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Anas Tahir,1,* Mohaimen Al-Zubaidy,1,* Danial Naqvi,1 Ali Tarfiee,1 Falak Naqvi,1 Anam Malik,1 Sarina Vara,2 Edgar Meyer31Imperial College School of Medicine, Imperial College, London, UK; 2Faculty of Medicine, University of Manchester, Manchester, UK; 3Imperial College Business School, Imperial College Business School, London, UK*These authors contributed equally to this workBackground: A pilot study to identify if the delivery of teaching session to medical students would have the potential to enhance communication and a culture of integration between primary and social care, ultimately improving interprofessional relationships between primary and social care. Health and social care integration is a topic of great debate in the developed world and the focus of the upcoming Green Paper by the Secretary of State for Health and Social Care in the NHS. There is much uncertainty to how this should be done and is hindered by the various current barriers. The literature identifies that collaborative cultures encourage effective interprofessional relationships and that communication is vital to integration of primary and social care and should be established early in medical training.Materials and Method: The General Medical Council’s Outcomes for Graduates and Imperial College School of Medicine curriculum were reviewed out to identify outcomes relating to inter-professional relationships between primary and social care. The relevant year group was surveyed to identify if the learning objective was delivered. In order to determine if delivery of a teaching session on nurturing interprofessional relationships between primary and social care would be effective, it was delivered to early clinical years to measure benefits as a pilot study. This was devised of case-based scenarios derived from learning objectives developed with experienced health care professionals. A survey was administered before and after the teaching session to determine if the students felt they had improved with respect to the learning objectives.Results: The initial survey identified the majority of students found the learning objectives were not delivered. The teaching session found a statistically significant improvement in confidence to nurture interprofessional relationships between primary and social care.Conclusion: Effective interprofessional relationships between primary and social care, improving communication and collaborative cultures, can be effectively taught in medical school, to improve integration of primary and social care.Keywords: interprofessional, primary care, social, integration, communication

Anas Tahir, Mohaimen Al-Zubaidy, Husein RajabaliFaculty of Medicine, Imperial College London, London, UKWe read with great interest the article by Patel and Burke-Gaffney exploring the benefits and potential drawbacks of using mobile tablet computers as part of the curriculum and discussing the use of devices across Imperial College School of Medicine (ICSM).1 As ICSM students involved in the scheme, we feel we might be able to offer unique perspectives on the daily use of devices and the use of devices for teaching.View original paper by Patel and Burke-Gaffney.

Synthetic model systems of single strength normal local lemon juice were prepared with different contents of some compounds ( ascorbic acid, reducing sugar, and amino acids ) that may play an important role in brown pigments (Melanoidins) formation samples were stored at 25 and 35 °C for 12 weeks. Results showed that the main brown pigment formation pathway in these highly acidic synthetic model systems (pH < 2.5) was ascorbic acid decomposition aerobic (oxidation) and anaerobic (acid catalysis) pathways rather than reducing sugar degradation by acid catalysis and Strecker decomposition of amino acids .The results showed that the highest rate of brown pigments formation was in synthetic model system which contain all components with similar ratio of model systems contain ascorbic acid .

Background: Ketamine produces ordinary general anesthesia characterized by weak hypnosis and analgesia leading to complications during surgical operations. Aims: The aim of this study was to evaluate the combination of ketorolac or tramadol to enhance ketamine anesthesia in 7 to 20-day-old chicks and its feasibility and practical application for induction of general anesthesia in veterinary medicine. Methods: Hypnotic and analgesic Median Effective Doses (ED50s) of ketamine alone and combination with tramadol or ketorolac were determined by the up-and-down method, then the ED50 values of these combinations were used for measurement of hypnotic and analgesic criteria moreover, their effect on serum Aspartate Aminotransferase (AST) and Alanine Aminotransferase (ALT) was assayed. Results: Ketamine hypnosis and analgesia were increased when mixed with tramadol (26 and 39%) or ketorolac (27 and 40%), respectively. Ketamine-ketorolac mixture was better combination of inducing the faster onset of anesthesia and short recovery with the longest duration of action and enhancing analgesia when compared to ketamine alone or in combination with tramadol and is preferred for induction of anesthesia. The liver function enzymes, including AST and ALT, showed no significant difference among all above mentioned groups. Conclusion: The data of this experimental study reveal the superiority of using ketorolac (instead of tramadol) in combination with ketamine for induction of general anesthesia in the chicks. [ABSTRACT FROM AUTHOR]

Limited information is available on the pharmacokinetics and bioavailability of aspirin and acetaminophen in young chicks. The purpose of the present study was to examine the pharmacokinetics of acetyl salicylic acid (aspirin) and acetaminophen in 12-day old chicks after a single intraperitoneal administration of each drug alone at the dose of 100 mg/kg body weight. Blood samples were collected from chicks (six/each time period) at 10, 20, 30, 60 and 120 min after each drug administration. The concentrations of aspirin and acetaminophen in the plasma were determined by spectrophotometric methods. The pharmacokinetic parameters of the drugs were calculated by a non-compartmental analysis. The elimination half-lives of aspirin and acetaminophen were 1.68 and 1.36 h with steady state volume of distributions 0.079 and 1.11 l/kg and total body clearances of 0.029 and 0.53 l/h/kg, respectively. The mean residence times of the drugs were 2.74 and 2.09 h and their area under the plasma concentration-time curves (0-∞) were 3486 and 188 µg·h/ml, respectively. In conclusion, the data show the pharmacokinetic profiles of single intraperitoneal doses of aspirin and acetaminophen in chicks and suggest that acetaminophen is well distributed in the body of the chicks and eliminated faster from the body compared to aspirin. These parameters should be taken into consideration in further therapeutic and toxicological studies of drugs in chickens. [ABSTRACT FROM AUTHOR]

The genus Bactrocera (Diptera: Tephritidae) includes ≈70 polyphagous species that are major pests of fruit and vegetable crops. Most Bactrocera species have limited geographic distributions, but several species are invasive, and many countries operate continuous trapping programs to detect infestations. In the United States, California maintains ≈25,000 traps (baited with male lures) specifically for Bactrocera detection distributed over an area of ≈6,400 km² (2,500 miles²) in the Los Angeles area. Although prior studies have used male lures to describe movement of Bactrocera males, they do not explicitly relate capture probability with fly distance from lure-baited traps; consequently, they do not address the relative effectiveness of male lures in detecting incipient populations of Bactrocera species. The objective of this study was to measure the distance-dependent capture probability of marked, released males of Bactrocera dorsalis (Hendel) and Bactrocera cucurbitac (Coquillett) (methyl eugenol- and cue lure-responding species, respectively) within the detection trapping grid operating in southern California. These data were then used to compute simple probability estimates for detecting populations of different sizes of the two species. Methyl eugenol was the more powerful attractant, and based on the mark-recapture data, we estimated that B. dorsalis populations with as few as ≈50 males would always (>99.9%) be detected using the current trap density of five methyl eugenol-baited traps per 2.6 km² (1 mile²). By contrast, we estimated that certain detection of B. cucurbitae populations would not occur until these contained ≈350 males. The implications of the results for the California trapping system are discussed, and the findings are compared with mark-release-recapture data obtained for the same two species in Hawaii. [ABSTRACT FROM AUTHOR]

Abstract Background Metoclopramide is a dopamine D2-receptor antagonist used as an antiemetic and gastroprokinetic agent in man and animals. The drug causes sedation as a side effect in man. Such a sedative action of metoclopramide has not been documented in the chicken as the drug is not used clinically in this species. The present study examines the central nervous system depressant effects of metoclopramide in 7–14 days old broiler chicks. Results Injection of metoclopramide at 50, 100 and 200 mg/kg, subcutaneously (s.c.) induced sedation in the chicks in a dose dependent manner. The chicks manifested, within 3.6–19 minutes of metoclopramide injection, signs of sedation characterized by drooping of the head and wings, closed eyelids, reduced motility and decreased distress calls. The duration of sedation ranged between 37.2 to 163.4 minutes. Metoclopramide at 100 and 200 mg/kg induced, within 12.2 and 6.2 minutes, sleep (loss of righting reflex) for 43.8 and 158.6 minutes, respectively. The median effective doses of metoclopramide for induction of sedation and sleep in the chicks were 11 and 53 mg/kg, s.c., respectively. Lower doses of metoclopramide (5 and 10 mg/kg, s.c.) significantly decreased the open-field activity of the chicks and increased the durations of their tonic immobility. All treated-chicks recovered from the central nervous system depressant effect of metoclopramide without any observable adverse effects. Conclusion The data suggest that metoclopramide induces central nervous system depression in chicks, and the drug could have potential clinical applications as a sedative-hypnotic agent in avian species not intended for human consumptions.

Background: To assess the effect of sex and laterality on clinical features of primary rhegmatogenous retinal detachment (RRD)., Method: This study is a retrospective analysis of data prospectively collected. We extracted data from two online datasets over a 7-year period of patients older than 16 years who had undergone surgery for primary RRD. Data on baseline characteristics were analyzed to compare males versus females, and right versus left eyes., Results: Of 8133 eyes analyzed, 4342 (53.4%) were right. The overall male predominance (63.7%) was more marked in the age range 50-69 years. Men were more commonly pseudophakic and presented more frequently with baseline posterior vitreous detachment (PVD). Female sex was significantly associated with baseline myopia, retinal holes as causative retinal break, and isolated inferior RD. Men had more frequent foveal involvement, greater RRD extent, greater numbers and larger sized retinal tears including dialysis and giant retinal tears. Regarding laterality, foveal involvement, larger retinal breaks, isolated temporal RD and temporal retinal breaks were more common in right eyes, whereas left eyes were more myopic at baseline and presented more frequently with isolated nasal RD and nasal retinal breaks., Conclusions: This study confirmed the predominance of male sex and right laterality in RRD. Sex and laterality were associated with multiple presenting features of RRD including extent, break distribution, number, size and type, as well as RD distribution., (© 2023. The Author(s).)

Long-term pulmonary sequelae of Coronavirus 2019 (COVID-19) remain unclear. Thus, we aimed to establish post-COVID-19 temporal changes in chest computed tomography (CT) features of pulmonary fibrosis and to investigate associations with respiratory symptoms and physiological parameters at 3 and 12 months' follow-up. Adult patients who attended our initial COVID-19 follow-up service and developed chest CT features of interstitial lung disease, in addition to cases identified using British Society of Thoracic Imaging codes, were evaluated retrospectively. Clinical data were gathered on respiratory symptoms and physiological parameters at baseline, 3 months, and 12 months. Corresponding chest CT scans were reviewed by two thoracic radiologists. Associations between CT features and functional correlates were estimated using random effects logistic or linear regression adjusted for age, sex and body mass index. In total, 58 patients were assessed. No changes in reticular pattern, honeycombing, traction bronchiectasis/bronchiolectasis index or pulmonary distortion were observed. Subpleural curvilinear lines were associated with lower odds of breathlessness over time. Parenchymal bands were not associated with breathlessness or impaired lung function overall. Based on our results, we conclude that post-COVID-19 chest CT features of irreversible pulmonary fibrosis remain static over time; other features either resolve or remain unchanged. Subpleural curvilinear lines do not correlate with breathlessness. Parenchymal bands are not functionally significant. An awareness of the different potential functional implications of post-COVID-19 chest CT changes is important in the assessment of patients who present with multi-systemic sequelae of COVID-19 infection., (© Royal College of Physicians 2023. All rights reserved.)

Background: To evaluate the influence of age on the clinical characteristics of primary rhegmatogenous retinal detachments (RRD)., Methods: We conducted a retrospective review of a prospectively collected dataset. Data regarding adult patients (aged 16-100 years) who had undergone primary RRD repair, were extracted from two online databases. Baseline demographics, preoperative clinical characteristics and surgical management details were collected. Age-based groups (16-30, 30-39, 40-49, 50-59, 60-69, 70-79, ≥80) were compared using univariate analysis, with multivariate testing for interaction of age with sex, laterality and pseudophakia., Results: In total, 8,133 eyes were analysed, of which the majority (59%) were in the 50-69 age-range peaking at 60, with a male predominance (64%). Myopia was significantly more frequent in patients aged <50 years. The presence of posterior vitreous detachment increased up to 50 years, then remained >95%. Foveal involvement, grade C proliferative vitreoretinopathy, total RD and greater RD extent were more common and progressively increased after 60 years, with worsening visual acuity. Isolated superior RRDs became more prevalent with age reaching a plateau in the age-range 50-69, before reducing again; conversely, isolated inferior RRDs were commoner in those <30, with a minimum in the 70-79 age-range. The incidence of fellow-eye RRD decreased linearly with age., Conclusions: Age appeared a key variable in RRD phenotype influencing a wide range of RRD characteristics. The higher incidence of myopia, PVD absent and bilateral RRD in patients <40 years and the significant phenotypical differences in the under 40 and over 50 age-groups highlight that there are several discrete forms of RRD., (© 2022. Crown.)

Topic: To define the effect of symptom duration on outcomes in people undergoing surgery for idiopathic full-thickness macular holes (iFTMHs) by means of an individual participant data (IPD) study of randomized controlled trials (RCTs). The outcomes assessed were primary iFTMH closure and postoperative best-corrected visual acuity (BCVA)., Clinical Relevance: Idiopathic full-thickness macular holes are visually disabling with a prevalence of up to 0.5%. Untreated BCVA is typically reduced to 20/200. Surgery can close holes and improve vision. Symptom duration is thought to affect outcomes with surgery, but the effect is unclear., Methods: A systematic review identified eligible RCTs that included adults with iFTMH undergoing vitrectomy with gas tamponade in which symptom duration, primary iFTMH closure, and postoperative BCVA were recorded. Bibliographic databases were searched for articles published between 2000 and 2020. Individual participant data were requested from eligible studies., Results: Twenty eligible RCTs were identified. Data were requested from all studies and obtained from 12, representing 940 eyes in total. Median symptom duration was 6 months (interquartile range, 3-10). Primary closure was achieved in 81.5% of eyes. There was a linear relationship between predicted probability of closure and symptom duration. Multilevel logistic regression showed each additional month of duration was associated with 0.965 times lower odds of closure (95% confidence interval [CI], 0.935-0.996, P = 0.026). Internal limiting membrane (ILM) peeling, ILM flap use, better preoperative BCVA, face-down positioning, and smaller iFTMH size were associated with increased odds of primary closure. Median postoperative BCVA in eyes achieving primary closure was 0.48 logarithm of the minimum angle of resolution (logMAR) (20/60). Multilevel logistic regression showed for eyes achieving primary iFTMH closure, each additional month of symptom duration was associated with worsening BCVA by 0.008 logMAR units (95% CI, 0.005-0.011, P < 0.001) (i.e., ∼1 Early Treatment Diabetic Retinopathy Study letter loss per 2 months). ILM flaps, intraocular tamponade using long-acting gas, better preoperative BCVA, smaller iFTMH size, and phakic status were also associated with improved postoperative BCVA., Conclusions: Symptom duration was independently associated with both anatomic and visual outcomes in persons undergoing surgery for iFTMH. Time to surgery should be minimized and care pathways designed to enable this., (Copyright © 2022 American Academy of Ophthalmology. Published by Elsevier Inc. All rights reserved.)

Background: The rhetoric surrounding clinical artificial intelligence (AI) often exaggerates its effect on real-world care. Limited understanding of the factors that influence its implementation can perpetuate this., Objective: In this qualitative systematic review, we aimed to identify key stakeholders, consolidate their perspectives on clinical AI implementation, and characterize the evidence gaps that future qualitative research should target., Methods: Ovid-MEDLINE, EBSCO-CINAHL, ACM Digital Library, Science Citation Index-Web of Science, and Scopus were searched for primary qualitative studies on individuals' perspectives on any application of clinical AI worldwide (January 2014-April 2021). The definition of clinical AI includes both rule-based and machine learning-enabled or non-rule-based decision support tools. The language of the reports was not an exclusion criterion. Two independent reviewers performed title, abstract, and full-text screening with a third arbiter of disagreement. Two reviewers assigned the Joanna Briggs Institute 10-point checklist for qualitative research scores for each study. A single reviewer extracted free-text data relevant to clinical AI implementation, noting the stakeholders contributing to each excerpt. The best-fit framework synthesis used the Nonadoption, Abandonment, Scale-up, Spread, and Sustainability (NASSS) framework. To validate the data and improve accessibility, coauthors representing each emergent stakeholder group codeveloped summaries of the factors most relevant to their respective groups., Results: The initial search yielded 4437 deduplicated articles, with 111 (2.5%) eligible for inclusion (median Joanna Briggs Institute 10-point checklist for qualitative research score, 8/10). Five distinct stakeholder groups emerged from the data: health care professionals (HCPs), patients, carers and other members of the public, developers, health care managers and leaders, and regulators or policy makers, contributing 1204 (70%), 196 (11.4%), 133 (7.7%), 129 (7.5%), and 59 (3.4%) of 1721 eligible excerpts, respectively. All stakeholder groups independently identified a breadth of implementation factors, with each producing data that were mapped between 17 and 24 of the 27 adapted Nonadoption, Abandonment, Scale-up, Spread, and Sustainability subdomains. Most of the factors that stakeholders found influential in the implementation of rule-based clinical AI also applied to non-rule-based clinical AI, with the exception of intellectual property, regulation, and sociocultural attitudes., Conclusions: Clinical AI implementation is influenced by many interdependent factors, which are in turn influenced by at least 5 distinct stakeholder groups. This implies that effective research and practice of clinical AI implementation should consider multiple stakeholder perspectives. The current underrepresentation of perspectives from stakeholders other than HCPs in the literature may limit the anticipation and management of the factors that influence successful clinical AI implementation. Future research should not only widen the representation of tools and contexts in qualitative research but also specifically investigate the perspectives of all stakeholder HCPs and emerging aspects of non-rule-based clinical AI implementation., Trial Registration: PROSPERO (International Prospective Register of Systematic Reviews) CRD42021256005; https://www.crd.york.ac.uk/prospero/display&#95;record.php?RecordID=256005., International Registered Report Identifier (irrid): RR2-10.2196/33145., (©Henry David Jeffry Hogg, Mohaimen Al-Zubaidy, Technology Enhanced Macular Services Study Reference Group, James Talks, Alastair K Denniston, Christopher J Kelly, Johann Malawana, Chrysanthi Papoutsi, Marion Dawn Teare, Pearse A Keane, Fiona R Beyer, Gregory Maniatopoulos. Originally published in the Journal of Medical Internet Research (https://www.jmir.org), 10.01.2023.)

In response to the first COVID-19 surge in 2020, secondary care outpatient services were rapidly reconfigured to provide specialist review for disease sequelae. At our institution, comprising hospitals across three sites in London, we initially implemented a COVID-19 follow-up pathway that was in line with expert opinion at the time but more intensive than initial clinical guidelines suggested. We retrospectively evaluated the resource requirements for this service, which supported 526 patients from April 2020 to October 2020. At the 6-week review, 193/403 (47.9%) patients reported persistent breathlessness, 46/336 (13.7%) desaturated on exercise testing, 167/403 (41.4%) were discharged from COVID-19-related secondary care services and 190/403 (47.1%) needed 12-week follow-up. At the 12-week review, 113/309 (36.6%) patients reported persistent breathlessness, 30/266 (11.3%) desaturated on exercise testing and 150/309 (48.5%) were discharged from COVID-19-related secondary care services. Referrals were generated to multiple medical specialties, particularly respiratory subspecialties. Our analysis allowed us to justify rationalising and streamlining provisions for subsequent COVID-19 waves while reassured that opportunities for early intervention were not being missed., (© Royal College of Physicians 2022. All rights reserved.)

Background: Quantitative systematic reviews have identified clinical artificial intelligence (AI)-enabled tools with adequate performance for real-world implementation. To our knowledge, no published report or protocol synthesizes the full breadth of stakeholder perspectives. The absence of such a rigorous foundation perpetuates the "AI chasm," which continues to delay patient benefit., Objective: The aim of this research is to synthesize stakeholder perspectives of computerized clinical decision support tools in any health care setting. Synthesized findings will inform future research and the implementation of AI into health care services., Methods: The search strategy will use MEDLINE (Ovid), Scopus, CINAHL (EBSCO), ACM Digital Library, and Science Citation Index (Web of Science). Following deduplication, title, abstract, and full text screening will be performed by 2 independent reviewers with a third topic expert arbitrating. The quality of included studies will be appraised to support interpretation. Best-fit framework synthesis will be performed, with line-by-line coding completed by 2 independent reviewers. Where appropriate, these findings will be assigned to 1 of 22 a priori themes defined by the Nonadoption, Abandonment, Scale-up, Spread, and Sustainability framework. New domains will be inductively generated for outlying findings. The placement of findings within themes will be reviewed iteratively by a study advisory group including patient and lay representatives., Results: Study registration was obtained from PROSPERO (CRD42021256005) in May 2021. Final searches were executed in April, and screening is ongoing at the time of writing. Full text data analysis is due to be completed in October 2021. We anticipate that the study will be submitted for open-access publication in late 2021., Conclusions: This paper describes the protocol for a qualitative evidence synthesis aiming to define barriers and facilitators to the implementation of computerized clinical decision support tools from all relevant stakeholders. The results of this study are intended to expedite the delivery of patient benefit from AI-enabled clinical tools., Trial Registration: PROSPERO CRD42021256005; https://tinyurl.com/r4x3thvp., International Registered Report Identifier (irrid): DERR1-10.2196/33145., (©Mohaimen Al-Zubaidy, HD Jeffry Hogg, Gregory Maniatopoulos, James Talks, Marion Dawn Teare, Pearse A Keane, Fiona R Beyer. Originally published in JMIR Research Protocols (https://www.researchprotocols.org), 01.04.2022.)

In aortic root aneurysms, the challenge of a valve-sparing aortic root replacement (VSRR) procedure is to ensure durable aortic valve function without reintervention. Although the Bentall procedure defers the durability of valve function to the prosthesis, short- and long-term complications tend to be higher. The aim of this study was to compare the outcomes of VSRR and Bentall procedures in patients with aortic root aneurysms. A systematic literature review was conducted using PubMed regarding the outcomes of the Bentall procedure compared with those of VSRR from the inception of the 2 procedures until July 2018. Studies with short- and long-term comparative data were included. An initial search yielded 9517 titles. Thirty-four studies were finally included for meta-analysis (all retrospective, non-randomized), comprising 7313 patients (2944 valve-sparing and 4369 Bentall procedures) with no evidence of publication bias. Operative mortality was found to be significantly lower in the VSRR group [odds ratio (OR) 0.51, 95% confidence interval (CI) 0.37-0.70; P < 0.001] despite overall higher cardiopulmonary bypass and aortic cross-clamp times. The 5-year survival rate was also more favourable in the VSRR group (OR 1.93 95% CI 1.15-3.23; P < 0.05). Significantly lower rates of cerebral thromboembolism (OR 0.668, 95% CI 0.477-0.935; P = 0.019) and heart block (OR 0.386, 95% CI 0.195-0.767; P = 0.007) were also found after VSRR. There was no significant difference in rates of reoperation between the groups at long-term follow-up (OR 1.32, 95% CI 0.75-2.33; P = 0.336). Meta-regression of patient and operative covariates yielded no influence on the main outcomes (P > 0.05). These findings suggest that VSRR is an appropriate and potentially better treatment option for a root aneurysm when the aortic valve is repairable., (© The Author(s) 2019. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.)

Objective: There is an ongoing challenge of effective integration between primary and social care in the United Kingdom; current systems have led to fragmentation of services preventing holistic patient-centred care for vulnerable populations. To improve clinical outcomes and achieve financial efficiencies, the barriers to integration need to be identified and addressed. This study aims to explore the unique perspectives of frontline staff (general practitioners and practice managers) towards these barriers to integration., Design: Qualitative study using semistructured interviews and thematic analysis to obtain results., Setting: General practices within London., Participants: 18 general practitioners (GPs) and 7 practice managers (PMs) based in London with experience of working with social care., Results: The study identified three overarching themes where frontline staff believed problems exist: accessing social services, interprofessional relationships and infrastructure. Issues with contacting staff from other sectors creates delays in referrals for patient care and perpetuates existing logistical challenges. Likewise, professionals noted a hostile working culture between sectors that has resulted in silo working mentalities. In addition to staff being overworked as well as often inefficient multidisciplinary team meetings, poor relationships across sectors cause a diffusion of responsibility, impacting the speed with which patient requests are responded to. Furthermore, participants identified that a lack of interoperability between information systems, lack of pooled budgets and misaligned incentives between managerial staff compound the infrastructural divide between both sectors., Conclusion: In this study, primary care staff identify intangible barriers to integration such as poor interprofessional relationships, in addition to more well-described structural issues such as insufficient funding and difficulty accessing social care. Participants believe that educating the next generation of medical professionals may lead to the development of collaborative, instead of siloed, working cultures and that change is needed at both an interpersonal and institutional level to successfully integrate care., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2019. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)