcare team. It was suggested that deactivation should be raised preimplantation and regularly reviewed. Identification of trigger points postimplantation for deactivation discussions may help ensure that these are timely and inappropriate shocks are avoided.Conclusions There is a need for early, ongoing and evolving discussion between ICD recipients and clinicians regarding the eventual need for ICD deactivation. The most appropriate clinician to instigate deactivation discussions is likely to vary between patients and models of care. Reminders at key trigger points, and routine discussion of deactivation at implantation and during advance care planning could prevent distressing experiences for both the patient and their family at the end of life.

This article looks at the different approaches which have been taken in the study of legal history in England and America by both historians in law and history faculties. The pioneer English legal historian was F.W. Maitland, who felt that the skills of the lawyer were needed to understand the legal materials which were the source of much medieval social and economic history. Maitland, who had no wish to use history to explain current doctrine, inspired a generation of medieval historians to look at legal questions. The study of legal history in English law schools was in turn revolutionized by S. F. C Milsom, who felt that the key to legal history was not to apply the skills of the present lawyer to the law of the past, but to attempt to get into the minds of previous generations of lawyers. Following Milson, doctrinal legal history flourished in England. In the United States, a different tradition dominated law schools. Here, the pioneer was J. Willard Hurst, who turned attention away from narrow doctrinal history, to a broader contextual study of law, looking at the operation of law in society. The article discusses the kind of historiography which developed in America after Hurst, before turning to what discuss what role doctrinal legal history can continue to play, both to inform historical and legal debates.

Rationale Clinical trials are the gold standard for testing interventions. COVID-19 has further raised their public profile and emphasised the need to deliver better, faster, more efficient trials for patient benefit. Considerable overlap exists between data required for trials and data already collected routinely in electronic healthcare records (EHRs). Opportunities exist to use these in innovative ways to decrease duplication of effort and speed trial recruitment, conduct and follow-up.Approach The National Institute of Health Research (NIHR), Health Data Research UK and Clinical Practice Research Datalink co-organised a national workshop to accelerate the agenda for ‘data-enabled clinical trials’. Showcasing successful examples and imagining future possibilities, the plenary talks, panel discussions, group discussions and case studies covered: design/feasibility; recruitment; conduct/follow-up; collecting benefits/harms; and analysis/interpretation.Reflection Some notable studies have successfully accessed and used EHR to identify potential recruits, support randomised trials, deliver interventions and supplement/replace trial-specific follow-up. Some outcome measures are already reliably collected; others, like safety, need detailed work to meet regulatory reporting requirements. There is a clear need for system interoperability and a ‘route map’ to identify and access the necessary datasets. Researchers running regulatory-facing trials must carefully consider how data quality and integrity would be assessed. An experience-sharing forum could stimulate wider adoption of EHR-based methods in trial design and execution.Discussion EHR offer opportunities to better plan clinical trials, assess patients and capture data more efficiently, reducing research waste and increasing focus on each trial’s specific challenges. The short-term emphasis should be on facilitating patient recruitment and for postmarketing authorisation trials where research-relevant outcome measures are readily collectable. Sharing of case studies is encouraged. The workshop directly informed NIHR’s funding call for ambitious data-enabled trials at scale. There is the opportunity for the UK to build upon existing data science capabilities to identify, recruit and monitor patients in trials at scale.

The World Heart Federation (WHF) commenced a Roadmap initiative in 2015 to reduce the global burden of cardiovascular disease and resultant burgeoning of healthcare costs. Roadmaps provide a blueprint for implementation of priority solutions for the principal cardiovascular diseases leading to death and disability. Atrial fibrillation (AF) is one of these conditions and is an increasing problem due to ageing of the world’s population and an increase in cardiovascular risk factors that predispose to AF. The goal of the AF roadmap was to provide guidance on priority interventions that are feasible in multiple countries, and to identify roadblocks and potential strategies to overcome them. Since publication of the AF Roadmap in 2017, there have been many technological advances including devices and artificial intelligence for identification and prediction of unknown AF, better methods to achieve rhythm control, and widespread uptake of smartphones and apps that could facilitate new approaches to healthcare delivery and increasing community AF awareness. In addition, the World Health Organisation added the non-vitamin K antagonist oral anticoagulants (NOACs) to the Essential Medicines List, making it possible to increase advocacy for their widespread adoption as therapy to prevent stroke. These advances motivated the WHF to commission a 2020 AF Roadmap update. Three years after the original Roadmap publication, the identified barriers and solutions were judged still relevant, and progress has been slow. This 2020 Roadmap update reviews the significant changes since 2017 and identifies priority areas for achieving the goals of reducing death and disability related to AF, particularly targeted at low-middle income countries. These include advocacy to increase appreciation of the scope of the problem; plugging gaps in guideline management and prevention through physician education, increasing patient health literacy, and novel ways to increase access to integrated healthcare including mHealth and digital transformations; and greater emphasis on achieving practical solutions to national and regional entrenched barriers. Despite the advances reviewed in this update, the task will not be easy, but the health rewards of implementing solutions that are both innovative and practical will be great.

Background: Limited research has explored sources of resilience for Latino immigrants or the potential of resilience-based interventions to promote Latino immigrant health and well-being. Purpose: To evaluate Latino immigrants' experiences with a resilience training and application of the training to participants' personal lives and their communities among Latino immigrants. Methods: We conducted a retrospective, qualitative study in Philadelphia, PA from 2017 to 2018. We completed semi-structured, key informant interviews with nine participants who had taken the resilience training, and one facilitator (N=10). Transcripts were analyzed via interpretive content analysis. Results: The training resonated deeply with participants because of their personal traumas and immigration-related adversity. Participants were primed by past experiences of violence, as well as by daily struggles they encounter as Latino immigrants in the United States amid worsening anti-immigrant rhetoric and policy. The training was found to be transformative by allowing participants to discover and tap into their own inherent resilience. Participants utilized the knowledge and skills acquired from the training to better manage daily situations, as well as worked to strengthen others within their networks. Conclusions: Resilience-based interventions can help to strengthen communities against adversity. Cultivating resilience in Latino immigrants can have positive effects on psychosocial health. Resilience-building approaches could be implemented as stand-alone or enhancing components of more complex health promotion interventions. More research is needed on resilience, as well as its utility in community-based interventions to promote the health and well-being of Latino immigrants.

Abstract Background The development of digital health interventions (DHIs) for severe mental health problems is fast-paced. Researchers are beginning to consult service users to inform DHIs; however, much of this involvement has been limited to feedback on specific interventions post-DHI development. This study had two aims: 1. explore service user views towards DHIs for severe mental health problems; and 2. make recommendations for specific content within DHIs based on service user needs and suggestions. Methods Qualitative interviews with eighteen people with severe mental health problems focussed on two domains: 1) views about DHIs for severe mental health problems; and 2) ideas for future DHI content and design features. Data were analysed thematically. Results Participants responses were captured in five key themes: 1) DHIs could be empowering tools that instigate reflection and change; 2) society is already divided; DHIs will further increase this divide; 3) considerations must be made about who has access to DHI data and how this data may be used; 4) DHIs should not be delivered without other support options; and 5) DHIs should provide a positive, fun, practical and interactive method for self-management. Conclusions Participants found DHIs acceptable due to the empowering nature of self-management and ability to take ownership of their own healthcare needs. However, concerns included the potential for digital exclusion, privacy and confidentiality and fears about DHIs being used to replace other mental health services. Service users want tools to help them self-manage their mental health, but also provide positive and recovery-focussed content that can be used in conjunction with other support options.

Abstract Background Late adolescence and early adulthood is a period of highest incidence for onset of mental health problems. Transition to college environment has been associated with many risk factors such as the initial disruption—and subsequent irregularity—of the student’s sleep and activity schedule. We tested the feasibility of using blue blocking glasses (BBG) at night in first year higher education students with sleep complaints, to obtain preliminary evidence for the impact of BBG on sleep, activity, and mood. Methods Participants were 13 first year undergraduates (from 10 different academic courses) living on campus for the first time with sleep complaints/disorders confirmed at screening via the Duke Structured Interview Schedule for Sleep Disorders. We used a 2-week, balanced crossover design (BBG vs placebo glasses; participants were unaware which was the active intervention) with computer-generated random allocation. Exploratory analyses provided descriptive and frequency summaries to evaluate feasibility of the intervention. Results Preliminary evidence supports the feasibility and acceptability of the trial; almost all screened participants consented and completed the protocol with high adherence; missing data were negligible. Additionally, the effectiveness of BBGs to enhance sleep, mood, and activity levels in young adults was supported. Conclusions The results of this feasibility trial suggest that BBG have potential as an inexpensive and feasible intervention for reducing sleep and circadian dysregulation in young adult students. A larger trial, following this successfully implemented protocol, is necessary to fully test the efficacy of BBG.

Leadless cardiac pacemakers were developed to reduce complications associated with conventional transvenous pacemakers. While this technology is still relatively new, devices are increasingly being implanted. The perioperative management of patients with these devices has been underreported; we thus seek to add to the limited body of knowledge of perioperative management of patients with leadless cardiac pacemakers. An elderly female patient with a Micra VR transcatheter pacing system leadless cardiac pacemaker placed for tachycardia-bradycardia syndrome with intermittent complete heart block was scheduled for elective tricuspid valve replacement for severe tricuspid regurgitation. Pacemaker interrogation was performed several hours prior to the scheduled surgery based on the electrophysiologist’s availability; the device was kept in its programmed VVIR mode, and the base rate was increased from 60 to 80 beats per minute in anticipation of the upcoming surgery. Upon preoperative evaluation, the anesthesiologist asked that the electrophysiology team be placed on standby intraoperatively due to the concern that either oversensing in the setting of pacemaker dependence and/or undesirable tachycardia from rate-responsive pacing could occur. The surgeon used monopolar electrocautery for the duration of the cardiac surgery. Despite the patient having evidence of pacemaker dependence in the intensive care unit preoperatively, no electromagnetic interference leading to oversensing nor rate modulation was detected during intraoperative electrocardiographic and intraarterial invasive monitoring. Evidence-based guidelines regarding perioperative management specifically of leadless cardiac pacemakers do not exist. As these devices become more prevalent, further evaluation will be paramount to determine whether existing guidelines for perioperative management of conventional transvenous pacemakers apply.

Background: Digital health interventions have the potential to improve the delivery of psychoeducation to people with mental health problems and their relatives. Despite substantial investment in the development of digital health interventions, successful implementation into routine clinical practice is rare. Objectives: Use the implementation of the Relatives’ Education And Coping Toolkit (REACT) for psychosis/bipolar disorder to identify critical factors affecting uptake and use, and develop an implementation plan to support the delivery of REACT. Design: This was an implementation study using a mixed-methods, theory-driven, multiple case study approach. A study-specific implementation theory for REACT based on normalisation process theory was developed and tested, and iterations of an implementation plan to address the key factors affecting implementation were developed. Setting: Early-intervention teams in six NHS mental health trusts in England (three in the north and three in the south). Participants: In total, 281 staff accounts and 159 relatives’ accounts were created, 129 staff and 23 relatives took part in qualitative interviews about their experiences, and 132 relatives provided demographic data, 56 provided baseline data, 21 provided data at 12 weeks’ follow-up and 20 provided data at 24 weeks’ follow-up. Interventions: REACT is an online supported self-management toolkit, offering 12 evidence-based psychoeducation modules and support via a forum, and a confidential direct messaging service for relatives of people with psychosis or bipolar disorder. The implementation intervention was developed with staff and iteratively adapted to address identified barriers. Adaptations included modifications to the toolkit and how it was delivered by teams. Main outcome measures: The main outcome was factors affecting implementation of REACT, assessed primarily through in-depth interviews with staff and relatives. We also assessed quantitative measures of delivery (staff accounts and relatives’ invitations), use of REACT (relatives’ logins and time spent on the website) and the impact of REACT [relatives’ distress (General Health Questionnaire-28), and carer well-being and support (Carer Well-being and Support Scale questionnaire)]. Results: Staff and relatives were generally positive about the content of REACT, seeing it as a valuable resource that could help services improve support and meet clinical targets, but only within a comprehensive service that included face-to-face support, and with some additional content. Barriers to implementation included high staff caseloads and difficulties with prioritising supporting relatives; technical difficulties of using REACT; poor interoperability with trust information technology systems and care pathways; lack of access to mobile technology and information technology training; restricted forum populations leading to low levels of use; staff fears of managing risk, online trolling, or replacement by technology; and uncertainty around REACT’s long-term availability. There was no evidence that REACT would reduce staff time supporting relatives (which was already very low), and might increase it by facilitating communication. In all, 281 staff accounts were created, but only 57 staff sent relatives invitations. In total, 355 relatives’ invitations were sent to 310 unique relatives, leading to the creation of 159 relatives’ accounts. The mean number of logins for relatives was 3.78 (standard deviation 4.43), but with wide variation from 0 to 31 (median 2, interquartile range 1–8). The mean total time spent on the website was 40.6 minutes (standard deviation 54.54 minutes), with a range of 0–298 minutes (median 20.1 minutes, interquartile range 4.9–57.5 minutes). There was a pattern of declining mean scores for distress, social dysfunction, depression, anxiety and insomnia, and increases in relatives’ well-being and eHealth literacy, but no changes were statistically significant. Conclusions: Digital health interventions, such as REACT, should be iteratively developed, evaluated, adapted and implemented, with staff and service user input, as part of a long-term strategy to develop integrated technology-enabled services. Implementation strategies must instil a sense of ownership for staff and ensure that they have adequate training, risk protocols and resources to deliver the technology. Cost-effectiveness and impact on workload and inequalities in accessing health care need further testing, along with the generalisability of our findings to other digital health interventions. Limitations: REACT was offered by the same team running the IMPlementation of A Relatives’ Toolkit (IMPART) study, and was perceived by staff and relatives as a time-limited research study rather than ongoing clinical service, which affected engagement. Access to observational data was limited. Trial registration: Current Controlled Trials ISRCTN16267685. Funding: This project was funded by the National Institute for Health Research (NIHR) Health Services and Delivery Research programme and will be published in full in Health Services and Delivery Research; Vol. 8, No. 37. See the NIHR Journals Library website for further project information.

BackgroundA reduced availability of resources has hampered the implementation of family work in psychosis. Web-based support programs have the potential to increase access to high-quality, standardized resources. This pilot study tested the Norwegian version of the Relatives Education and Coping Toolkit (REACT), a web-based United Kingdom National Health Service program in combination with phone-based support by trained family therapists. ObjectiveWe investigated how the program was perceived by its users and identified the facilitators and barriers to its clinical implementation. MethodsRelatives of people with psychosis were offered access to REACT and to weekly family therapist support (with 1 of 2 trained family therapists) for 26 weeks. Level of distress and level of expressed emotion data were collected at baseline and after 26 weeks using the Family Questionnaire and the Relatives Stress Scale. Both family therapists and a subset of the relatives were interviewed about their experiences after completing the program. ResultsDuring the program, relatives (n=19) had a median of 8 (range 4-11) consultations with the family therapists. Postintervention, there was a significant reduction in stress and in expressed emotions in the relatives of people with psychosis. Interviews with the relatives (n=7) and the family therapists (n=2) indicated the following themes as important—the intervention turned knowledge into action; the intervention strengthened the feeling of being involved and taken seriously by the health services; and management support and the ability for self-referral were important, while lack of reimbursement and clinician resistance to technology were barriers to implementation. ConclusionsThe service was found to offer a valued clinical benefit; however, strategies that aim to engage clinicians and increase organizational support toward new technology need to be developed.

International Registered Report Identifier (IRRID)RR2-10.1136/bmjopen-2017-016965

Background: Relatives caring for people with severe mental health problems find information and emotional support hard to access. Online support for self-management offers a potential solution. Objective: The objective was to determine the clinical effectiveness and cost-effectiveness of an online supported self-management tool for relatives: the Relatives’ Education And Coping Toolkit (REACT). Design and setting: This was a primarily online (UK), single-blind, randomised controlled trial, comparing REACT plus a resource directory and treatment as usual with the resource directory and treatment as usual only, by measuring user distress and other well-being measures at baseline and at 12 and 24 weeks. Participants: A total of 800 relatives of people with severe mental health problems across the UK took part; relatives who were aged ≥ 16 years, were experiencing high levels of distress, had access to the internet and were actively seeking help were recruited. Intervention: REACT comprised 12 psychoeducation modules, peer support through a group forum, confidential messaging and a comprehensive resource directory of national support. Trained relatives moderated the forum and responded to messages. Main outcome measure: The main outcome was the level of participants’ distress, as measured by the General Health Questionnaire-28 items. Results: Various online and offline strategies, including social media, directed potential participants to the website. Participants were randomised to one of two arms: REACT plus the resource directory (n = 399) or the resource directory only (n = 401). Retention at 24 weeks was 75% (REACT arm, n = 292; resource directory-only arm, n = 307). The mean scores for the General Health Questionnaire-28 items reduced substantially across both arms over 24 weeks, from 40.2 (standard deviation 14.3) to 30.5 (standard deviation 15.6), with no significant difference between arms (mean difference –1.39, 95% confidence interval –3.60 to 0.83; p = 0.22). At 12 weeks, the General Health Questionnaire-28 items scores were lower in the REACT arm than in the resource directory-only arm (–2.08, 95% confidence interval –4.14 to –0.03; p = 0.027), but this finding is likely to be of limited clinical significance. Accounting for missing data, which were associated with higher distress in the REACT arm (0.33, 95% confidence interval –0.27 to 0.93; p = 0.279), in a longitudinal model, there was no significant difference between arms over 24 weeks (–0.56, 95% confidence interval –2.34 to 1.22; p = 0.51). REACT cost £142.95 per participant to design and deliver (£62.27 for delivery only), compared with £0.84 for the resource directory only. A health economic analysis of NHS, health and Personal Social Services outcomes found that REACT has higher costs (£286.77), slightly better General Health Questionnaire-28 items scores (incremental General Health Questionnaire-28 items score adjusted for baseline, age and gender: –1.152, 95% confidence interval –3.370 to 1.065) and slightly lower quality-adjusted life-year gains than the resource directory only; none of these differences was statistically significant. The median time spent online was 50.8 minutes (interquartile range 12.4–172.1 minutes) for REACT, with no significant association with outcome. Participants reported finding REACT a safe, confidential environment (96%) and reported feeling supported by the forum (89%) and the REACT supporters (86%). No serious adverse events were reported. Limitations: The sample comprised predominantly white British females, 25% of participants were lost to follow-up and dropout in the REACT arm was not random. Conclusions: An online self-management support toolkit with a moderated group forum is acceptable to relatives and, compared with face-to-face programmes, offers inexpensive, safe delivery of National Institute for Health and Care Excellence-recommended support to engage relatives as peers in care delivery. However, currently, REACT plus the resource directory is no more effective at reducing relatives’ distress than the resource directory only. Future work: Further research in improving the effectiveness of online carer support interventions is required. Trial registration: Current Controlled Trials ISRCTN72019945. Funding: This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 24, No. 32. See the NIHR Journals Library website for further project information.

Abstract Background Web-based interventions to support people to manage long-term health conditions are available and effective but rarely used in clinical services. The aim of this study is to identify critical factors impacting on the implementation of an online supported self-management intervention for relatives of people with recent onset psychosis or bipolar disorder into routine clinical care and to use this information to inform an implementation plan to facilitate widespread use and inform wider implementation of digital health interventions. Methods A multiple case study design within six early intervention in psychosis (EIP) services in England, will be used to test and refine theory-driven hypotheses about factors impacting on implementation of the Relatives’ Education And Coping Toolkit (REACT). Qualitative data including behavioural observation, document analysis, and in-depth interviews collected in the first two EIP services (wave 1) and analysed using framework analysis, combined with quantitative data describing levels of use by staff and relatives and impact on relatives’ distress and wellbeing, will be used to identify factors impacting on implementation. Consultation via stakeholder workshops with staff and relatives and co-facilitated by relatives in the research team will inform development of an implementation plan to address these factors, which will be evaluated and refined in the four subsequent EIP services in waves 2 and 3. Transferability of the implementation plan to non-participating services will be explored. Discussion Observation of implementation in a real world clinical setting, across carefully sampled services, in real time provides a unique opportunity to understand factors impacting on implementation likely to be generalizable to other web-based interventions, as well as informing further development of implementation theories. However, there are inherent challenges in investigating implementation without influencing the process under observation. We outline our strategies to ensure our design is transparent, flexible, and responsive to the timescales and activities happening within each service whilst also meeting the aims of the project. Trial registration ISCTRN 16267685 (09/03/2016).

Background: Bipolar disorder (BD) costs £5.2B annually, largely as a result of incomplete recovery after inadequate treatment. Objectives: A programme of linked studies to reduce relapse and suicide in BD. Design: There were five workstreams (WSs): a pragmatic randomised controlled trial (RCT) of group psychoeducation (PEd) versus group peer support (PS) in the maintenance of BD (WS1); development and feasibility RCTs of integrated psychological therapy for anxiety in bipolar disorder (AIBD) and integrated for problematic alcohol use in BD (WS2 and WS3); survey and qualitative investigations of suicide and self-harm in BD (WS4); and survey and qualitative investigation of service users’ (SUs) and psychiatrists’ experience of the Mental Capacity Act 2005 (MCA), with reference to advance planning (WS5). Setting: Participants were from England; recruitment into RCTs was limited to certain sites [East Midlands and North West (WS1); North West (WS2 and WS3)]. Participants: Aged ≥ 18 years. In WS1–3, participants had their diagnosis of BD confirmed by the Structural Clinical Interview for the Diagnostic and Statistical Manual of Mental Disorders. Interventions: In WS1, group PEd/PS; in WS3 and WS4, individual psychological therapy for comorbid anxiety and alcohol use, respectively. Main outcome measures: In WS1, time to relapse of bipolar episode; in WS2 and WS3, feasibility and acceptability of interventions; in WS4, prevalence and determinants of suicide and self-harm; and in WS5, professional training and support of advance planning in MCA, and SU awareness and implementation. Results: Group PEd and PS could be routinely delivered in the NHS. The estimated median time to first bipolar relapse was 67.1 [95% confidence interval (CI) 37.3 to 90.9] weeks in PEd, compared with 48.0 (95% CI 30.6 to 65.9) weeks in PS. The adjusted hazard ratio was 0.83 (95% CI 0.62 to 1.11; likelihood ratio test p = 0.217). The interaction between the number of previous bipolar episodes (1–7 and 8–19, relative to 20+) and treatment arm was significant (χ2 = 6.80, degrees of freedom = 2; p = 0.034): PEd with one to seven episodes showed the greatest delay in time to episode. A primary economic analysis indicates that PEd is not cost-effective compared with PS. A sensitivity analysis suggests potential cost-effectiveness if decision-makers accept a cost of £37,500 per quality-adjusted life-year. AIBD and motivational interviewing (MI) cognitive–behavioural therapy (CBT) trials were feasible and acceptable in achieving recruitment and retention targets (AIBD: n = 72, 72% retention to follow-up; MI-CBT: n = 44, 75% retention) and in-depth qualitative interviews. There were no significant differences in clinical outcomes for either trial overall. The factors associated with risk of suicide and self-harm (longer duration of illness, large number of periods of inpatient care, and problems establishing diagnosis) could inform improved clinical care and specific interventions. Qualitative interviews suggested that suicide risk had been underestimated, that care needs to be more collaborative and that people need fast access to good-quality care. Despite SUs supporting advance planning and psychiatrists being trained in MCA, the use of MCA planning provisions was low, with confusion over informal and legally binding plans. Limitations: Inferences for routine clinical practice from WS1 were limited by the absence of a ‘treatment as usual’ group. Conclusion: The programme has contributed significantly to understanding how to improve outcomes in BD. Group PEd is being implemented in the NHS influenced by SU support. Future work: Future work is needed to evaluate optimal approaches to psychological treatment of comorbidity in BD. In addition, work in improved risk detection in relation to suicide and self-harm in clinical services and improved training in MCA are indicated. Trial registration: Current Controlled Trials ISRCTN62761948, ISRCTN84288072 and ISRCTN14774583. Funding: This project was funded by the National Institute for Health Research (NIHR) Programme Grants for Applied Research programme and will be published in full in Programme Grants for Applied Research; Vol. 6, No. 6. See the NIHR Journals Library website for further project information.

Background and aims Early diagnosis of autism spectrum disorder, while providing many benefits, also presents challenges. Accurately predicting symptom severity allows clinicians to confidently diagnose and assign the most appropriate intervention. Little available research predicts symptom severity in children with autism spectrum disorder who have not been exposed to significant levels of intervention. Methods The present file review study examined preverbal skills as predictors of symptom severity, approximately one year later, in a group of young children (18–64 months) with autism spectrum disorder ( n = 199). Results Of the two core diagnostic features (social communicative deficits and restricted repetitive behaviors), social communicative skills best predicted symptom severity. Furthermore, social communicative gestures predicted symptom severity after age, adaptive behavior, restricted repetitive behaviors, and functional gestures had been accounted for. Conclusions Social communicative gestures are excellent predictors of future symptom severity independent of intervention effects in very young children with autism spectrum disorder. Implications Previously, the social aspect of gestures has been missing in the literature on language and symptom prediction in children with autism spectrum disorder. Careful attention to social communicative gestures in the future may help with early diagnosis and more accurate predictions of symptom and developmental trajectories.

Background: Atrial fibrillation (AF) is a common cardiac arrhythmia that increases the risk of thromboembolic events. Anticoagulation therapy to prevent AF-related stroke has been shown to be cost-effective. A national screening programme for AF may prevent AF-related events, but would involve a substantial investment of NHS resources. Objectives: To conduct a systematic review of the diagnostic test accuracy (DTA) of screening tests for AF, update a systematic review of comparative studies evaluating screening strategies for AF, develop an economic model to compare the cost-effectiveness of different screening strategies and review observational studies of AF screening to provide inputs to the model. Design: Systematic review, meta-analysis and cost-effectiveness analysis. Setting: Primary care. Participants: Adults. Intervention: Screening strategies, defined by screening test, age at initial and final screens, screening interval and format of screening {systematic opportunistic screening [individuals offered screening if they consult with their general practitioner (GP)] or systematic population screening (when all eligible individuals are invited to screening)}. Main outcome measures: Sensitivity, specificity and diagnostic odds ratios; the odds ratio of detecting new AF cases compared with no screening; and the mean incremental net benefit compared with no screening. Review methods: Two reviewers screened the search results, extracted data and assessed the risk of bias. A DTA meta-analysis was perfomed, and a decision tree and Markov model was used to evaluate the cost-effectiveness of the screening strategies. Results: Diagnostic test accuracy depended on the screening test and how it was interpreted. In general, the screening tests identified in our review had high sensitivity (> 0.9). Systematic population and systematic opportunistic screening strategies were found to be similarly effective, with an estimated 170 individuals needed to be screened to detect one additional AF case compared with no screening. Systematic opportunistic screening was more likely to be cost-effective than systematic population screening, as long as the uptake of opportunistic screening observed in randomised controlled trials translates to practice. Modified blood pressure monitors, photoplethysmography or nurse pulse palpation were more likely to be cost-effective than other screening tests. A screening strategy with an initial screening age of 65 years and repeated screens every 5 years until age 80 years was likely to be cost-effective, provided that compliance with treatment does not decline with increasing age. Conclusions: A national screening programme for AF is likely to represent a cost-effective use of resources. Systematic opportunistic screening is more likely to be cost-effective than systematic population screening. Nurse pulse palpation or modified blood pressure monitors would be appropriate screening tests, with confirmation by diagnostic 12-lead electrocardiography interpreted by a trained GP, with referral to a specialist in the case of an unclear diagnosis. Implementation strategies to operationalise uptake of systematic opportunistic screening in primary care should accompany any screening recommendations. Limitations: Many inputs for the economic model relied on a single trial [the Screening for Atrial Fibrillation in the Elderly (SAFE) study] and DTA results were based on a few studies at high risk of bias/of low applicability. Future work: Comparative studies measuring long-term outcomes of screening strategies and DTA studies for new, emerging technologies and to replicate the results for photoplethysmography and GP interpretation of 12-lead electrocardiography in a screening population. Study registration: This study is registered as PROSPERO CRD42014013739. Funding: The National Institute for Health Research Health Technology Assessment programme.

The marine diatom flora of the tropical western Pacific island of Guam is all but unknown. Following several taxonomic/systematic papers, this floristics paper documents 179 new records of diatoms identified from light microscopy and/or scanning electron microscopy. Samples were collected from diverse habitats for several research projects in the authors’ laboratories, but the majority reported here are epiphytic, especially from pomacentrid farmer-fish territories. While many of the species are well known from other regions, some recently named, rarely seen, or poorly-described taxa include Amphora decussata Grunow;Ardissonea fulgens var. fulgens (Greville) Grunow and var. gigantea (Lobarzewsky) De Toni; Campylodiscus humilis Greville; Falcula paracelsianus Voigt; Hyalosira interrupta (Ehrenberg) Navarro; Olifantiella pilosella Riaux-Gobin; andTriceratium pulchellum (Grunow) Grunow. A preliminary checklist incorporating the new records and our previous records totals 237 taxa, which is a step towards the development of the regional flora. Many taxa remain to be identified from the documentation so far and few samples have been analyzed from other habitats such as sediments and mangroves. Only 28–42% of the species in this checklist also occurred in lists from the Society Islands, Mahé, Puerto Rico and The Bahamas—but all regions remain seriously undersampled. We do, however note some apparent differences in common and distinctive species.