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The Common Sense Model (CSM) is a useful framework for understanding mood and treatment adherence amongst survivors in the acute phase of stroke. CSM stroke studies have thus far focused on the single outcomes, mood and medication adherence, neglecting other aspects of post-stroke recovery (i.e., Health-Related Quality of Life (HRQL) and disability). The purpose of this study was to examine relationships between baseline illness beliefs and three-month post-stroke HRQL, mood and disability. A longitudinal observational design was adopted, involving 50 survivors (mean age = 66.9 years, 68% male). The primary outcome, HRQL, was measured using EQ-5D-5L. The secondary outcome, mood was measured using the Patient Health Questionnaire-9; and disability, using the Nottingham Extended Activities of Daily Living Scale. The Stroke Illness Perception Questionnaire-Revised measured illness beliefs. Spearman's correlations showed that beliefs about the fluctuating effects of stroke (ρ = 0.50, p < 0.001) and considerable distress at baseline were significantly associated with worse mood three-months post-stroke (ρ = 0.41, p < 0.001). Baseline illness beliefs were not significantly related to three-month post-stroke HRQL or disability. Despite being limited by a modest sample size, the findings reiterated the need for routine clinical assessment of mood immediately after stroke, and indicated that simultaneous measurement of illness beliefs may also be beneficial. [ABSTRACT FROM AUTHOR]

Purpose: Novel uses of genome sequencing (GS) present an opportunity for return of results to healthy individuals, prompting the need for scalable genetic counseling strategies. We evaluate the effectiveness of a genomic counseling model (GCM) and explore preferences for GS findings in the general population., Methods: Participants (N = 466) completed GS and our GCM (digital genomics platform and group-based webinar) and indicated results preferences. Surveys were administered before (T0) and after (T1) GCM. Change in knowledge and decisional conflict (DC) were evaluated using paired-sample T and Wilcoxon tests. Factors influencing knowledge and results preferences were evaluated using linear and logistic regression models., Results: Participants were 56% female, 58% white, and 53% ≥40 years of age. Mean knowledge scores increased (Limitations: 3.73 to 5.63; Benefits: 4.34 to 5.48, P < .0001), and DC decreased (-21.9, P < .0001) at T1 versus T0. Eighty-six percent of participants wished to learn all GS findings at T1 vs 78% at T0 (P < .0001). Older age, negative/mixed attitudes toward genetics and greater DC were associated with change in preferences after intervention., Conclusion: In a population-based cohort undergoing GS interested in learning GS findings, our GCM increased knowledge and reduced DC, illustrating the GCM's potential effectiveness for GS counseling in the general population., Competing Interests: Conflict of Interest Yvonne Bombard holds the Canada Research Chair in Genomics Health Services and Policy. Yvonne Bombard and Marc Clausen are co-founders of the Genetics Adviser. All other authors declare no conflicts of interest., (Copyright © 2024 American College of Medical Genetics and Genomics. All rights reserved.)

Existing models for the safe, timely and effective delivery of health and social care are challenged by an ageing population. Services and care pathways are often optimised for single-disease management, while many older people are presenting with multiple long-term conditions and frailty. Systems engineering describes a holistic, interdisciplinary approach to change that is focused on people, system understanding, design and risk management. These principles are the basis of many established quality improvement (QI) tools in health and social care, but implementation has often been limited to single services or condition areas. Newer engineering techniques may help reshape more complex systems. Systems thinking is an essential component of this mindset to understand the underlying relationships and characteristics of a working system. It promotes the use of tools that map, measure and interrogate the dynamics of complex systems. In this New Horizons piece, we describe the evolution of systems approaches while noting the challenges of small-scale QI efforts that fail to address whole-system problems. The opportunities for novel soft-systems approaches are described, along with a recent update to the Systems Engineering Initiative for Patient Safety model, which includes human-centred design. Systems modelling and simulation techniques harness routine data to understand the functioning of complex health and social care systems. These tools could support better-informed system change by allowing comparison of simulated approaches before implementation, but better effectiveness evidence is required. Modern systems engineering and systems thinking techniques have potential to inform the redesign of services appropriate for the complex needs of older people., (© The Author(s) 2024. Published by Oxford University Press on behalf of the British Geriatrics Society.)

Background: Innovation for reforming health and social care is high on the policy agenda in the United Kingdom in response to the growing needs of an ageing population. However, information about new innovations of care being implemented is sparse., Methods: We mapped innovations for people in later life in two regions, North East England and South East Scotland. Data collection included discussions with stakeholders (n = 51), semi-structured interviews (n = 14) and website searches that focused on technology, evaluation and health inequalities. We analysed qualitative data using framework and thematic analyses. Quantitative data were analysed descriptively., Results: One hundred eleven innovations were identified across the two regions. Interviewees reported a wide range of technologies that had been rapidly introduced during the COVID-19 pandemic and many remained in use. Digital exclusion of certain groups of older people was an ongoing concern. Innovations fell into two groups; system-level ones that aimed to alleviate systems pressures such as preventing hospital (re)admissions, and patient-level ones which sought to enhance health and wellbeing directly. Interviewees were aware of the importance of health inequalities but lacked data to monitor the impact of innovations on these, and evaluation was challenging due to lack of time, training, and support. Quantitative findings revealed that two thirds of innovations (n = 74, 67%) primarily focused on the system level, whilst a third (n = 37, 33%) primarily focused on the patient-level. Overall, over half (n = 65, 59%) of innovations involved technologies although relatively few (n = 12, 11%) utilised advanced technologies. Very few (n = 16, 14%) focused on reducing health inequalities, and only a minority of innovations (n = 43, 39%) had undergone evaluation (most of which were conducted by the service providers themselves)., Conclusions: We found a wide range of innovative care services being developed for people in later life, yet alignment with key policy priorities, such as addressing health inequalities, was limited. There was a strong focus on technology, with little consideration for the potential to widen the health inequality gap. The absence of robust evaluation was also a concern as most innovations were implemented without support to monitor effectiveness and/or without plans for sustainability and spread., (© 2024. The Author(s).)

This systematic review evaluates the efficacy of self-care interventions for atrial fibrillation (AF), focusing on strategies for maintenance, monitoring, and management applied individually or in combination. Adhering to the 2020 PRISMA guidelines, the search strategy spanned literature from 2005 to 2023, utilizing keywords and subject headings for "atrial fibrillation" and "self-care" combined with the Boolean operator AND. The databases searched included Medline, Embase, and CINAHL. The initial search, conducted on February 17, 2021, and updated on May 16, 2023, identified 5160 articles, from which 2864 unique titles and abstracts were screened. After abstract screening, 163 articles were reviewed in full text, resulting in 27 articles being selected for data extraction; these studies comprised both observational and randomized controlled trial designs. A key finding in our analysis reveals that self-care interventions, whether singular, dual, or integrated across all three components, resulted in significant improvements across patient-reported, clinical, and healthcare utilization outcomes compared to usual care. Educational interventions, often supported by in-person sessions or telephone follow-ups, emerged as a crucial element of effective AF self-care. Additionally, the integration of mobile and web-based technologies alongside personalized education showed promise in enhancing outcomes, although their full potential remains underexplored. This review highlights the importance of incorporating comprehensive, theory-informed self-care interventions into routine clinical practice and underscores the need for ongoing innovation and the implementation of evidence-based strategies. The integration of education and technology in AF self-care aligns with the recommendations of leading health organizations, advocating for patient-centered, technology-enhanced approaches to meet the evolving needs of the AF population., Competing Interests: The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (© 2024 The Authors.)

Objective: The purpose of this study was to recontact individuals with clinically actionable test results identified through a retrospective research study and to provide a framework for laboratories to recontact patients., Methods: Genetic testing was conducted on 2977 individuals originally referred for BRCA1 and BRCA2 hereditary breast and ovarian cancer testing that had a negative genetic test result. A gene panel was used to identify pathogenic variants in known or newly discovered genes that could explain the underlying cause of disease; however, analysis was restricted to PALB2 for the purposes of this study. A patient recontact decision tree was developed to assist in the returning of updated genetic test results to clinics and patients., Results: Novel clinically actionable pathogenic variants were identified in the PALB2 gene in 18 participants (0.6%), the majority of whom were recontacted with their new or updated genetic test results. Eight individuals were unable to be recontacted; five individuals had already learnt about their new or updated findings from genetic testing outside the context of this study; three individuals prompted cascade testing in family members; two individuals were deceased., Conclusion: Novel pathogenic variants in PALB2 were identified in 18 individuals through retrospective gene panel testing. Recontacting these individuals regarding these new or updated findings had a range of outcomes. The process of conveying genomic results within this framework can be effectively accomplished while upholding patient autonomy, potentially leading to advantageous outcomes for patients and their families., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2024. No commercial re-use. See rights and permissions. Published by BMJ.)

Purpose: To address the care needs of older adults, it is important to identify and understand the forms of care support older adults received. This systematic review aims to examine the social networks of older adults receiving informal or formal care and the factors that influenced their networks., Methods: A systematic review was conducted by searching six databases from inception to January 31, 2023. The review included primary studies focusing on older adults receiving long-term care, encompassing both informal and formal care. To assess the risk of bias in the included studies, validated appraisal tools specifically designed for different study types were utilized. Network analysis was employed to identify the grouping of study concepts, which subsequently formed the foundation for describing themes through narrative synthesis., Results: We identified 121 studies relating to the formal and informal care of older adults' networks. A variety of social ties were examined by included studies. The most commonly examined sources of care support were family members (such as children and spouses) and friends. Several factors were consistently reported to influence the provision of informal care, including the intensity of networks, reciprocity, and geographical proximity. In terms of formal care utilization, older age and poor health status were found to be associated with increased use of healthcare services. Additionally, physical limitations and cognitive impairment were identified as factors contributing to decreased social engagement., Conclusion: This review found that older people were embedded within a diverse network. The findings of this review emphasize the importance of recognizing and incorporating the diversity of social networks in care plans and policies to enhance the effectiveness of interventions and improve the overall well-being of older adults., (© 2023. BioMed Central Ltd., part of Springer Nature.)

The GENCOV study aims to identify patient factors which affect COVID-19 severity and outcomes. Here, we aimed to evaluate patient characteristics, acute symptoms and their persistence, and associations with hospitalization. Participants were recruited at hospital sites across the Greater Toronto Area in Ontario, Canada. Patient-reported demographics, medical history, and COVID-19 symptoms and complications were collected through an intake survey. Regression analyses were performed to identify associations with outcomes including hospitalization and COVID-19 symptoms. In total, 966 responses were obtained from 1106 eligible participants (87% response rate) between November 2020 and May 2022. Increasing continuous age (aOR: 1.05 [95%CI: 1.01-1.08]) and BMI (aOR: 1.17 [95%CI: 1.10-1.24]), non-White/European ethnicity (aOR: 2.72 [95%CI: 1.22-6.05]), hypertension (aOR: 2.78 [95%CI: 1.22-6.34]), and infection by viral variants (aOR: 5.43 [95%CI: 1.45-20.34]) were identified as risk factors for hospitalization. Several symptoms including shortness of breath and fever were found to be more common among inpatients and tended to persist for longer durations following acute illness. Sex, age, ethnicity, BMI, vaccination status, viral strain, and underlying health conditions were associated with developing and having persistent symptoms. By improving our understanding of risk factors for severe COVID-19, our findings may guide COVID-19 patient management strategies by enabling more efficient clinical decision making.

Aims: To implement a diabetes prevention programme in primary care METHODS: The programme was implemented for 12 months in two neighbouring towns, served by eight general practices. Practices requested a referral pathway involving an external administrator running electronic searches and sending postal invitations. If interested, people called and booked a place on the programme. Practices were also provided with resources to refer people directly. Six Educators were trained to deliver the programme. The RE-AIM constructs "Adoption", "Reach" and "Uptake" were assessed., Results: All practices engaged in the searches and postal invitations. Overall, 3.9 % of those aged ≥ 25 years had an HbA1c level indicative of non-diabetic hyperglycaemia (NDH) and were invited. Overall uptake (attended as percentage of invited) was 16 % (practice range 10.5-26.6 %) and was highest in two practices where the invitation was followed by a telephone call. Four people were referred directly by their practice. Groups at risk of being excluded were the Bengali population and those unable to attend because of issues such as health, mobility and frailty., Conclusions: Comprehensive electronic searches meant everyone previously diagnosed with NDH was invited to attend. Follow-up telephone call improved uptake and providing practices with resources to make these calls themselves would likely increase uptake further., Competing Interests: Conflicts of Interest An adapted version of the Let’s Prevent Diabetes intervention is on the framework for the NHS Diabetes Prevention Programme. This work was led by Ingeus (main contractor at the time), with Leicester Diabetes Centre, University Hospitals of Leicester NHS Trust providing training and quality assurance for which funding was received. MJD, KK, TY, and LG were involved in the development of this adapted programme. MJD, KK, and TY were members (KK chair) of the NICE PH 38 (Preventing Type 2 diabetes: risk identification and interventions for individuals at high risk) Programme Development Group. KK is a member of the Expert Reference Group of the NHS Diabetes Prevention Programme. JK ad NA were involved in the qualitative evaluation of the programme., (Copyright © 2023 The Authors. Published by Elsevier Ltd.. All rights reserved.)

Background: community-based complex interventions for older adults have a variety of names, including Comprehensive Geriatric Assessment, but often share core components such as holistic needs assessment and care planning., Objective: to summarise evidence for the components and effectiveness of community-based complex interventions for improving older adults' independent living and quality of life (QoL)., Methods: we searched nine databases and trial registries to February 2022 for randomised controlled trials comparing complex interventions to usual care. Primary outcomes included living at home and QoL. Secondary outcomes included mortality, hospitalisation, institutionalisation, cognitive function and functional status. We pooled data using risk ratios (RRs) or standardised mean differences (SMDs) with 95% confidence intervals (CIs)., Results: we included 50 trials of mostly moderate quality. Most reported using holistic assessment (94%) and care planning (90%). Twenty-seven (54%) involved multidisciplinary care, with 29.6% delivered mainly by primary care teams without geriatricians. Nurses were the most frequent care coordinators. Complex interventions increased the likelihood of living at home (RR 1.05; 95% CI 1.00-1.10; moderate-quality evidence) but did not affect QoL. Supported by high-quality evidence, they reduced mortality (RR 0.86; 95% CI 0.77-0.96), enhanced cognitive function (SMD 0.12; 95% CI 0.02-0.22) and improved instrumental activities of daily living (ADLs) (SMD 0.11; 95% CI 0.01-0.21) and combined basic/instrumental ADLs (SMD 0.08; 95% CI 0.03-0.13)., Conclusions: complex interventions involving holistic assessment and care planning increased the chance of living at home, reduced mortality and improved cognitive function and some ADLs., (© The Author(s) 2023. Published by Oxford University Press on behalf of the British Geriatrics Society. All rights reserved. For permissions, please email: journals.permissions@oup.com.)

Background: Responsibility for health and social care was devolved to Scotland in 1999 with evidence of diverging policy and organisation of care compared to England. This paper provides a comparative overview of major health and social care policies in England and Scotland published between 2011 and 2023 relating to the care of older people., Methods: We searched United Kingdom (UK) and Scotland government websites for macro-level policy documents between 2011 and 2023 relating to the health and social care of older people (aged 65+). Data were extracted and emergent themes were summarised according to Donabedian's structure-process-outcome model., Results: We reviewed 27 policies in England and 28 in Scotland. Four main policy themes emerged that were common to both countries. Two related to the structure of care: integration of care and adult social care reform. Two related to service delivery/processes of care: prevention and supported self-management and improving mental health care. Cross-cutting themes included person-centred care, addressing health inequalities, promoting use of technology, and improving outcomes., Conclusion: Despite differences in the structure of care, including more competition, financial incentivization, and consumer-based care in England compared to Scotland, there are similarities in policy vision around delivery/processes of care (e.g. person-centred care) and performance and patient outcomes. Lack of UK-wide health and social care datasets hinders evaluation of policies and comparison of outcomes between both countries., Competing Interests: Declaration of Competing Interest The authors have no conflicts of interest to declare., (Copyright © 2023 The Author(s). Published by Elsevier B.V. All rights reserved.)

Rapid advancements of genome sequencing (GS) technologies have enhanced our understanding of the relationship between genes and human disease. To incorporate genomic information into the practice of medicine, new processes for the analysis, reporting, and communication of GS data are needed. Blood samples were collected from adults with a PCR-confirmed SARS-CoV-2 (COVID-19) diagnosis (target N = 1500). GS was performed. Data were filtered and analyzed using custom pipelines and gene panels. We developed unique patient-facing materials, including an online intake survey, group counseling presentation, and consultation letters in addition to a comprehensive GS report. The final report includes results generated from GS data: (1) monogenic disease risks; (2) carrier status; (3) pharmacogenomic variants; (4) polygenic risk scores for common conditions; (5) HLA genotype; (6) genetic ancestry; (7) blood group; and, (8) COVID-19 viral lineage. Participants complete pre-test genetic counseling and confirm preferences for secondary findings before receiving results. Counseling and referrals are initiated for clinically significant findings. We developed a genetic counseling, reporting, and return of results framework that integrates GS information across multiple areas of human health, presenting possibilities for the clinical application of comprehensive GS data in healthy individuals., (© 2022. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature.)

Objective: To identify factors associated with accessing and utilisation of healthcare and provision of health services in slums., Design: A scoping review incorporating a conceptual framework for configuring reported factors., Data Sources: MEDLINE, Embase, CINAHL, Web of Science and the Cochrane Library were searched from their inception to December 2021 using slum-related terms., Eligibility Criteria: Empirical studies of all designs reporting relevant factors in slums in low and middle-income countries., Data Extraction and Synthesis: Studies were categorised and data were charted according to a preliminary conceptual framework refined by emerging findings. Results were tabulated and narratively summarised., Results: Of the 15 469 records retrieved from all years, 4368 records dated between 2016 and 2021 were screened by two independent reviewers and 111 studies were included. The majority (63 studies, 57%) were conducted in Asia, predominantly in India. In total, 104 studies examined healthcare access and utilisation from slum residents' perspective while only 10 studies explored provision of health services from providers/planners' perspective (three studies included both). A multitude of factors are associated with accessing, using and providing healthcare in slums, including recent migration to slums; knowledge, perception and past experience of illness, healthcare needs and health services; financial constraint and competing priorities between health and making a living; lacking social support; unfavourable physical environment and locality; sociocultural expectations and stigma; lack of official recognition; and existing problems in the health system., Conclusion: The scoping review identified a significant body of recent literature reporting factors associated with accessing, utilisation and provision of healthcare services in slums. We classified the diverse factors under seven broad categories. The findings can inform a holistic approach to improving health services in slums by tackling barriers at different levels, taking into account local context and geospatial features of individual slums. SYSTEMATIC REVIEW REGISTRATION NUMBER: https://osf.io/694t2., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2022. Re-use permitted under CC BY. Published by BMJ.)

Background: Research conducted in the United States suggests that two primes (citrus smells and pictures of a person's eyes) can increase hand gel dispenser use on the day they are introduced in hospital. The current study, conducted at a hospital in the United Kingdom, evaluated the effectiveness of these primes, both in isolation and in combination, at the entry way to four separate wards, over a longer duration than the previous work., Methods: A crossover randomized controlled trial was conducted. Four wards were allocated for 6 weeks of observation to each of four conditions, including "control," "olfactory," "visual," or "both" (i.e., "olfactory" and "visual" combined). It was hypothesized that hand hygiene compliance would be greater in all priming conditions relative to the control condition. The primary outcome was whether people used the gel dispenser when they entered the wards. After the trial, a follow up survey of staff at the same hospital assessed the barriers to, and facilitators of, hand hygiene compliance. The trial data were analyzed using regression techniques and the survey data were analyzed using descriptive statistics., Results: The total number of individuals observed in the trial was 9,811 (female = 61%), with similar numbers across conditions, including "control" N = 2,582, "olfactory" N = 2,700, "visual" N = 2,488, and "both" N = 2,141. None of the priming conditions consistently increased hand hygiene. The lowest percentage compliance was observed in the "both" condition (7.8%), and the highest was observed in the "visual" condition (12.7%). The survey was completed by 97 staff (female = 81%). "Environmental resources" and "social influences" were the greatest barriers to staff cleaning their hands., Conclusions: Taken together, the current findings suggest that the olfactory and visual priming interventions investigated do not influence hand hygiene consistently. To increase the likelihood of such interventions succeeding, future research should focus on prospectively determined mechanisms of action., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2022 Schmidtke, Aujla, Marshall, Hussain, Hodgkinson, Arheart, Birnbach, Kudrna and Vlaev.)

Background: Improving the quality of primary healthcare provision is a key goal in low-and middle-income countries (LMICs). However, to develop effective quality improvement interventions, we first need to be able to accurately measure the quality of care. The methods most commonly used to measure the technical quality of care all have some key limitations in LMICs settings. Video-observation is appealing but has not yet been used in this context. We examine preliminary feasibility and acceptability of video-observation for assessing physician quality in a hospital outpatients' department in Nigeria. We also develop measurement procedures and examine measurement characteristics., Methods: Cross-sectional study at a large tertiary care hospital in Ibadan, Nigeria. Consecutive physician-patient consultations with adults and children under five seeking outpatient care were video-recorded. We also conducted brief interviews with participating physicians to gain feedback on our approach. Video-recordings were double-coded by two medically trained researchers, independent of the study team and each other, using an explicit checklist of key processes of care that we developed, from which we derived a process quality score. We also elicited a global quality rating from reviewers., Results: We analysed 142 physician-patient consultations. The median process score given by both coders was 100 %. The modal overall rating category was 'above standard' (or 4 on a scale of 1-5). Coders agreed on which rating to assign only 44 % of the time (weighted Cohen's kappa = 0.26). We found in three-level hierarchical modelling that the majority of variance in process scores was explained by coder disagreement. A very high correlation of 0.90 was found between the global quality rating and process quality score across all encounters. Participating physicians liked our approach, despite initial reservations about being observed., Conclusions: Video-observation is feasible and acceptable in this setting, and the quality of consultations was high. However, we found that rater agreement is low but comparable to other modalities that involve expert clinician judgements about quality of care including in-person direct observation and case note review. We suggest ways to improve scoring consistency including careful rater selection and improved design of the measurement procedure for the process score.

Clinical records in primary healthcare settings in low- and middle-income countries (LMIC) are often lacking or of too poor quality to accurately assess what happens during the patient consultation. We examined the most common methods for assessing healthcare workers' clinical behaviour: direct observation, standardized patients and patient/healthcare worker exit interview. The comparative feasibility, acceptability, reliability, validity and practicalities of using these methods in this setting are unclear. We systematically review and synthesize the evidence to compare and contrast the advantages and disadvantages of each method. We include studies in LMICs where methods have been directly compared and systematic and narrative reviews of each method. We searched several electronic databases and focused on real-life (not educational) primary healthcare encounters. The most recent update to the search for direct comparison studies was November 2019. We updated the search for systematic and narrative reviews on the standardized patient method in March 2020 and expanded it to all methods. Search strategies combined indexed terms and keywords. We searched reference lists of eligible articles and sourced additional references from relevant review articles. Titles and abstracts were independently screened by two reviewers and discrepancies resolved through discussion. Data were iteratively coded according to pre-defined categories and synthesized. We included 12 direct comparison studies and eight systematic and narrative reviews. We found that no method was clearly superior to the others-each has pros and cons and may assess different aspects of quality of care provision by healthcare workers. All methods require careful preparation, though the exact domain of quality assessed and ethics and selection and training of personnel are nuanced and the methods were subject to different biases. The differential strengths suggest that individual methods should be used strategically based on the research question or in combination for comprehensive global assessments of quality., (© The Author(s) 2020. Published by Oxford University Press in association with The London School of Hygiene and Tropical Medicine.)

This longitudinal observational study examined how individual versus illness belief schema compare as predictors of post-stroke recovery. A total of 42 stroke survivors (mean age = 66.9 years/range = 29-96 years; 68% male) were involved. The primary outcome, Health-Related Quality of Life was measured using EQ-5D-5L, mood using Patient Health Questionnaire-9 and disability using Nottingham Extended Activities of Daily Living Scale. Stroke Illness Perception Questionnaire-Revised measured illness beliefs. Linear regressions showed that individual illness beliefs significantly explained more of the variance in 3-month post-stroke recovery than schema (7.4%-22.5% versus 1.9%-9.9%). Individual versus illness belief schema predict outcomes differently , but which approach predicts outcomes better remains unclear.

The main purpose was to evaluate, using the Think-Aloud method, a version of the Illness Perception Questionnaire-Revised for stroke survivors. Six stroke survivors (mean age = 58.8 years, range = 31-78 years, standard deviation = 18.9 years) took part in Think-Aloud interviews, analysed according to established guidelines. Overall, 179 problems emerged. The most noteworthy was missing or insufficient Think-Aloud data generated, where participants did not think out loud. Others included complex and negative item wording, and items on the treatment control sub-scale. Questionnaire length, simpler wording and verbal probing are important considerations in further development of an Illness Perception Questionnaire-Revised for stroke survivors.

Introduction: With COVID-19, there is urgency for policymakers to understand and respond to the health needs of slum communities. Lockdowns for pandemic control have health, social and economic consequences. We consider access to healthcare before and during COVID-19 with those working and living in slum communities., Methods: In seven slums in Bangladesh, Kenya, Nigeria and Pakistan, we explored stakeholder perspectives and experiences of healthcare access for non-COVID-19 conditions in two periods: pre-COVID-19 and during COVID-19 lockdowns., Results: Between March 2018 and May 2020, we engaged with 860 community leaders, residents, health workers and local authority representatives. Perceived common illnesses in all sites included respiratory, gastric, waterborne and mosquitoborne illnesses and hypertension. Pre-COVID, stakeholders described various preventive, diagnostic and treatment services, including well-used antenatal and immunisation programmes and some screening for hypertension, tuberculosis, HIV and vectorborne disease. In all sites, pharmacists and patent medicine vendors were key providers of treatment and advice for minor illnesses. Mental health services and those addressing gender-based violence were perceived to be limited or unavailable. With COVID-19, a reduction in access to healthcare services was reported in all sites, including preventive services. Cost of healthcare increased while household income reduced. Residents had difficulty reaching healthcare facilities. Fear of being diagnosed with COVID-19 discouraged healthcare seeking. Alleviators included provision of healthcare by phone, pharmacists/drug vendors extending credit and residents receiving philanthropic or government support; these were inconsistent and inadequate., Conclusion: Slum residents' ability to seek healthcare for non-COVID-19 conditions has been reduced during lockdowns. To encourage healthcare seeking, clear communication is needed about what is available and whether infection control is in place. Policymakers need to ensure that costs do not escalate and unfairly disadvantage slum communities. Remote consulting to reduce face-to-face contact and provision of mental health and gender-based violence services should be considered., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2020. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Objectives: To explore service-user and provider experience of the acceptability and value of the Let's Prevent Diabetes programme, a pragmatic 6-hour behavioural intervention using structured group education, introduced into primary care practice., Design: Qualitative interview-based study with thematic analysis., Setting: Primary care and community., Participants: Purposeful sample of 32 participants, including 22 people at high risk of diabetes who either attended, defaulted from or declined the intervention; and 10 stakeholder professionals involved in implementation., Results: Participants had low prior awareness of their elevated risk and were often surprised to be offered intervention. Attenders were commonly older, white, retired and motivated to promote their health; who found their session helpful, particularly for social interaction, raising dietary awareness, and convenience of community location. However attenders highlighted lack of depth, repetition within and length of session, difficulty meeting culturally diverse needs and no follow-up as negative features. Those who defaulted from, or who declined the intervention were notably apprehensive, uncertain or unconvinced about whether they were at risk of diabetes; sought more specific information about the intervention, and were deterred by its group nature and day-long duration, with competing work or family commitments. Local providers recognised inadequate communication of diabetes risk to patients. They highlighted significant challenges for implementation, including resource constraints, and facilitation at individual general practice or locality level., Conclusions: This pragmatic diabetes prevention intervention was acceptable in practice, particularly for older, white, retired and health-motivated people. However, pre-intervention information and communication of diabetes risk should be improved to increase engagement and reduce potential fear or uncertainty, with closer integration of services, and more appropriate care pathways, to facilitate uptake and follow-up. Further development of this, or other interventions, is needed to enable wider, and more socially diverse, engagement of people at risk. Balancing a locality and individual practice approach, and how this is resourced are considerations for long-term sustainability., Competing Interests: Competing interests: NA, JK have no conflicts of interest to declare. TY and HD were involved in intervention implementation as part of the Let's Prevent team. TY has also contributed to the design of a diabetes prevention programme run through an NHS (University Hospitals of Leicester NHS Trust) and industry (Ingeus UK Limited) collaboration which is part of the tendering framework for Healthier You: The NHS Diabetes Prevention Service., (© Author(s) (or their employer(s)) 2019. Re-use permitted under CC BY. Published by BMJ.)

Introduction: Compliance with hand hygiene recommendations in hospital is typically less than 50%. Such low compliance inevitably contributes to hospital-acquired infections that negatively affect patients' well-being and hospitals' finances. The design of the present study is predicated on the assumption that most people who fail to clean their hands are not doing so intentionally, they just forget. The present study will test whether psychological priming can be used to increase the number of people who clean their hands on entering a ward. Here, we present the protocol for this study., Methods and Analysis: The study will use a randomised cross-over design. During the study, each of four wards will be observed during four conditions: olfactory prime, visual prime, both primes and neither prime. Each condition will be experienced for 42 days followed by a 7-day washout period (total duration of trial=189 days). We will record the number of people who enter each ward and whether they clean their hands during observation sessions, the amount of cleaning material used from the dispensers each week and the number of hospital-acquired infections that occur in each period. The outcomes will be compared using a regression analysis. Following the initial trail, the most effective priming condition will be rolled out for 3 months in all the wards., Ethics and Dissemination: Research ethics approval was obtained from the South Central-Oxford C Research Ethics Committee (16/SC/0554), the Health Regulatory Authority and the sponsor., Trial Registration Number: ISRCTN (15397624); Edge ID 86357., Competing Interests: Competing interests: None declared., (© Article author(s) (or their employer(s) unless otherwise stated in the text of the article) 2017. All rights reserved. No commercial use is permitted unless otherwise expressly granted.)

Unlabelled: Closed lateral subtalar dislocation is a very rare injury. We report a case of closed lateral subtalar dislocation with entrapment of flexor hallucis longus tendon producing a checkrein deformity. The patient was managed immediately with closed reduction under regional anesthesia and fixated with percutaneous Kirschner wires. Early mobilization and weightbearing was started and there were no complications till the last follow-up visit., Levels of Evidence: Therapeutic, Level IV: Case study., (© 2016 The Author(s).)

Unlabelled: When conditions change, organisms need to learn about the changed conditions without interfering with what they already know. To do so, they can assign the new learning to a new "state" and the old learning to a previous state. This state assignment is fundamental to behavioral flexibility. Cholinergic interneurons (CINs) in the dorsomedial striatum (DMS) are necessary for associative information to be compartmentalized in this way, but the mechanism by which they do so is unknown. Here we addressed this question by recording putative CINs from the DMS in rats performing a task consisting of a series of trial blocks, or states, that required the recall and application of contradictory associative information. We found that individual CINs in the DMS represented the current state throughout each trial. These state correlates were not observed in dorsolateral striatal CINs recorded in the same rats. Notably, DMS CIN ensembles tracked rats' beliefs about the current state such that, when states were miscoded, rats tended to make suboptimal choices reflecting the miscoding. State information held by the DMS CINs also depended completely on the orbitofrontal cortex, an area that has been proposed to signal environmental states. These results suggest that CINs set the stage for recalling associative information relevant to the current environment by maintaining a real-time representation of the current state. Such a role has novel implications for understanding the neural basis of a variety of psychiatric diseases, such as addiction or anxiety disorders, in which patients generalize inappropriately (or fail to generalize) between different environments., Significance Statement: Striatal cholinergic interneurons (CINs) are thought to be identical to tonically active neurons. These neurons have long been thought to have an important influence on striatal processing during reward-related learning. Recently, a more specific function for striatal CINs has been suggested, which is that they are necessary for striatal learning to be compartmentalized into different states as the state of the environment changes. Here we report that putative CINs appear to track rats' beliefs about which environmental state is current. We further show that this property of CINs depends on orbitofrontal cortex input and is correlated with choices made by rats. These findings could provide new insight into neuropsychiatric diseases that involve improper generalization between different contexts., (Copyright © 2016 the authors 0270-6474/16/366242-16$15.00/0.)

Epidermolysis bullosa (EB) is a genetic condition characterized by skin fragility and blistering. There is no instrument available for clinical outcome research measurements. Our aim was to develop a comprehensive instrument that is easy to use in the context of interventional studies. Item collection was accomplished using a two-step Delphi Internet survey process for practitioners and qualitative content analysis of patient and family interviews. Items were reduced based on frequency and importance using a 4-point Likert scale and were subject to consensus (>80% agreement) using the nominal group technique. Pilot data testing was performed in 21 consecutive patients attending an EB clinic. The final score, Instrument for Scoring Clinical Outcome of Research for Epidermolysis Bullosa (iscorEB), is a combined score that contains clinician items grouped in five domains (skin, mucosa, organ involvement, laboratory abnormalities, and complications and procedures; maximum score 114) and patient-derived items (pain, itch, functional limitations, sleep, mood, and effect on daily and leisurely activities; maximum score 120). Pilot testing revealed that combined (see below) and subscores were able to differentiate between EB subtypes and degrees of clinical severity (EB simplex 21.7 ± 16.5, junctional EB 28.0 ± 20.7, dystrophic EB 57.3 ± 24.6, p = 0.007; mild 17.3 ± 9.6, moderate 41.0 ± 19.4, and severe 64.5 ± 22.6, p < 0.001). There was high correlation between clinician and patient subscores (correlation coefficient = 0.79, p < 0.001). iscorEB seems to be a sensitive tool in differentiating between EB types and across the clinical spectrum of severity. Further validation studies are needed., (© 2014 Wiley Periodicals, Inc.)

Purpose: A systematic review was conducted to (1) collate and synthesise the available evidence for the role of cortisol in relation to IVF treatment outcomes; (2) to establish the strength of an association between cortisol and IVF; and (3) to assess the overall quality of the studies and guide future research in this area., Methods: Seven electronic databases, including the reference lists of published papers, were searched. Inclusion criteria qualified any prospective/observational cohort study that reported original data. Quality assessment of eligible studies was conducted using the STROBE statement, which was used to assess the risk of bias and the quality of observational studies included in this review., Results: A total of eight studies reported a significant association between cortisol and IVF outcomes. Three studies found that higher cortisol may be associated with more favourable IVF outcomes, whereas five studies found that lower cortisol levels may be conducive to IVF success. Eleven of all studies included in this review were regarded as low quality publications., Conclusions: Study findings were that the evidence for the role of cortisol in relation to IVF outcomes is currently mixed. Future researchers are encouraged to consider the methodological limitations highlighted in this review and to utilise more robust assessment methods when examining the influence that chronic, rather than acute, stress may have on IVF outcomes., Competing Interests: There are no conflicts of interest.

Aims: This paper focuses mainly on explanations and lessons from a research-based programme for identifying undiagnosed type 2 diabetes and high risk. In addition to outlining key quantitative findings, we specifically aim to explore reasons for low uptake from the perspective of primary care staff involved., Methods: The MY-WAIST study was conducted in UK primary care and included the use of oral glucose tolerance tests (OGTTs) and waist measurement. Qualitative data from interviews with healthcare providers and records of meetings were analysed thematically., Results: The key quantitative finding was low uptake of the assessments offered (8.6% overall, 2.6% in inner-city locations with high South Asian residency). In addition to confirming patient-reported barriers including those associated with OGTTs, qualitative findings highlighted a number of primary care provider barriers, including limited staff capacity. Interviewees suggested that those who attended were typically the 'worried well' rather than those from hard-to-reach groups., Conclusions: Implications discussed include the impact of low uptake on the usefulness of the quantitative data obtained, and lessons relevant to research design. Relevance to current guidance regarding early identification strategies is discussed and the importance of addressing the needs of less accessible groups is highlighted., (Copyright © 2013 Primary Care Diabetes Europe. Published by Elsevier Ltd. All rights reserved.)

Background: To address the increasing global prevalence of type 2 diabetes healthcare organisations have been contemplating different screening and intervention strategies. Patient acceptability is a key criterion of a screening programme., Aim: To explore the perspectives of those invited to attend the MY-WAIST screening study for type 2 diabetes, particularly explanations for attending or not, and views on the specific screening strategy., Design and Setting: Qualitative study of 11 general practices in Leicestershire, UK., Method: Semi-structured interviews were conducted with 24 individuals (40-69 years) invited to attend the MY-WAIST screening study, comprising 13 who attended and 11 who did not attend the screening. Additional data included reply slips from 73 individuals who declined the offer of screening. Analysis was informed by the constant comparative method., Results: Two categories of influence on the decision about attending screening emerged. 1) Beliefs about type 2 diabetes candidacy and type 2 diabetes was more common among those who had attended; lack of perceived severity of type 2 diabetes was more common among those who did not attend. 2) Practical aspects about the screening strategy: the lengthy, early morning screening appointments were a barrier to uptake; screening attendees found the procedure largely acceptable. Pre-screening waist self-measurement was more memorable than the remainder of the risk-score calculation; neither impacted on uptake., Conclusion: The barriers to screening uptake highlighted contribute to current debates about different screening and diagnostic tests for type 2 diabetes and future risk of type 2 diabetes. The findings are useful for those contemplating implementation of screening programmes for identifying type 2 diabetes and pre-diabetes.

Background: There is a clear relationship between depression and diabetes. However, the directionality of the relationship remains unclear and very little research has considered a multi-ethnic population. The aim of this study was to determine the prevalence of depression in a White-European (WE) and South-Asian (SA) population attending a community diabetes screening programme, and to explore the association of depression with screen-detected Type 2 diabetes mellitus (T2DM) and impaired glucose regulation (IGR)., Methodology/principal Findings: Participants were recruited from general practices in Leicestershire (United Kingdom) between August 2004 and December 2007. 4682 WE (40-75 years) and 1327 SA participants (25-75 years) underwent an Oral Glucose Tolerance Test, detailed history, anthropometric measurements and completed the World Health Organisation-Five (WHO-5) Wellbeing Index. Depression was defined by a WHO-5 wellbeing score < or =13. Unadjusted prevalence of depression for people in the total sample with T2DM and IGR was 21.3% (21.6% in WE, 20.6% in SA, p = 0.75) and 26.0% (25.3% in WE, 28.9% in SA, p = 0.65) respectively. For people with normal glucose tolerance, the prevalence was 25.1% (24.9% in WE, 26.4% in SA, p = 0.86). Age-adjusted prevalences were higher for females than males. Odds ratios adjusted for age, gender, and ethnicity, showed no significant increase in prevalent depression for people with T2DM (OR = 0.95, 95%CI 0.62 to 1.45) or IGR (OR = 1.17, 95%CI 0.96 to 1.42)., Conclusions: Prior to the knowledge of diagnosis, depression was not significantly more prevalent in people with screen detected T2DM or IGR. Differences in prevalent depression between WE and SA people were also not identified. In this multi-ethnic population, female gender was significantly associated with depression.

The widespread use of subclavian dialysis catheters has revealed a high incidence of venous thrombosis and exposed their potential to cause major obstructive complications that may compromise permanent vascular access. We describe for the first time a patient who developed superior vena cava syndrome secondary to central vein stenosis caused by multiple uses of subclavian dialysis catheters. Central vein stenosis in our patient probably caused the failure of permanent vascular accesses in the upper extremities and rendered both arms useless for any further temporary or permanent vascular access. In view of these late vascular complications, use of subclavian dialysis catheters should be kept to a minimum by creating an early permanent vascular access.

Intraperitoneal insulin requirements were evaluated in six diabetic patients who were switched from continuous ambulatory peritoneal dialysis to continuous cyclic peritoneal dialysis. The mean total daily intraperitoneal insulin dose on continuous cyclic peritoneal dialysis was 85% of the mean dose on continuous ambulatory peritoneal dialysis (66 +/- 33 vs. 78 +/- 47 units/day, respectively, not significant), with comparable glycemic control. Twenty-five to 58% (mean value, 41%) of the total daily intraperitoneal insulin was administered in the diurnal exchange of the patients on continuous cyclic peritoneal dialysis. The ratio of the total intraperitoneal insulin dose on continuous cyclic peritoneal dialysis to the subcutaneous insulin dose predialysis was between 1.2 and 2.4 (mean value, 1.9). As guidelines for converting intraperitoneal insulin doses for patients switched from continuous ambulatory peritoneal dialysis to continuous cyclic peritoneal dialysis, we recommend starting continuous cyclic peritoneal dialysis with a total daily insulin dose 15% less than the continuous ambulatory peritoneal dialysis dose and giving approximately 40% of the total daily insulin dose in the diurnal exchange.

Renal atheroembolism is a well-recognized cause of renal insufficiency. Two renal allograft recipients with cholesterol atheroemboli in their allograft biopsies are described. In one patient, the origin of the atheroemboli was the recipient aorta while in the second patient the source was the donor. Renal allograft atheroembolism should be considered in elderly recipients or recipients of kidneys from older donors.