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Purpose To systematically review the evidence for health coaching as an intervention to improve health-related quality of life (HRQoL) and reduce hospital admissions in people with chronic obstructive pulmonary disease (COPD). Methods We systematically searched MEDLINE, EMBASE, PsycINFO, and CINAHL from database inception to August 2018 to identify all randomized controlled trials (RCTs) of health coaching for people with COPD. Eligible health coaching interventions had to include three components: goal setting, motivational interviewing, and COPD-related health education. Data were extracted on study characteristics and the effects of the intervention on HRQoL, hospital admissions, physical activity, self-care behaviour, and mood. Study quality was appraised by two authors using the Cochrane tool for assessing the risk of bias in RCTs. Effect sizes (standardized mean differences [SMD] or odds ratios [OR]) with 95% confidence intervals (CIs) were calculated and pooled using random effects meta-analyses. Results Of 1578 articles, 10 RCTs were included. Meta-analysis showed that health coaching has a significant positive effect on HRQoL (SMD = -0.69, 95% CI: -1.28, -0.09, p = .02, from k = 4) and leads to a significant reduction in COPD-related hospital admissions (OR = 0.46, 95% CI: 0.31, 0.69, p = .0001, from k = 5), but not in all-cause hospital admissions (OR = 0.70, 95% CI: 0.41-1.12, p = .20, from k = 3). Three of four studies reported significant improvements to self-care behaviours such as medication adherence and exercise compliance. Conclusions This is the first systematic review to show that health coaching may be a candidate intervention to improve HRQoL and reduce costly hospital admissions in people with COPD. Statement of contribution What is already known on this subject? COPD is a leading cause of death worldwide and considerably reduces HRQoL. In turn, HRQoL is associated with a range of adverse health outcomes in COPD. Health coaching is a self-management intervention for people with long-term conditions such as COPD. Studies have examined whether health coaching improves HRQOL and other health outcomes in people with COPD, but no systematic review has been conducted. What does this study add? The first systematic review and meta-analysis of RCTs of health coaching for people with COPD. Health coaching may be a candidate intervention for improving HRQoL and reducing COPD-related hospital admissions in people with COPD. The need to establish the most effective health coaching components, delivery modality, and economic impact.

Objective: To identify factors influencing clinicians decision-making about ongoing stroke rehabilitation for people with pre-existing dementia/cognitive impairment and the impact on clinical practice. Design: Qualitative semi-structured interviews with stroke specialist healthcare professionals analysed using thematic analysis. Setting: Acute stroke unit, inpatient stroke rehabilitation units, and community stroke services. Participants: Twenty three professionals from six multidisciplinary stroke teams involved in decision-making about stroke patients’ rehabilitation potential and clinical pathways. Results: Factors influencing decision-making about ongoing rehabilitation were (1) gaining understanding of the individual patient, (2) clinician’s knowledge of dementia/cognitive impairment, (3) predicting rehabilitation potential, (4) organizational constraints, and (5) clinician’s perceptions of their role within the team. Decision-making led to two outcomes, either accommodating the pre-existing dementia/cognitive impairment within delivery of rehabilitation or ending rehabilitation for that patient to allocate limited resources where they were perceived more likely to be effective. Participants felt that patients with pre-existing dementia/cognitive impairment had difficulty demonstrating the required rehabilitation potential within the short timescales available in the current model of service delivery. Participants identified a need for training to improve their knowledge and confidence for decision-making and delivery of rehabilitation for this growing population. Conclusion: Clinicians’ decision-making about ongoing rehabilitation for patients with prestroke dementia/cognitive impairments is influenced by gaps in their knowledge and by service constraints. Increased training and more flexible, patient-centred services would enable clinicians to better accommodate these patients in rehabilitation.

Background. National Health Service [NHS] England encourages staff to use everyday interactions with patients to discuss healthy lifestyle changes as part of the ‘Making Every Contact Count’ [MECC] approach. Although healthcare, government and public health organisations are now expected to adopt this approach, evidence is lacking about how MECC is currently implemented in practice. This study explored the views and experiences of those involved in designing, delivering and evaluating MECC. Methods. We conducted a qualitative study using semi-structured interviews with 13 public health practitioners with a range of roles in implementing MECC across England. Interviews were conducted via telephone, transcribed verbatim and analysed using an inductive thematic approach. Results. Four key themes emerged identifying factors accounting for variations in MECC implementation: (i) ‘Design, quality and breadth of training’, (ii) ‘Outcomes attended to and measured’, (iii) ‘Engagement levels of trainees and trainers’ and (iv) ‘System-level influences’. Conclusions. MECC is considered a valuable public health approach but because organisations interpret MECC differently, staff training varied in nature. Practitioners thought that implementation could be improved, and an evidence-base underpinning MECC developed, by sharing experiences more widely, introducing some elements of standardisation to staff training and finding better methods for assessing meaningful outcomes.

Health psychologists have succeeded in identifying theory-congruent behaviour change techniques (BCTs) to prevent and reduce lifestyle-related illnesses, such as cardiovascular disease, cancers and diabetes. Obesity management discussions between doctors and patients can be challenging and are often avoided. Despite a clear training need, it is unknown how best to tailor BCT research findings to inform obesity-management training for future healthcare professionals. The primary objective of this descriptive study was to gather information on the feasibility and acceptability of delivering and evaluating health psychology-informed obesity training to UK medical students. Medical students (n = 41) attended an obesity management session delivered by GP tutors. Sessions were audio-recorded to enable fidelity checks. Acceptability of training was explored qualitatively. Tutors consistently delivered training according to the intervention protocol; and students and tutors found the training highly acceptable. This psychology-informed training can be delivered successfully by GP tutors and further research is warranted to explore its efficacy.

European guidelines recommend that, unless there are clear benefits of autosomal recessive carrier testing in childhood, it should be deferred to protect children's autonomous decision making. Although it is believed that children receive testing in the United Kingdom, it is unclear how or why professionals make decisions to provide tests. Semi-structured interviews were conducted with 25 professionals in the United Kingdom who advise about, and undertake, childhood sickle cell trait testing. Data were analysed using thematic analysis. Few professionals were aware of, or used, guidelines to inform testing decisions and instead, considered the reproductive and clinical relevance of testing, and autonomous rights of parents. Many professionals believed testing was important and readily offered it to parents. Professionals who discouraged testing were met with parental resistance and often provided testing when conflict was difficult to manage. Children were rarely considered to be capable of making decisions and few were engaged in discussions. When consulted, older children demonstrated interest, but younger children usually declined testing. Wide variation in testing advice emerged because of opposing beliefs about children's best interests and potential benefits or harms of testing. An explanation of how children's best interests should be determined in light of conflicting evidence regarding the psychosocial and clinical implications of carrier status is needed. Improved awareness of guidelines might encourage professionals to support the role of children in testing decisions. Strategies are also required to help professionals determine children's cognitive capacity and to protect children's future autonomy during discussions with persistent parents.

In an era of globalisation, positivist research methodologies and voices are privileged and funded over those of qualitative researchers. This has led to narrowing beliefs about what constitutes knowledge, and about the ways in which knowledge is constructed and evaluated, impacting upon the conduct, funding and reporting of arts research, and also upon curricular content and pedagogical practices in arts education in schools and universities. Focusing upon the practices of four contemporary arts practitioners in postcolonial contexts this paper seeks to decolonise and re-map concepts of place, history, power and authority. The authors disrupt singular narratives of place and history through their use of socially engaged, performative and democratising arts practice as research. Using “little stories” to re-map the hidden histories of place the authors contest notions of certainty of knowledge in the arts, research and in their work as educators.

OBJECTIVE: Persistent pain in the face, mouth, and jaws is a common presentation to dental and medical services. The aetiology remains unclear, but a growing evidence base recognizes the effectiveness of psychological rather than biomedical interventions. To understand how this approach might be implemented into clinical practice, knowledge is needed of patients' and clinicians' experience of chronic orofacial pain (COFP). The aim of this study was to explore the experience and understanding of COFP by patients and primary and secondary care medical and dental practitioners. DESIGN: Qualitative interview study. METHODS: Audio-recorded semi-structured interviews with a purposive sample of 12 dentists, 11 general practitioners, and seven patients were thematically analysed. RESULTS: Clinicians and patients recognized the role that psychological factors could play in the development and maintenance of COFP, yet management and self-management strategies were largely limited to biomedical interventions. Achieving a diagnosis proved problematic but largely functional for both parties. GPs and dentists viewed COFP as a non-dental problem and felt inadequately equipped to manage the condition. GPs, unlike dentists, felt obligated to support patients using techniques for managing patients with other long-term conditions. Frustration at the current inadequacy of COFP management often led to conflict with (or disengagement from) the clinician-patient relationship. CONCLUSIONS: Current management of COFP is ineffective and unsatisfactory for patients and practitioners, which impacts on their relationship. Fundamental barriers to accessing and implementing psychological interventions for COFP arise from ineffective communication between physicians and patients, and between medical and dental practitioners. Statement of contribution What is already known on this subject? COFP is characterized by persistent pain in the face, mouth, or jaws that are not the result of organic disease or physical trauma. Patients with COFP present to both medical and dental services and receive sub-optimal care. No studies have examined the experiences of managing this problem from the perspectives of dentists, general practitioners and patients. What does this study add? Patients, dentists, and GPs recognize the role that psychological factors have in maintaining and addressing facial pain symptoms, yet principally manage it through biomedical interventions. Challenges exist over arriving at a diagnosis and managing the problem, and challenges are exacerbated by poor communication between doctors and medical services. Improvements are needed in liaison between medical and dental services and further training to support primary care clinicians to facilitate a stepped care approach to managing COFP.

One of several living lab experiences within the Fostering Digital Participation Project, the storyelling group provided an opportunity for young people in the Toowoomba region to develop their skills in digital storytelling. As a living lab experience, storyelling became increasingly self-directed as members accepted the various roles necessary to achieve their aim of building a website to publish digital stories. Built on the WIX platform, storyelling has published a variety of digital stories in a number of audio-visual formats ( http://toowoombaconnect.wixsite.com/storyelling ). The following interview was conducted by Roger Osborne with storyelling members Sarah Peters and Rosie O’Shannessy. Here they discuss the origins of the group, their living lab experience, the challenges they faced in building their website and the future of storyelling in Toowoomba.

Attention deficit hyperactivity disorder (ADHD), affecting 11% of children and adolescents, increases risk for injury and may predispose children to illness. However, the prevalence of ADHD and other developmental disorders in the pediatric intensive care unit (PICU) has not been previously studied. We performed a single-center, prospective cohort study of children aged 6 to 12 years who were hospitalized in the PICU from May through August 2016. Parents described their child’s educational and neurodevelopmental history, and completed ADHD and emotional/behavioral disorder screening on enrollment and 1 month after discharge. Twenty-four children were enrolled. Ten patients (42%) had a prior neurodevelopmental diagnosis, and 7 (29%) met study criteria for ADHD. Children hospitalized for critical illness have a high prevalence of neurodevelopmental disabilities and are more susceptible to the impact of critical illness on development and behavior. More research is needed to better understand how to support this vulnerable population after critical illness.

Haemophilus parasuis is a diverse bacterial species that is found in the upper respiratory tracts of pigs and can also cause Glässer's disease and pneumonia. A previous pangenome study of H. parasuis identified 48 genes that were associated with clinical disease. Here, we describe the development of a generalized linear model (termed a pathotyping model) to predict the potential virulence of isolates of H. parasuis based on a subset of 10 genes from the pangenome. A multiplex PCR (mPCR) was constructed based on these genes, the results of which were entered into the pathotyping model to yield a prediction of virulence. This new diagnostic mPCR was tested on 143 field isolates of H. parasuis that had previously been whole-genome sequenced and a further 84 isolates from the United Kingdom from cases of H. parasuis- related disease in pigs collected between 2013 and 2014. The combination of the mPCR and the pathotyping model predicted the virulence of an isolate with 78% accuracy for the original isolate collection and 90% for the additional isolate collection, providing an overall accuracy of 83% (81% sensitivity and 93% specificity) compared with that of the “current standard” of detailed clinical metadata. This new pathotyping assay has the potential to aid surveillance and disease control in addition to serotyping data.

Rationale: Prostate cancer and its treatment have significant sexual side effects that necessitate timely patient information and open communication with healthcare professionals. However, very little is known about men’s experiences of talking to clinicians about the psychosexual difficulties associated with the disease. Objective: This study aims to advance understanding of men’s perceptions of the communication and information challenges associated with the psychosexual aspects of prostate cancer and its treatment. Method: Between October 2013 and April 2014, semi-structured interviews were conducted with 21 men from the UK who had been treated for prostate cancer. Interview transcripts were analysed using thematic analysis. Results: Three themes describe the communication challenges men face: (1) It can be too soon to talk about sex; (2) The psychology of sex is missing; (3) Communication is not individually tailored. Conclusions: Clinicians might usefully (1) consider and discuss with patients how their psychosexual communication needs and information processing abilities may fluctuate across the cancer timeline; (2) initiate discussions about the consequences of treatment that extend beyond biological and mechanical aspects to include emotional and relational factors; (3) tailor communication to the dynamic mix of attributes that shape men’s individual psychosexual needs, including their relationship status, sexual orientation, sexual motivations and values. Skills-based training in communication and psychosexual awareness may facilitate the proactive and permissive stance clinicians need to discuss sexual side effects with a heterogeneous group of patients.

Objective: Theory and clinical literature suggest that pride may play an important role in the maintenance of restrictive eating disorders. A grounded theory study explored experiences of, and reflections on, pride among women with a current or past diagnosis of anorexia nervosa. Design: This is a qualitative study using grounded theory. Method: Semistructured interviews were conducted with 21 women recruited from an eating disorder unit in England, and from a UK self-help organization. Grounded theory from a constructivist lens was used. Analysis involved coding, constant comparison, and memo-writing. Results: Pride evolves over the course of anorexia nervosa. Two overarching conceptual categories were identified: 'pride becoming intertwined with anorexia' and 'pride during the journey towards recovery'. These categories encompassed different forms of pride: 'alluring pride', 'toxic pride', 'pathological pride', 'anorexia pride', 'shameful pride', 'recovery pride', and 'resilient pride'. Initially, pride contributed to self-enhancement and buffered negative emotions. As the condition progressed, pride became a challenge to health and interfered with motivation to change. During recovery, perceptions of pride altered as a healthy approach to living ensued. Conclusions: The evolving nature of pride plays a central role in development, maintenance, and treatment of anorexia nervosa. Understanding of pride and its role in psychotherapeutic work with this client group may increase motivation to change and promote recovery. Future work should investigate whether tackling pride in eating disorders increases treatment efficacy and reduces the risk of relapsing. Practitioners points: Pride associated with anorexia appeared to evolve in nature. During early stages of the eating disorder, it stopped people from seeking help. Later on, it prevented them from seeing pride in healthy domains of life (outside anorexia). Over time, pride in anorexia became an overwhelming emotion that interfered with motivation to change. It is important for practitioners to assess and discuss pride in anorexia and its evolving nature during treatment. Understanding of pride and its role in psychotherapeutic work with this client group may increase motivation to change and promote recovery.

Objective To (1) explore patients' expectations and experiences of nurse and pharmacist non-medical prescriber-led management of respiratory tract infections (RTIs), (2) examine whether patient expectations for antibiotics affect the likelihood of receiving them and (3) understand factors influencing patient satisfaction with RTI consultations. Design Mixed methods. Setting Primary care. Participants Questionnaires from 120 patients and follow-up interviews with 22 patients and 16 nurse and pharmacist non-medical prescribers (NMPs). Results Patients had multiple expectations of their consultation with 43% expecting to be prescribed an antibiotic. There was alignment between self-reported patient expectations and those perceived by NMPs. Patient expectations for non-antibiotic strategies, such as education to promote self-management, were associated with receipt of those strategies, whereas patient expectations for an antibiotic were not associated with receipt of these medications. ‘Patient-centred’ management strategies (including reassurance and providing information) were received by 86.7% of patients. Regardless of patients' expectations or the management strategy employed, high levels of satisfaction were reported for all aspects of the consultation. Taking concerns seriously, conducting a physical examination, communicating the treatment plan, explaining treatment decisions and lack of time restrictions were each reported to contribute to patient satisfaction. Conclusions NMPs demonstrate an understanding of patient expectations of RTI consultations and use a range of non-antibiotic management strategies, particularly those resembling a patient-centred approach. Overall, patients' expectations were met and prescribers were not unduly influenced by patient expectations for an antibiotic. Patients were satisfied with the consultation, indicating that strategies used by NMPs were acceptable. However, the lower levels of satisfaction among patients who expected but did not receive an antibiotic indicates that although NMPs appear to have strategies for managing RTI consultations, there is still scope for improvement and these prescribers are therefore an important group to involve in antimicrobial stewardship.

Bread was a central component of the medieval English diet; all social classes consumed bread on a daily basis. Because of a general dependency upon bakers, towns in late medieval England instituted a variety of regulations, like the Assisa Panis, on the weight and quality of bread to ensure that consumers purchased a good-quality loaf, regardless of what type of bread they could afford. Bakers produced tens of types of bread, each made of different grains and associated with different social classes. Medieval regulations also fixed the price of bread, even when the price of grain fluctuated. Many bakers, however, violated these regulations. I have examined printed excerpts of assize hearings for Oxford (1309-1338), Southampton (1482-1483), and London (1292-1437). Using the quantified data from hundreds of hearings and narrative descriptions of baking incidents, I explore the process of regulating bakers, as well as the profession and products of baking.

AimTo investigate GPs’ beliefs about complementary and alternative medicine (CAM) and its role in clinical practice.BackgroundDespite the prevalence of CAM in the United Kingdom, little is known about GPs beliefs regarding these alternative approaches to patient management and how they view it in relation to their clinical conduct and practice.MethodA qualitative study conducted on 19 GPs recruited from the North West of England. Semi-structured telephone interviews were analysed using an inductive thematic analysis.ResultsThree themes emerged from the data: limited evidence base, patient demand and concerns over regulation.ConclusionDespite recognising the limited evidence base of CAM, GPs continue to see a role for it within clinical practice. This is not necessarily led by patient demand that is highly related to affluence. However, GPs raised concerns over the regulation of CAM practitioners and CAM therapies.

Purpose Novel multiple myeloma (MM) therapies have increased patient longevity but are often associated with notable symptom burden. This study quantified the effect of general symptom level, specific symptoms, and treatment-related adverse events (AEs) on MM patients’ health-related quality of life (HRQoL). Methods The European Organization for Research and Treatment of Cancer (EORTC) generic cancer questionnaire (Quality of Life Questionnaire Core 30) and MM-specific questionnaire (QLQ-MY20) were used in this study to assess patients’ HRQoL. Data were collected on sociodemographics, disease and treatment history, and the presence/severity of MM-related symptoms or treatment-related AEs from patients with MM in 11 UK and German centers. Multiple regression analyses were conducted. Results Of 154 patients (63 % male; mean age, 66.4 years; mean time since diagnosis, 3.7 years; 52 % currently on treatment; and 43 % with ≥1 prior MM therapy), 25, 32, 31, and 11 % were severely symptomatic, moderately symptomatic, mildly symptomatic, and asymptomatic, respectively. Fatigue (59 %), bone pain (51 %), sleepiness (36 %), hypoesthesia or paresthesia (33 %), and muscle cramps (31 %) were most commonly reported. Moderate and severe general symptom levels, bone symptoms, depression, and mental status changes were identified as strong determinants of HRQoL. Conclusions Severity, type of disease symptoms, and treatment-related AEs are important HRQoL determinants in patients with MM, allowing for targeted treatment.

While the contribution of behavioural and social sciences for understanding health, illness and medical practice is made explicit in documents such as Tomorrow’s Doctors, research shows that the pr...

Chronic fatigue syndrome receives little attention in the medical curriculum. This study explores UK medical students’ knowledge of and attitudes towards chronic fatigue syndrome. Semi-structured interviews (average length 22 minutes) were conducted with 21 participants (7 females and 14 males) in years 3 ( n = 4), 4 ( n = 11) and 5 ( n = 6) of their studies. Inductive thematic analysis taking a realist perspective produced three themes: limited knowledge, influences on attitudes and training needs. Students acquired their knowledge and attitudes largely from informal sources and expressed difficulty understanding chronic fatigue syndrome within a traditional biomedical framework. Incorporating teaching about chronic fatigue syndrome into the medical curriculum within the context of a biopsychosocial understanding of illness could encourage more positive attitudes towards chronic fatigue syndrome.

BackgroundFibromyalgia syndrome (FMS) is a long-term condition that affects between 1-5% of the general population and lies within the spectrum of medically unexplainedsymptoms (MUS). FMS can be difficult to diagnose and is usually done so as adiagnosis of exclusion. There is continuing debate regarding its legitimacy excluding other causes of symptoms. It is known that the diagnosis and management of MUS, including FMS, receives little attention in medical curricula and attitudes towards patients with FMS amongst medical professionals and trainees can be negative. The purpose of this study was to investigate how attitudes and perspectives of undergraduate medical students towards FMS are acquired during their training.MethodsQualitative interviews with 21 medical students were conducted to explore their views on FMS, encounters with patients with FMS, and where learning about FMS occurs. Participants were recruited from two English medical schools and the study was approved by two University Ethics committees. Interviews were digitally recorded with consent and data analysed thematically, using principles of constant comparison.ResultsThe data were organised within three themes: i) FMS is a complex, poorly understood condition; ii) multiple sources for learning about FMS; and iii) consequences of negative attitudes for patients with FMS.ConclusionUndergraduate medical students have limited understanding of, and are sceptical over the existence of FMS. These attitudes are influenced by the 'hidden curriculum' and witnessing attitudes and actions of their clinical teachers. Students interpret a lack of formal curriculum teaching around FMS to mean that it is not serious and hence a low priority. Encountering a patient, friend or family member with FMS can increase knowledge and lead to altered perceptions of the condition. Teaching and learning about FMS needs to be consistent to improve knowledge and attitudes of clinicians. Undergraduate students should be exposed to patients with FMS so that they better understand patients with FMS.

Summary Background Group psychoeducation is a low-cost National Institute for Health and Care Excellence-recommended treatment for bipolar disorder. However, the clinical effectiveness and acceptability of this intervention are unclear compared with unstructured peer support matched for delivery and aim of treatment, and for previous bipolar history. We aimed to assess the clinical effectiveness and acceptability of structured group psychoeducation versus optimised unstructured peer support for patients with remitted bipolar disorder. Methods We did this pragmatic, multicentre, parallel-group, observer-blind, randomised controlled superiority trial at eight community sites in two regions in England. Participants aged 18 years or older with bipolar disorder and no episode in the preceding 4 weeks were recruited via self-referral or secondary care referral. Participants were individually randomly assigned (1:1), via a computer-generated stochastic allocation sequence, to attend 21 2-h weekly sessions of either structured group psychoeducation or optimised unstructured peer support. Randomisation was minimised by number of previous episodes (one to seven, eight to 19, or ≥20) and stratified by clinical site. Outcome assessors were masked to group allocation. The primary outcome was time from randomisation to next bipolar episode, with planned moderator analysis of number of previous bipolar episodes and qualitative interview of participant experience. We did analysis by intention to treat. This trial is registered with the International Standard Randomised Controlled Trial registry, number ISRCTN62761948. Findings Between Sept 28, 2009, and Jan 9, 2012, we randomly assigned 304 participants to receive psychoeducation (n=153) or peer support (n=151); all (100%) participants had complete primary outcome data. Attendance at psychoeducation groups was higher than at peer-support groups (median 14 sessions [IQR three to 18] vs nine sessions [two to 17]; p=0·026). At 96 weeks, 89 (58%) participants in the psychoeducation group had experienced a next bipolar episode compared with 98 (65%) participants in the peer-support group; time to next bipolar episode did not differ between groups (hazard ratio [HR] 0·83, 95% CI 0·62–1·11; p=0·217). Planned moderator analysis showed that psychoeducation was most beneficial in participants with few (one to seven) previous bipolar episodes (χ 2 ; HR 0·28, 95% CI 0·12–0·68; p=0·034). Four (1%) participants (one in the psychoeducation group and three in the peer-support group) died during follow-up; these deaths were deemed unrelated to the study interventions or procedures. Interpretation Structured group psychoeducation was no more clinically effective than similarly intensive unstructured peer support, but was more acceptable and improved outcome in participants with fewer previous bipolar episodes. Optimum provision of structured psychological interventions, such as group psychoeducation, early in the course of bipolar disorder might have important benefits on the course of illness, and merits further research. Funding National Institute for Health Research.

Objective Sleep problems are associated with increased risk of suicide, independent of depression. This analysis explores narrative accounts of the role of sleep in relation to suicidal thoughts and behaviours. Design Qualitative study, based on in-depth semistructured interviews which were analysed with an inductive, latent thematic analysis. Participants A maximum variation sample of 18 people with experience of a major depressive episode, and suicidal thoughts and behaviours. Setting Primary care, North West England. Results Respondents emphasised the importance of sleep for recovery and management of their mental well-being. Moreover, three inter-related pathways were identified, whereby beliefs about sleep contributed to suicidal thoughts and behaviours. First, being awake during the biological night heightened risk of suicidal behaviours, as this was perceived to be an opportune time for a suicide attempt due to the decreased chances that a friend of family member would intervene during a suicide attempt. Additionally, the reduction in available support at night added to suicide risk. Second, failure to achieve good sleep was perceived to make life harder through contributing to core features of depression, such as negative thinking, attention difficulties and inactivity. Third, sleep acted as an alternative to suicide, by providing an escape from problems, including mental health problems, in waking life. However, this desire to sleep to escape was associated with excessive daytime sleeping, which subsequently may reinforce disturbed sleeping patterns. Conclusions Sleep problems should be an important treatment target when working with suicidal clients. More broadly, night-time service provision should be considered when developing suicide prevention initiatives.

RationaleProstate cancer is a leading cause of cancer in men, affecting one in eight. An ageing population coupled with increased testing indicates that the incidence of early-stage prostate cancer is rising rapidly. Treatments are effective, but all can result in chronic sexual side effects and impact on the psychological, emotional and relational components of sexual functioning. Whilst the physical consequences of treatment are well documented, we lack a comprehensive picture of the effects of localised prostate cancer treatment on men’s experience of sexual intimacy and how this may affect survivorship and recovery.ObjectiveThis study synthesises the qualitative literature related to men’s experience of sexual intimacy in the context of localised prostate cancer.MethodsA systematic search strategy identified 12 studies, which were assessed using a modified version of the Critical Appraisal Skills Programme. Using Noblit and Hare’s (1988) approach, a meta-synthesis was conducted.ResultsFindings are organised within four inter-related themes that form the basis of a new conceptual explanatory model: (i) Loss and grief: Destroyed intimacy; (ii) Going through the motions: Artificial intimacy; (iii) Fear of failure: Avoiding intimacy and (iv) Breaking barriers: Constructing an alternative intimacy.ConclusionThe LMAC (Loss, Motions, Avoidance and Construction) model provides a new way of conceptualising sexual recovery following prostate cancer treatment and opportunities for health care professionals to support men and their partners.

Background Rheumatoid arthritis (RA) is a long term condition that requires early treatment to control symptoms and improve long-term outcomes. Lack of response to RA treatments is not only a waste of healthcare resources, but also causes disability and distress to patients. Identifying biomarkers predictive of treatment response offers an opportunity to improve clinical decisions about which treatment to recommend in patients and could ultimately lead to better patient outcomes. The aim of this study was to explore the understanding of and factors affecting Rheumatoid Arthritis (RA) patients’ decisions around predictive treatment testing. Methods A qualitative study was conducted with a purposive sample of 16 patients with RA from three major UK cities. Four focus groups explored patient perceptions of the use of biomarker tests to predict response to treatments. Interviews were audio-recorded, transcribed verbatim and analysed using thematic analysis by three researchers. Results Data were organised within three interlinking themes: [1] Perceptions of predictive tests and patient preference of tests; [2] Utility of the test to manage expectations; [3] The influence of the disease duration on take up of predictive testing. During consultations for predictive testing, patients felt they would need, first, careful explanations detailing the consequences of untreated RA and delayed treatment response and, second, support to balance the risks of tests, which might be invasive and/or only moderately accurate, with the potential benefits of better management of symptoms. Conclusions This study provides important insights into predictive testing. Besides supporting clinical decision making, the development of predictive testing in RA is largely supported by patients. Developing strategies which communicate risk information about predictive testing effectively while reducing the psychological burden associated with this information will be essential to maximise uptake.

Background: The way parents care for children during displacement plays a key role in their emotional and behavioural outcomes. Sparse literature exists regarding the parenting challenges faced by families fleeing conflict in transitional, preresettlement stages. This study aimed to identify the parenting experiences of Syrian families living in refugee camps, focusing on understanding how their parenting had changed and the impact this had on their parenting.Method: Interviews and focus groups were conducted with 27 mothers living in refugee contexts, plus two interviews with professional aid workers. Data were analysed using thematic analysis.Results: Data were structured in three themes; 1) environmental challenges; 2) child specific challenges, such as an increase in negative behaviours and emotions and symptoms of trauma; 3) parent specific challenges, including maladaptive parenting techniques and emotional difficulties. Parents reported how these challenges impacted on their perceived ability to support their children. Conclusion: Parents struggled physically and emotionally to support their children. There are clear ways such challenges could be addressed by parenting interventions to reduce the trauma impact experienced by children, the challenges they are living with and will face in the future. This study is important for policy and humanitarian organisations working in preresettlement contexts.

Objective: To systematically search and synthesise qualitative studies of physicians’ views and experiences of discussing weight management within a routine consultation.Methods: A systematic search of four electronic databases identified 11,169 articles of which 16 studies met inclusion criteria. Quality was appraised using the Critical Appraisal Skills Programme tool and a thematic synthesis conducted of extracted data. Results: Four analytical themes were found: (1) physicians’ pessimism about patients’ weight loss success (2) physicians’ feel hopeless and frustrated (3) the dual nature of the physician-patient relationship (4) who should take responsibility for weight management.Conclusion: Despite clinical recommendations barriers remain during consultations between physicians and patients about weight management. Many of these barriers are potentially modifiable. Practice implications: Improving training, providing clearer guidelines and placing a greater emphasis on collaboration within and between clinicians will help reduce barriers for both physicians and patients. In particular, there is an urgent need for more specialised training for physicians about weight management to promote knowledge and skills in behaviour change techniques and ways to broach sensitive topics without damaging patient relationships. Key words: weight management, patient-physician relationship, meta synthesis

Background Previous research has highlighted that many GPs lack the confidence and knowledge to diagnose and manage people with CFS/ME. Following the development of an online training module for GPs, and an information pack and DVD for patients, this study explored the extent to which these resources can be implemented in routine primary care. Methods Semi structured qualitative interviews were completed with patients and GPs across North West England. All interviews were transcribed and analysed using open exploratory thematic coding. Following this thematic analysis, the authors conducted a further theory-driven analysis of the data guided by Normalisation Process Theory. Results When used in line with advice from the research team, the information resource and training were perceived as beneficial to both patients and GPs in the diagnosis and management of CFS/ME. However, 47 % of patients in this study did not receive the information pack from their GP. When the information pack was used, it was often incomplete, sent in the post, and GPs did not work with patients to discuss the materials. Only13 out of 21 practices completed the training module due to time pressures and the low priority placed on low prevalence, contentious, hard to manage conditions. When the module was completed, many GPs stated that it was not feasible to retain the key messages as they saw so few patients with the condition. Due to the complexity of the condition, GPs also believed that the diagnosis and management of CFS/ME should take place in a specialist care setting. Conclusion While barriers to the implementation of training and resources for CFS/ME remain, there is a need to support CFS/ME patients to access reliable, evidence based information outside primary care. Our findings suggest that future research should develop an online resource for patients to support self-management. Electronic supplementary material The online version of this article (doi:10.1186/s12875-016-0453-8) contains supplementary material, which is available to authorized users.

Introduction: Evidence suggests that psychosocial management may produce improved outcomes for patients suffering from chronic orofacial pain (COFP), when symptoms cannot be attributed to pathology. A complex intervention, based on cognitive behavioural therapy (CBT) was developed by a multi-disciplinary team, using evidence synthesis. An important element of developing and evaluating complex interventions is to establish acceptability to stakeholders; therefore qualitative interviews with patients were carried out. Objectives: To explore levels of acceptability of a complex intervention to manage COFP. Method: Semi-structured interviews were carried out with 17 participants who had been referred to the intervention. Thematic analysis was used to identify emerging issues and themes from the data. Results: Themes relating to processes of engagement with the intervention emerged. Important processes were: identification with the intervention; feeling believed and understood; obtaining a plausible explanation for symptoms; degree of perceived effort required to engage; acceptance of having a long-term condition; and receiving demonstrative, positive feedback. Conclusion: Patients presenting with unexplained COFP in a secondary care setting are able to accept a CBT based intervention to manage their condition. Findings may offer guidance for dentists who are not used to referring patients to psychosocial interventions and inform the way dentists communicate the nature of unexplained symptoms to patients.

Almost all introductory physics classes will, at some point, include springs and elastic forces. When studying such topics, it is interesting to consider the spring system shown in Fig. 1. In this system, two identical springs are arranged with the top of one spring anchored to the ceiling and the bottom of the second spring attached to a hanging weight. The two springs are then connected by a “middle” string, c. There are two other strings that are not tensioned (strings d and b), one connecting the ceiling and the bottom spring, and the other connecting to the hanging weight and the top spring. As indicated in Fig. 1, these two “support” strings have some slack in them.

Exposure to environmental contaminants, particularly pesticides, may be an important etiological factor in Parkinson's disease (PD); and evidence suggests a role for microglia-dependent inflammatory and oxidative processes in nigrostriatal pathology induced by such toxins. Yet, the events mediating microglial activation and their effects are not fully known. To this end, we hypothesized that the proinflammatory cytokine, interferon-gamma (IFN-γ), may be a prime factor in the pathogenesis of PD, given its critical role in regulating microglial responses to pathogens. Indeed, the present investigation demonstrated that genetic deletion of IFN-γ protected substantia nigra pars compacta (SNc) dopamine (DA) neurons from the toxic effects of the pesticide, paraquat, and normalized changes in inflammatory and oxidative factors within this brain region. Specifically, IFN-γ knockout prevented the paraquat-induced morphological signs of microglial activation and expression of key nicotinamide adenine dinucleotide phosphate (NADPH) oxidase subunits, while also preventing time-dependent changes in proinflammatory enzymes (inducible nitric oxide synthase [iNOS], cyclooxygenase-2 [COX-2]), cytokines (interleukin-1β [IL-1β], tumor necrosis factor-α [TNF-α]), and signaling factors (c-Jun N-terminal kinase [JNK], p38 MAP kinase [p38], Signal transducer and activator of transcription-1 [STAT1], nuclear factor kappa B [NF-κB]). Moreover, paraquat transiently suppressed substantia nigra pars compacta expression of trophic and proneuroplastic factors (cyclic-AMP response element binding protein [CREB], brain-derived neurotrophic factor [BDNF]), and IFN-γ deficiency again reversed these effects. These data suggest that IFN-γ is important for paraquat-induced neurodegeneration and the accompanying oxidative, inflammatory, and trophic changes that characterize the response to the toxin. Targeting IFN-γ could thus have therapeutic implications for PD and other neurodegenerative conditions that involve multiple inflammatory pathways.

PURPOSE: Doctors will increasingly encounter opportunities to support obese patients in lifestyle change efforts, but the extent to which medical schools prepare their students for this challenge is unknown. Further, despite evidence indicating theory-based techniques are effective in facilitating patients' behavioral changes, the methods taught to medical students and the means of content delivery are unclear. The authors reviewed the literature to investigate how effective educational interventions are in preparing medical students to facilitate lifestyle changes with obese patients. METHOD: The authors systematically searched Excerpta Medica (EMBASE), PsycINFO, MEDLINE, and Scopus for educational interventions on obesity management for medical students published in English between January 1990 and November 2010 and matching PICOS (Population, Interventions, Comparators, Outcomes, Study design) inclusion criteria. RESULTS: Results of a narrative synthesis are presented. Of 1,680 studies initially identified, 36 (2%) full-text articles were reviewed, and 12 (1%) were included in the final dataset. Eleven (92%) of these studies had quantitative designs; of these, 7 (64%) did not include control groups. Nine (75%) of the 12 studies were atheoretical, and 4 (33%) described behavior management strategies. Despite positive reported outcomes regarding intervention evaluations, procedures to control for bias were infrequently reported, and conclusions were often unsupported by evidence. CONCLUSIONS: Evidence from this systematic review revealed data highly susceptible to bias; thus, intervention efficacy could not be determined. Additionally, evidence-based strategies to support patients' obesity-related behavior changes were not applied to these studies, and thus it remains unknown how best to equip medical students for this task.

AIMS: To report a qualitative study of the experiences of nurse prescribers in managing patients with self-limiting respiratory tract infections. BACKGROUND: Patients frequently attend primary care with respiratory tract infections. Although a no-prescribing strategy is recommended for these consultations, general practitioners frequently prescribe antibiotics, citing non-clinical reasons such as patient pressure. Nurses increasingly manage people with respiratory tract infections, but research has not yet explored their experiences within such consultations. DESIGN: Semi-structured interviews and focus groups. METHODS: Fifteen semi-structured interviews and three focus groups (n=5, n=4, and n=12) with a purposive sample of nurse prescribers (n=34) and other non-medical prescribers (n=2) were conducted between November 2009-November 2010. A qualitative approach was used to develop conceptual categories from the dataset, and emerging themes were explored in subsequent interviews/focus groups. FINDINGS: Although participants reported experiencing numerous challenges within these consultations, they believed that they possessed some of the communication skills to deal effectively with patients without prescribing antibiotics. Participants reported that protocols supported their decision-making and welcomed the benefits of peer support in dealing with 'demanding' patients. However, the newness of nurses and other non-medical prescribers to the prescribing role meant that some were cautious in dealing with patients with respiratory tract infections. CONCLUSION: Training for nurses and other non-medical prescribers should focus on building their confidence and skills to manage people with respiratory tract infections without recourse to antibiotics. Further work should seek to explore which strategies are most effective in managing respiratory tract infections while maintaining patient satisfaction with care.

Salmonella enterica is a major cause of morbidity worldwide and mortality in children and immunocompromised individuals in sub-Saharan Africa. Outer membrane proteins of Salmonella are of significance because they are at the interface between the pathogen and the host, they can contribute to adherence, colonization, and virulence, and they are frequently targets of antibody-mediated immunity. In this study, the properties of SadA, a purported trimeric autotransporter adhesin of Salmonella enterica serovar Typhimurium, were examined. We demonstrated that SadA is exposed on the Salmonella cell surface in vitro and in vivo during infection of mice. Expression of SadA resulted in cell aggregation, biofilm formation, and increased adhesion to human intestinal Caco-2 epithelial cells. Immunization of mice with folded, full-length, purified SadA elicited an IgG response which provided limited protection against bacterial challenge. When anti-SadA IgG titers were enhanced by administering alum-precipitated protein, a modest additional protection was afforded. Therefore, despite SadA having pleiotropic functions, it is not a dominant, protective antigen for antibody-mediated protection against Salmonella .

Equitable access to primary care for people with common mental health problems in the UK remains problematic. The experiences of people from hard-to-reach groups offer important insights into barriers to accessing care. In this study, we report on secondary analysis of qualitative data generated within seven previously-reported studies. Thirty-three of ninety-two available transcripts were re-analysed using a new heuristic of access, generated to frame narrative-based comparative case analysis. The remaining transcripts were used to triangulate the findings via a process of collaborative analysis between a secondary researcher, naïve to research findings of the original studies, and primary researchers involved in data generation and analysis within the original studies. This method provided a rich body of 'fine grain' insights into the ways in which problem formulation, help-seeking, use of services and perceptions of service quality are interlinked in a recursive and socially embedded matrix of inequitable access to primary mental health care. The findings indicate both extensive commonalities between experiences of people from different 'hard-to-reach groups', and considerable diversity within each group. An idiographic generalisation and aggregation of this variety of experiences points to one main common facilitator (communicated availability of acceptable mental health services) and two main common barriers (lack of effective information and multiple forms of stigma) to equitable access to primary mental health care. We conclude that there is a need to provide local care that is pluralistic, adaptive, holistic, resonant and socially conscious in order to ensure that equitable access to mental health services can become a reality.

Background Suicide is one of the leading causes of premature death in schizophrenia. The lifetime risk of death by suicide in people with schizophrenia is around 10 per 100 people. Some people can counter the impact of suicide risk (e.g., life stressors) by incorporating personal skills and experiences. Although exposure to life stressors can have a detrimental effect on mental health, this does not apply to everyone, as some individuals appear protected from the impact of stress. The notion of resilience in mental health has recently gained research attention. Resilience has been defined as an individual’s skills or resources that help them manage suicidal thoughts and feelings. Consistent with this definition, it is important to understand the psychological factors that contribute to resilience to the frequency and severity of suicidal thoughts and behaviours. We aimed to examine the experiences of psychological resilience to suicidal thoughts and behaviours of people with schizophrenia-spectrum mental health problems. Methods We conducted face-to-face interviews with 20 individuals with experiences on the schizophrenia spectrum and lifetime experiences of suicidal thoughts, plans, and behaviours. Participants were recruited from community mental health services in the North-West of England, UK. A topic guide for semi-structured interviews was used to facilitate participants’ descriptions of their experiences in their own words. All interviews were audio-recorded, with participants’ consent, and transcribed verbatim. Thematic analysis was used to examine the themes and patterns within the data which were important in addressing the research aim. Results The majority of the participants were white British, single, and living alone. The average age of the sample was 48 years (SD = 14.4; range: 23–75 years) and 50% were female. Several factors were involved in promoting psychological resilience. Participants described strategies that indicated they were being active in maintaining and developing their resilience. These included cognitive reasoning (e.g., rationalising and validating experiences) and active coping strategies (e.g., acceptance of experiences, perseverance). Perceived social support from significant others and mental health professionals (e.g., care coordinators, psychiatrists) also played an important role in bolstering individual resilience. Discussion This is the first study to showcase the experiences of resilience to suicidal thoughts and behaviours from the unique perspective of individuals with mental health problems on the schizophrenia spectrum and a range of suicidal experiences (e.g., ideation, attempts, plans). The data indicated that resilience to suicidal thoughts and behaviours developed over time, through the experience of managing psychotic symptoms and their deleterious impact on individual wellbeing. People employed different types of coping strategies, depending on the severity of their psychotic symptoms and suicidal feelings. However, if their symptoms became severe, they usually sought support from mental health services. Efforts to develop psychological resilience to suicidal thoughts and behaviours in individuals with schizophrenia are of paramount importance to clinical research and practice. It is important to consider the impact of psychotic symptoms, which were the main precipitating factors of suicidal thoughts and behaviours for most participants, in the development of psychological resilience. Of note, only individuals under the care of mental health services were recruited into the study. Future research should explore the resilience experiences of people not accessing mental health services.

Purpose: Gastrointestinal dysmotility (GID) covers a spectrum of disorders disrupting enteric neuromuscular co-ordination which, when severe, causes intractable gastrointestinal symptoms, malnutrition and is a recognised cause of chronic intestinal failure. To date, no study has provided an in-depth account of the experiences of patients with severe GID and their psychosocial needs. This study aimed to explore patients’ experiences from symptom onset and the process of seeking and receiving a diagnosis. It specifically explored the psychological effect of this process and the effect on relationships.Methods: Participants (n=20, mean age=47.9, female n=16, parenteral nutrition=13) were recruited from a UK centre with tertiary Neurogastroenterology and Intestinal Failure services. A qualitative exploratory design with semi-structured in-depth interviews was used. Data was analysed using thematic analysis. Results: Significant delays were experienced in obtaining a diagnosis. Participants reported having their mental health questioned and felt they had to fight to prove their symptoms had a physical basis to access appropriate treatment. Although a diagnosis helped legitimise symptoms, the condition remained poorly understood by participants themselves, relatives, and health professionals. Participants discussed the impact that ‘feeling delegitimised’ and the ‘lack of coherent understanding of GID’ had on their relationships and mental health.Conclusions: The distressing experience of GID symptoms are compounded by a delay in validating symptoms and lack of coherent understanding. More knowledge of GID is needed by health professionals to speed up diagnosis and offer more coherent information. The psychological impact of a GID diagnosis should be acknowledged early to help facilitate adjustment.

BackgroundRelapse prevention for bipolar disorder increases time to relapse but is not available in routine practice.AimsTo determine the feasibility and effectiveness of training community mental health teams (CMHTs) to deliver enhanced relapse prevention.MethodIn a cluster randomised controlled trial, CMHT workers were allocated to receive 12 h training in enhanced relapse prevention to offer to people with bipolar disorder or to continue giving treatment as usual. The primary outcome was time to relapse and the secondary outcome was functioning.ResultsTwenty-three CMHTs and 96 service users took part. Compared with treatment as usual, enhanced relapse prevention increased median time to the next bipolar episode by 8.5 weeks (hazard ratio 0.79, 95% CI 0.45–1.38). Social and occupational functioning improved with the intervention (regression coefficient 0.68, 95% CI 0.05–1.32). The clustering effect was negligible but imprecise (intracluster correlation coefficient 0.0001, 95% CI 0.0000–0.5142).ConclusionsTraining care coordinators to offer enhanced relapse prevention for bipolar disorder may be a feasible effective treatment. Large-scale cluster trials are needed.

BackgroundIn reattribution, general practitioners (GPs) request psychosocial information directly and explain medically unexplained symptoms (MUS) using psychosocial information in the consultation. We explored whether reattribution training (RT) increased the communication of psychosocial information and decreased communication about somatic intervention between GPs and their MUS patients.MethodA cluster randomized controlled trial (RCT) of RT versus usual treatment in GPs from 16 practices and 141 patients with MUS on audio-recorded and transcribed doctor–patient communication in an index consultation. In a secondary data analysis, the Liverpool Clinical Interaction Analysis Scheme (LCIAS) was applied by an experienced rater to each turn of speech in the transcript from the index consultation blind to treatment allocation.ResultsAfter RT, patients were more likely to disclose and discuss psychosocial problems, and propose psychosocial explanations for symptoms; around 25% of patients discussed psychosocial information extensively. In the RT group, GPs did not seek new psychosocial disclosure but they reduced advocacy for somatic intervention. After RT, GPs suggested, on average, two utterances of psychosocial explanation and six utterances of somatic intervention.ConclusionsAfter RT, some patients discussed psychosocial issues extensively but GPs did not probe underlying psychosocial issues. They gave mixed psychosocial and somatic messages about MUS, which may have increased patients' concerns about their health. GPs should actively seek the disclosure of underlying psychosocial problems and give clear, unambiguous messages to MUS patients when they are willing to discuss psychosocial issues.

The glycolytic enzyme triosephosphate isomerase (tpi) (EC 5.3.1.1) plays a key role in central carbon metabolism yet few studies have characterized isogenic bacterial mutants lacking this enzyme and none have examined its role in the in vivo fitness of a bacterial pathogen. Here we have deleted tpiA in Salmonella enterica serovar Typhimurium and found that the mutant had an altered morphology, displaying an elongated shape compared with the wild type. In a mouse model of typhoid fever the tpiA mutant was attenuated for growth as assessed by bacterial counts in the livers and spleens of infected mice. However, this attenuation was not deemed sufficient for consideration of a tpiA mutant as a live attenuated vaccine strain. These phenotypes were complemented by provision of tpiA on pBR322. We therefore provide the first demonstration that tpiA is required for full in vivo fitness of a bacterial pathogen, and that it has a discernable impact on cell morphology.

Background Few systematic studies have examined the reasons why patients with bipolar disorder and substance use disorders misuse alcohol and drugs of abuse. Such reasons may depend heavily on context so qualitative research methods that made no prior theoretical assumptions were employed. We explored the reasons patients give for misusing drugs and alcohol and how these relate to their illness course. Method Qualitative semi-structured interviews and thematic analysis with a purposive sample of 15 patients with bipolar disorder and a current or past history of drug or alcohol use disorders. Results Patients based their patterns of and reasons for substance use on previous personal experiences rather than other sources of information. Reasons for substance use were idiosyncratic, and were both mood related and unrelated. Contextual factors such as mood, drug and social often modified the patient's personal experience of substance use. Five thematic categories emerged: experimenting in the early illness; living with serious mental illness; enjoying the effects of substances; feeling normal; and managing stress. Limitations The prevalence of these underlying themes was not established and the results may not apply to populations with different cultural norms. Conclusions Patterns of substance use and reasons for use are idiosyncratic to the individual and evolve through personal experience. Motivating the patient to change their substance use requires an understanding of their previous personal experience of substance use both in relation to the different phases of their bipolar disorder and their wider personal needs.

Salmonella enterica serovar Typhimurium (S. Typhimurium) infection causes an inflammatory response through activation of Toll-like receptor 4 by lipopolysaccharide. Dexamethasone, a glucocorticoid analogue, suppresses inflammatory responses by many mechanisms including inhibition of the lipopolysaccharide-induced production of proinflammatory mediators. There is little information on the effect of glucocorticoids on murine salmonellosis. In this study, we treated susceptible BALB/c mice by subcutaneous implantation of slow-release dexamethasone pellets before infection with S. Typhimurium. Dexamethasone promotes bacterial growth early in infection and induces a dose-dependent increase in bacterial growth within mouse livers and spleens. The bacterial load in organs from infected placebo-treated mice was lower than that in dexamethasone-treated mice. Glucocorticoids inhibit lipopolysaccharide-induced inflammation partially through the steroid-inducible protein annexin-A1 (ANXA1). Infection of wild-type and ANXA1 knock-out mice with S. Typhimurium led to similar organ bacterial loads. ANXA1 also did not affect the bacterial load in organs from infected dexamethasone-treated mice. This suggests that glucocorticoids, independently of ANXA1, accelerate S. Typhimurium growth in vivo in susceptible BALB/c mice.

PURPOSE Chronic fatigue syndrome (CFS), or myalgic encephalitis (ME), is a contentious condition and often a diagnosis of exclusion. Current policy in the United Kingdom recommends management in primary care. We explored how patients with CFS/ME and family physicians understand this condition and how their understanding might affect the primary care consultation. METHODS We undertook a qualitative study with patients and family physicians from North West England participating in a primary care–based randomized controlled trial (FINE Trial). Data were collected through purposive sampling and in-depth semistructured interviews with 24 patients and 14 family physicians. We analyzed interview transcripts using constant comparison methods. RESULTS Family physicians access social and cultural knowledge to reach a clinical understanding of CFS/ME and its management. Patients recognize the difficulties family physicians encounter in understanding their symptoms and access similar nonclinical sources of information. We suggest that both patients and physicians use biomedical discourse within the consultation: the physician to maintain the position as an expert, the patient to engage the physician. CONCLUSIONS Family physicians obtain information about CFS/ME from their nonprofessional world, which they incorporate into their professional realm. Patients and physicians describe the use of the discourse of science within consultations about CFS/ME. This form of shared understanding could lead to a positive collaborative interaction. Family physicians need a biomedical, evidence-based knowledge about CFS/ME. There is potential to use the rich knowledge base that patients can bring to consultations in training initiatives directed at family physicians.

PurposeWith a growing focus on the importance of men's reproductive health, including preconception health, the ways in which young men's knowledge, attitudes, and beliefs (KAB) predict their reproductive paths are understudied. To determine if reproductive KAB predicts fatherhood status, timing and residency (living with child or not).MethodsReproductive KAB and fatherhood outcomes were analyzed from the National Longitudinal Study of Adolescent Health, a 20-year, nationally representative study of individuals from adolescence into adulthood. Four measures of reproductive KAB were assessed during adolescence in waves I and II. A generalized linear latent and mixed model predicted future fatherhood status (nonfather, resident/nonresident father, adolescent father) and timing while controlling for other socio-demographic variables.ResultsOf the 10,253 men, 3,425 were fathers (686 nonresident/2,739 resident) by wave IV. Higher risky sexual behavior scores significantly increased the odds of becoming nonresident father (odds ratio [OR], 1.30; p < .0001), resident father (OR, 1.07; p = .007), and adolescent father (OR, 1.71; p < .0001); higher pregnancy attitudes scores significantly increased the odds of becoming a nonresident father (OR, 1.20; p < .0001) and resident father (OR, 1.11; p < .0001); higher birth control self-efficacy scores significantly decreased the odds of becoming a nonresident father (OR, .72; p < .0001) and adolescent father (OR, .56; p = .01).ConclusionsYoung men's KAB in adolescence predicts their future fatherhood and residency status. Strategies that address adolescent males' reproductive KAB are needed in the prevention of unintended reproductive consequences such as early and nonresident fatherhood.

BackgroundReattribution is frequently taught to general practitioners (GPs) as a structured consultation that provides a psychological explanation for medically unexplained symptoms.AimsTo determine if practice-based training of GPs in reattribution changes doctor–patient communication, thereby improving outcomes in patients with medically unexplained symptoms of 3 months' duration.MethodCluster randomised controlled trial in 16 practices, 74 GPs and 141 patients with medically unexplained symptoms of 6 hours of reattribution training v. treatment as usual.ResultsWith training, the proportion of consultations mostly consistent with reattribution increased (31 v. 2%, P=0.002). Training was associated with decreased quality of life (health thermometer difference −0.9, 95% CI −1.6 to −0.1; P=0.027) with no other effects on patient outcome or health contacts.ConclusionsPractice-based training in reattribution changed doctor–patient communication without improving outcome of patients with medically unexplained symptoms.

BACKGROUND: The level of participation in research by GPs is low internationally. Previous reports of the reasons why practitioners decline opportunities for research participation have tended to recount the barriers that they describe as if they are objective accounts. OBJECTIVE: By theoretical sampling of practitioners who had declined to participate in a research trial, we sought to interpret the functional significance and interrelationship of the barriers that they reported. METHODS: Twenty-three GPs who had declined to participate in a trial of training to manage medically unexplained symptoms were interviewed and their accounts analysed interpretatively. RESULTS: The practitioners described general practice and research as alien fields. Research lacked intrinsic, clinical or professional value and was linked to evidence-based medicine which they rejected as incompatible with person-centered care. Every doctor described a lack of time for research, but time was an elastic resource that payment could release from the reservoir of their 'own time'. CONCLUSION: The findings should inform the design and interpretation of future quantitative surveys to identify how common the attitudes that we report are. Doctors with the attitudes of those whom we interviewed will not be drawn into research by measures predicated on the assumption that it is intrinsically, clinically or professionally valuable. If they cannot be convinced of its utility, value could be conferred by payment for participation.

Background General practitioners’ (GPs) communication with patients presenting medically unexplained symptoms (MUS) has the potential to somatize patients’ problems and intensify dependence on medical care. Several reports indicate that GPs have negative attitudes about patients with MUS. If these attitudes deter participation in training or other methods to improve communication, practitioners who most need help will not receive it. Objective To identify how GPs’ attitudes to patients with MUS might inhibit their participation with training to improve management. Design Qualitative study. Participants GPs (N = 33) who had declined or accepted training in reattribution techniques in the context of a research trial. Approach GPs were interviewed and their accounts analysed qualitatively. Results Although attitudes that devalued patients with MUS were common in practitioners who had declined training, these coexisted, in the same practitioners, with evidence of intuitive and elaborate psychological work with these patients. However, these practitioners devalued their psychological skills. GPs who had accepted training also described working psychologically with MUS but devalued neither patients with MUS nor their own psychological skills. Conclusions GPs’ attitudes that suggested disengagement from patients with MUS belied their pursuit of psychological objectives. We therefore suggest that, whereas negative attitudes to patients have previously been regarded as the main barrier to involvement in measures to improve patient management, GPs devaluing of their own psychological skills with these patients may be more important.