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The remarkable archaeological record of Neolithic Orkney has ensured that these islands play a prominent role in narratives of European late prehistory, yet knowledge of the subsequent Bronze Age is comparatively poor. The Bronze Age settlement and cemetery at the Links of Noltland, on the island of Westray, offers new evidence, including aDNA, that points to a substantial population replacement between the Late Neolithic and Bronze Age. Focusing on funerary practice, the authors argue for interconnecting identities centred on household and community, patrilocality and inheritance. The findings prompt a reconsideration of the Orcadian Bronze Age, with wider implications for population movement and the uptake of cultural innovations more widely across prehistoric north-western Europe.

Aims Despite the COVID-19 pandemic, incidence of hip fracture has not changed. Evidence has shown increased mortality rates associated with COVID-19 infection. However, little is known about the outcomes of COVID-19 negative patients in a pandemic environment. In addition, the impact of vitamin D levels on mortality in COVID-19 hip fracture patients has yet to be determined. Methods This multicentre observational study included 1,633 patients who sustained a hip fracture across nine hospital trusts in North West England. Data were collected for three months from March 2020 and for the same period in 2019. Patients were matched by Nottingham Hip Fracture Score (NHFS), hospital, and fracture type. We looked at the mortality outcomes of COVID-19 positive and COVID-19 negative patients sustaining a hip fracture. We also looked to see if vitamin D levels had an impact on mortality. Results The demographics of the 2019 and 2020 groups were similar, with a slight increase in proportion of male patients in the 2020 group. The 30-day mortality was 35.6% in COVID-19 positive patients and 7.8% in the COVID-19 negative patients. There was a potential association of decreasing vitamin D levels and increasing mortality rates for COVID-19 positive patients although our findings did not reach statistical significance. Conclusion In 2020 there was a significant increase in 30-day mortality rates of patients who were COVID-19 positive but not of patients who were COVID-19 negative. Low levels of vitamin D may be associated with high mortality rates in COVID-19 positive patients. Cite this article: Bone Joint J 2021;103-B(4):782–787.

Defining categories of musical actions in improvisation with young children is challenging due to the spontaneous, creative and emergent nature of interactions. Following a literature review, two new constructs were proposed to circumscribe and classify different types of events in improvisation, Creative Musical Agency (CMA) and Socio-Musical Aptitude (S-MA). These were refined and tested through eight phases of mixed-methods research. Two cycles of improvisation workshops were video-recorded. Multimodal Video Analysis of musical, gaze and gestural Modes of Communication contextualized with field notes was used to refine constructs. Two raters independently observed and rated children’s improvisations as showing CMA, S-MA or neither, giving reasons for difficulty or ambiguity in using constructs in separate interviews. Raters demonstrated fair agreement for CMA (Κappa 0.21) and moderate agreement for S-MA (Kappa 0.5). Development of these constructs offers a valuable way of understanding the complexity of young children’s musical actions and mental processes in improvisation.

Raw sequencing reads of ancient samples produced for this study have been deposited in the European Nucleotide Archive under accession no. PRJEB46830. Modern mitochondrial genomes generated as part of this study have been deposited in GenBank, accession nos. MZ846240 to MZ848095., Orkney was a major cultural center during the Neolithic, 3800 to 2500 BC. Farming flourished, permanent stone settlements and chambered tombs were constructed, and long-range contacts were sustained. From ∼3200 BC, the number, density, and extravagance of settlements increased, and new ceremonial monuments and ceramic styles, possibly originating in Orkney, spread across Britain and Ireland. By ∼2800 BC, this phenomenon was waning, although Neolithic traditions persisted to at least 2500 BC. Unlike elsewhere in Britain, there is little material evidence to suggest a Beaker presence, suggesting that Orkney may have developed along an insular trajectory during the second millennium BC. We tested this by comparing new genomic evidence from 22 Bronze Age and 3 Iron Age burials in northwest Orkney with Neolithic burials from across the archipelago. We identified signals of inward migration on a scale unsuspected from the archaeological record: As elsewhere in Bronze Age Britain, much of the population displayed significant genome-wide ancestry deriving ultimately from the Pontic-Caspian Steppe. However, uniquely in northern and central Europe, most of the male lineages were inherited from the local Neolithic. This suggests that some male descendants of Neolithic Orkney may have remained distinct well into the Bronze Age, although there are signs that this had dwindled by the Iron Age. Furthermore, although the majority of mitochondrial DNA lineages evidently arrived afresh with the Bronze Age, we also find evidence for continuity in the female line of descent from Mesolithic Britain into the Bronze Age and even to the present day., We thank Steve Birch, Jenny Murray, and Sue Black for help with samples; Harald Ringbauer for advice on hapROH; and Joyce Richards for comments on an early draft. Excavations at LoN and KoS are directed by H.M. and G.W., EASE (Environment and Archaeology Services), grant funded by Historic Environment Scotland. M. Ni Challanain, M. McCormick, and D. Gooney undertook osteological identifications and sample selection. K.D., M.G.B.F, P.J., M.S., G.O.-G, A.F., and S.R. were supported by a Leverhulme Trust Doctoral Scholarship program awarded to M.B.R. and M.P. DNA sequencing was also supported by the UK Natural Environment Research Council Biomolecular Analysis Facility (NBAF) at the University of Liverpool, under NBAF Pilot Scheme NBAF685, awarded to C.J.E. whilst at the University of Oxford. P.S., M.P., and M.B.R. acknowledge FCT (Fundação para a Ciência e a Tecnologia) support through project PTDC/EPH-ARQ/4164/2014, partially funded by FEDER (Fundo Europeu de Desenvolvimento Regional) funds (COMPETE 2020 project 016899). PS was supported by FCT, European Social Fund, Programa Operacional Potencial Humano, and the FCT Investigator Programme and acknowledges FCT/MEC (Ministério da Educação e Ciência) for support to CBMA through Portuguese funds (PIDDAC: Programa de Investimentos e Despesas de Desenvolvimento da Administração Central)—PEst-OE/BIA/UI4050/2014. V.M. and D.G.B. acknowledge the Science Foundation Ireland/Health Research Board/Wellcome Trust Biomedical Research Partnership Investigator Award No. 205072 to D.G.B., “Ancient Genomics and the Atlantic Burden.” The ORCADES was supported by the Chief Scientist Office of the Scottish Government (CZB/4/276, CZB/4/710), a Royal Society University Research Fellowship to J.F.W., the MRC (Medical Research Council) Human Genetics Unit quinquennial programme “QTL in Health and Disease,” Arthritis Research UK, and the EU FP6 EUROSPAN project (contract no. LSHG-CT-2006-018947). The Edinburgh Clinical Research Facility, University of Edinburgh, performed DNA extractions and the Sanger Institute performed whole-genome sequencing. The Viking Health Study–Shetland (VIKING) was supported by the MRC Human Genetics Unit quinquennial programme grant “QTL in Health and Disease.” DNA extractions were performed at the Edinburgh Clinical Research Facility, University of Edinburgh. Whole genome sequencing was supported by the Scottish Genomes Partnership award from the Chief Scientist Office of the Scottish Government and the MRC (grant reference SGP/1) and the MRC Whole Genome Sequencing for Health and Wealth Initiative (MC/PC/15080). We acknowledge Wellcome Trust funding (098051) for the ORCADES whole-genome sequencing. J.F.W. acknowledges support from the MRC Human Genetics Unit programme grant, “Quantitative traits in health and disease” (U. MC_UU_00007/10). We also acknowledge the invaluable contributions of the research nurses in Orkney and Shetland, the administrative team in Edinburgh, and the people of Orkney and Shetland.

Prone positioning has been demonstrated to significantly reduce mortality in invasively ventilated patients with moderate to severe acute respiratory distress syndrome through several physiological mechanisms, including optimization of ventilation and perfusion and a reduction in ventilator-associated lung injury. The marked increase of hospitalisation rates of patients with acute hypoxaemic respiratory failure during the COVID-19 pandemic, and associated strain on healthcare resources, led to interest in the use of prone positioning in conscious self-ventilating, or “awake”, patients, as an adjunct to the provision of oxygen therapy and respiratory support. The adoption of this technique was with the intent of reducing the likelihood of progressive respiratory failure and thus the need for invasive mechanical ventilation. In this review we summarize the background, physiological mechanisms and current evidence for the use of awake prone positioning in both COVID-19 related hypoxaemic respiratory failure and that attributed to other aetiologies. Whilst several studies note an improvement in respiratory parameters including oxygenation, the effect on clinically important outcomes such as rates of intubation and mortality remain unclear. The evidence base beyond COVID-19 related respiratory failure remains constrained and there is a paucity of evidence to help identify those most likely to benefit from this therapy. There remains no agreed consensus on how to implement awake prone positioning and significant variation exists in practice. Several clinical questions should be the focus for future research studies of this treatment modality including how to identify early responders and non-responders to therapy.

There has been a recent expansion of school curricula and extra-curricular activities emphasizing musical creativity and collaboration. Parents have a crucial role in providing children with access to such experiences; their views on music and the nature of creativity influence the types of musical engagement their children will access. Teachers also have an important role, yet can have difficulties when supporting children in open-ended tasks. A qualitative study investigated parents’ and teachers’ constructions of creativity and music. Interviews were held with 11 parents and 4 teachers of preschool children who took part in improvisation workshops. Data were analyzed with thematic analysis, resulting in identification of three themes. Creativity and musicality were described as fundamental to children’s “human nature” but positioned as a non-fundamental part of their own adult identities. “Values” explored conceptualizations of creativity through artistic products; musicality was appreciated demonstration of technical skill. “Frames for engaging” identified adults engaging with their children in creative tasks mainly through child-led narratives; in contrast, parents took on the role of “teacher” in musical tasks. Understanding these influential views offers insight into the types of activities and guidance offered to pre-schoolers and how they can be built on to foster children’s musical creativity.

Introduction Undiagnosed obstructive sleep apnoea (OSA) is increasingly recognized as a serious post-operative risk with bariatric surgery, hence increasing demand for pre-operative screening and a need for simpler ways for screening than the clinical standard, respiratory polygraphy, to mitigate strain on sleep services. WatchPAT 300 (WP) is a finger-mounted sensor that uses peripheral arterial tonometry to estimate the apnoea hyponoea index (AHI). While its use is increasing it has not yet been validated in patients with a BMI >35, the target population in bariatric surgery. Aims To validate WP against polygraphy in pre-bariatric surgery patients with clinically suspected OSA and a BMI>35 and to assess patient acceptability of WP. Methods AHI was measured simultaneously with WP and Embletta. Outcome measures were 1) autoscored AHI from WP and 2) manually re-scored AHI from Embletta. Agreement between AHI from Embletta and WP was assessed using intra-class correlation coefficient (ICC), bland Altman and ROC plots. Results 28 patients (22 female/6 male, mean ± SD age 44.1 ± 11.6, BMI 45.7 ± 7.5) participated. One study failed due to the patient removing the WP probe prematurely. AHI was higher in WP than Embletta (28.1± 17.9 versus 15.0 ±13.4; p 15 (Area under the curve 0.917; p Discussion WP accurately estimates the AHI in pre bariatric surgery patients, has a low failure rate and is clinically acceptable in this group. Further larger scale studies are needed to confirm these findings before incorporating into clinical guidelines.

Older adults undergoing emergency abdominal surgery have significantly poorer outcomes than younger adults. For those who survive, the level of care required on discharge from hospital is unknown and such information could guide decision-making. The ELF (Emergency Laparotomy and Frailty) study aimed to determine whether preoperative frailty in older adults was associated with increased dependence at the time of discharge.The ELF study was a UK-wide multicentre prospective cohort study of older patients (65 years or more) undergoing emergency laparotomy during March and June 2017. The objective was to establish whether preoperative frailty was associated with increased care level at discharge compared with preoperative care level. The analysis used a multilevel logistic regression adjusted for preadmission frailty, patient age, sex and care level.A total of 934 patients were included from 49 hospitals. Mean(s.d.) age was 76·2(6·8) years, with 57·6 per cent women; 20·2 per cent were frail. Some 37·4 per cent of older adults had an increased care level at discharge. Increasing frailty was associated with increased discharge care level, with greater predictive power than age. The adjusted odds ratio for an increase in care level was 4·48 (95 per cent c.i. 2·03 to 9·91) for apparently vulnerable patients (Clinical Frailty Score (CFS) 4), 5·94 (2·54 to 13·90) for those mildly frail (CFS 5) and 7·88 (2·97 to 20·79) for those moderately or severely frail (CFS 6 or 7), compared with patients who were fit.Over 37 per cent of older adults undergoing emergency laparotomy required increased care at discharge. Frailty scoring was a significant predictor, and should be integrated into all acute surgical units to aid shared decision-making and discharge planning.Los adultos mayores sometidos a cirugía abdominal de urgencia tienen resultados significativamente peores que los adultos jóvenes. Para aquellos pacientes que sobreviven, el nivel de atención que requieren tras el alta hospitalaria se desconoce y esta información podría servir de guía en la toma de decisiones. El estudio ELF (Emergency Laparotomy and Frailty) tenía como objetivo determinar si la fragilidad preoperatoria en adultos mayores se asociaba con un aumento de la dependencia en el momento del alta. MÉTODOS: El estudio ELF era un estudio multicéntrico extenso efectuado en el Reino Unido (n = 49) que incluyó una cohorte prospectiva de 934 pacientes mayores ( 65 años) sometidos a laparotomía de urgencia durante marzo-junio de 2017. El objetivo fue establecer si la fragilidad preoperatoria aumentaba el nivel de asistencia en el momento del alta en comparación con el nivel de asistencia preoperatorio. Para el análisis se utilizó una regresión logística multinivel ajustada a características previas al ingreso: fragilidad, edad del paciente, género, y nivel de asistencia.La edad media de los pacientes fue 76,2 años (DE = 6,83), con un 57% de mujeres, un 20,2% de pacientes frágiles y un 37,4% de adultos mayores que presentaron un aumento en el nivel de asistencia en el momento del alta. Un aumento de la fragilidad se asoció con un incremento en el nivel de asistencia en el momento del alta (y mayor poder predictivo que la edad). La razón de oportunidades (odds ratio, OR) ajustada por el aumento del nivel de asistencia fue 4,48 (i.c. del 95% 2,03-9,91) para pacientes aparentemente vulnerables (Clinical Frailty Scale, CFS 4); 5,94 (i.c. del 95% 2,54-13,90) para aquellos ligeramente frágiles (CFS 5); y 7,88 (i.c. del 95% 2,97-20,79) para aquellos con fragilidad moderada o grave (CFS 6 and 7) en comparación con pacientes en buenas condiciones. CONCLUSIÓN: Este es el primer estudio que documenta que más del 37% de adultos mayores sometidos a laparotomía de urgencia precisaron un aumento en el nivel de asistencia en el momento del alta. La evaluación de la fragilidad debería integrarse en todas las unidades quirúrgicas de agudos para ayudar a compartir la toma de decisiones y los planes de tratamiento.

Participating in musical activities involves an immersive spectrum of psychological and social engagement. Connections between musical participation and health have been discussed for centuries, and relationships between the processes of music making and well-being outcomes have garnered considerable research interest. This chapter reviews studies investigating such associations to identify how creative aspects of musical engagement in particular can be understood to enhance health. The chapter begins by offering some suggestions about why these processes may have beneficial effects. Three key contexts for beneficial musical engagement (music education, music therapy, and community music) are examined: an organization (Limelight) that delivers music activities for individuals from disadvantaged groups; group improvisation music therapy sessions for individuals with cancer; and songwriting sessions for individuals following spinal injury. The relative contributions of creative process and creative product are considered, and psychological concepts such as identity, flow, agency, and scaffolding are suggested as important. The discussion extrapolates wider implications of this work to include general music making beyond clinical, educational, and community contexts.

Despite the COVID-19 pandemic, incidence of hip fracture has not changed. Evidence has shown increased mortality rates associated with COVID-19 infection. However, little is known about the outcomes of COVID-19 negative patients in a pandemic environment. In addition, the impact of vitamin D levels on mortality in COVID-19 hip fracture patients has yet to be determined.This multicentre observational study included 1,633 patients who sustained a hip fracture across nine hospital trusts in North West England. Data were collected for three months from March 2020 and for the same period in 2019. Patients were matched by Nottingham Hip Fracture Score (NHFS), hospital, and fracture type. We looked at the mortality outcomes of COVID-19 positive and COVID-19 negative patients sustaining a hip fracture. We also looked to see if vitamin D levels had an impact on mortality.The demographics of the 2019 and 2020 groups were similar, with a slight increase in proportion of male patients in the 2020 group. The 30-day mortality was 35.6% in COVID-19 positive patients and 7.8% in the COVID-19 negative patients. There was a potential association of decreasing vitamin D levels and increasing mortality rates for COVID-19 positive patients although our findings did not reach statistical significance.In 2020 there was a significant increase in 30-day mortality rates of patients who were COVID-19 positive but not of patients who were COVID-19 negative. Low levels of vitamin D may be associated with high mortality rates in COVID-19 positive patients. Cite this article

People with disabilities face inequalities in mental wellbeing, for which social exclusion is a contributing factor. Musical activities offer a promising but complex intervention, making impacts on a population with highly varied characteristics and needs challenging to capture. This paper reports on a mixed methods, person-centered study investigating a community music intervention for such a population. Three groups of adult service users with varied disabilities (either physical, learning, or both), took part in weekly music workshops in different locations. Music staff, housing and resource center staff, as well as participants and members of their families, took part in semi-structured interviews. A quantitative measure administered by service staff was used to rate service users’ social development. Two lay researchers, both individuals with a disability contributed to all aspects of the study. Interviews were analyzed through thematic analysis. Improvements in individuals’ self-expression, confidence, mood, and social skills were consistent with previous findings. Differences in effect between centers included: Group 1, some of whom had previous experience of workshops, showed an improvement in musical skills; Group 2 showed a mixed response, some participated with enthusiasm but others chose art activities over music workshops; Group 3 had lasting positive impact, this group had very limited opportunities for music due to their rural location. Quantitative analysis showed significant increase over all groups in communication, interaction with others, and joint attention. The intervention was beneficial for participants in separate locations in similar ways, but also highlighted that context and prior experience mediated effects in distinct ways. The lay researchers enhanced the qualitative analysis by emphasizing (1) the importance of recognizing participants’ self-expression in non-verbal modes of communication and (2) the importance of having music staff with a disability to provide a positive role model. This paper proposes that mixed methods person-centered research is the most suitable approach to capture and understand the multiple and varied effects of this complex intervention for a diverse group of participants.

Improvisation represents a unique process of social creativity in real time, practiced in widely varying musical contexts with different levels of experience. Yet psychologist have mostly studied the practices of individual jazz soloists with an expectation that shared understanding, knowledge and technical abilities are a prerequisite for group improvising. A qualitative study interviewed six trios of free improvisers (n=18) to illuminate the processes of shared musical improvisation across a range of contemporary artistic practice. Comparison of different members' accounts of events during recorded free improvisations indicated that their understandings of who did what and why converged at some points, notably during relative stasis, and diverged at others. Improvisers anticipated and interpreted musical behaviors of their collaborators with reference to previous shared social or musical experience, but considered that such expectations could, and should, be confounded. Familiarity between improvisers could be seen as helpful in building trust within dynamic and highly uncertain musical contexts, and in allowing a less conscious approach to interaction. Improvisers individually assumed that their group shared certain tastes and asserted that others recognized certain musical material as connected to previous practice together. These ideas of shared tastes and practices could best be understood as constructions within this particular social context, since they were not necessarily consistent across the ensemble. The findings emphasize the fundamentally social nature of improvising: shared understanding is not a prerequisite for participation, but shared experience over time enriches the resources of meaning an individual can bring to their interaction in an improvising group.

There is evidence that music interventions can offer opportunities for creative, psychological and social developments for individuals with mild to profound learning disabilities, addressing the disadvantages they face in respect of social outcomes. This paper reports on a qualitative study investigating a community music intervention for such a population. Thirty-seven adult service users (12 female, 25 male) took part in weekly music workshops for ten weeks. Their learning difficulties ranged from mild to profound, and their levels of independence ranged from requiring constant one-to-one care to living alone in sheltered accommodation. Interviews were conducted at multiple time points with music and resource centre staff as well as participants and members of their families and other centre users; researchers also observed all workshops, taking field notes. Thematic analysis of the data informed understanding of the disadvantages facing participants, their experience of the workshop programme and its immediate and wider social outcomes, as well as suggesting key mechanisms for effects. Disadvantages and barriers facing participants included: limited access to enjoying or learning music; boredom, isolation and limited networks; lack of experience of new social contexts; and an associated lack of confidence, low mood or self-esteem. Participants were found to enjoy and sustain engagement with a programme of dedicated group music workshops delivered by staff trained in an empathic and inclusive approach. Impacts included an ongoing enthusiasm to engage in music; wider recognition of musicality; increased self-confidence; being happier, more relaxed and/or enthusiastic after the workshops; better ability to interact with unfamiliar situations and people; and participation in social activities for an unprecedented length of time. Key factors in achieving those impacts are that participants: had fun and interacted socially; felt secure, welcomed and involved at all times; exercised choice; worked with others in non-verbal tasks; and encountered challenge while engaging and progressing at their own rate.

Background: cancellation of planned surgery impacts substantially on patients and health systems. This study describes the incidence and reasons for cancellation of inpatient surgery in the UK NHS. Methods: we conducted a prospective observational cohort study over 7 consecutive days in March 2017 in 245 NHS hospitals. Occurrences and reasons for previous surgical cancellations were recorded. Using multilevel logistic regression, we identified patient- and hospital-level factors associated with cancellation due to inadequate bed capacity. Results: we analysed data from 14 936 patients undergoing planned surgery. A total of 1499 patients (10.0%) reported previous cancellation for the same procedure; contemporaneous hospital census data indicated that 13.9% patients attending inpatient operations were cancelled on the day of surgery. Non-clinical reasons, predominantly inadequate bed capacity, accounted for a large proportion of previous cancellations. Independent risk factors for cancellation due to inadequate bed capacity included requirement for postoperative critical care [odds ratio (OR)=2.92; 95% confidence interval (CI), 2.12–4.02; PConclusions: a significant proportion of patients presenting for surgery have experienced a previous cancellation for the same procedure. Cancer surgery is relatively protected, but bed capacity, including postoperative critical care requirements, are significant risk factors for previous cancellations.

SummaryBackground Endoscopic balloon dilatation (EBD) is recognised treatment for symptomatic Crohn's strictures. Several case series report its efficacy. A systematic analysis for overall efficacy can inform the design of future studies. Aim To examine symptomatic (SR) and technical response (TR) and adverse events (AE) of EBD. Stricture characteristics were also explored. Methods A systematic search strategy of COCHRANE, MEDLINE and EMBASE was performed. All original studies reporting outcomes of EBD for Crohn's strictures were included. SR was defined as obstructive symptom-free outcome at the end of follow-up, TR as post-dilatation passage of the endoscope through a stricture, and adverse event as the presence of complication (perforation and/or bleeding). Pooled event rates across studies were expressed with summative statistics. Results Twenty-five studies included 1089 patients and 2664 dilatations. Pooled event rates for SR, TR, complications and perforations were 70.2% (95% CI: 60–78.8%), 90.6% (95% CI: 87.8–92.8%), 6.4% (95% CI: 5.0–8.2) and 3% (95% CI: 2.2–4.0%) respectively. Cumulative surgery rate at 5 year follow-up was 75%. Pooled unweighted TR, SR, complication, perforation and surgery rates were 84%, 45%, 15%, 9% and 21% for de novo and 84%, 58%, 22%, 5% and 32% for anastomotic strictures. Outcomes between two stricture types were no different on subgroup meta-analysis. Conclusions Efficacy and complication rates for endoscopic balloon dilatation were higher than previously reported. From the few studies with 5 year follow-up the majority required surgery. Future studies are needed to determine whether endoscopic balloon dilatation has significant long-term benefits.

The authors describe an unusual cause of ventriculoperitoneal shunt malfunction presenting as acute hydrocephalus.

Background and aims Key performance indicators [KPIs] exist across a range of areas in medicine. They help to monitor outcomes, reduce variation, and drive up standards across services. KPIs exist for inflammatory bowel disease [IBD] care, but none specifically cover inflammatory bowel disease [IBD] surgical service provision. Methods This was a consensus-based study using a panel of expert IBD clinicians from across Europe. Items were developed and fed through a Delphi process to achieve consensus. Items were ranked on a Likert scale from 1 [not important] to 5 [very important]. Consensus was defined when the inter quartile range was ≤ 1, and items with a median score > 3 were considered for inclusion. Results A panel of 21 experts [14 surgeons and 7 gastroenterologists] was recruited. Consensus was achieved on procedure-specific KPIs for ileocaecal and perianal surgery for Crohn's disease, [N = 10] with themes relating to morbidity [N = 7], multidisciplinary input [N = 2], and quality of life [N = 1]; and for subtotal colectomy, proctocolectomy and ileoanal pouch surgery for ulcerative colitis [N = 11], with themes relating to mortality [N = 2], morbidity [N = 8], and service provision [N = 1]. Consensus was also achieved for measures of the quality of IBD surgical service provision and quality assurance in IBD surgery. Conclusions This study has provided measurable KPIs for the provision of surgical services in IBD. These indicators cover IBD surgery in general, the governance and structures of the surgical services, and separate indicators for specific subareas of surgery. Monitoring of IBD services with these KPIs may reduce variation across services and improve quality.

There is evidence that alcohol consumption among those in middle-class occupations consistently exceeds safe levels, yet there has been little research into why this occurs. This article explores the meanings associated with alcohol use among professional, managerial and clerical workers. Qualitative data were collected from five focus groups of male and female employees aged 21–55 (N =49: 32 male, 17 female). Each focus group was conducted on the premises of a medium-scale or large-scale employer, four public sector and one private sector, in the north-east of England. Using Bourdieu's concepts of ‘habitus’, ‘capitals’ and ‘fields’ we found that, among these middle-class occupational groups, alcohol use was associated with two habitus: a ‘home drinking’ habitus and a ‘traditional drinking’ habitus. Those of the home drinking habitus particularly used wine as a source of cultural capital and a means of distinction, whereas those in the traditional habitus consumed lager, beer and spirits to have fun in social settings. A small minority appeared to belong to a third, omnivorous, habitus where a wide range of alcoholic drinks were consumed in a variety of contexts. Existing public health initiatives to reduce alcohol consumption may require modification to accommodate a range of drinking cultures.

Aims To ascertain views, perceptions and attitudes of paramedics when working with patients presenting with alcohol-related injury or illness, and to explore perceived barriers and facilitators for the introduction of alcohol interventions to the NHS ambulance services. Methods A total of 142 (24%) from 589 paramedics from the North East Ambulance Service NHS Foundation Trust returned completed surveys between January 2013 to April 2013, which included measures of current perceptions and attitudes of working with patients with alcohol-related injury or illness, and the Shortened Alcohol and Alcohol Problems Perception Questionnaire (SAAPPQ). Results Paramedics reported little to no formal training on working with patients with alcohol-related injury or illness (77%). Paramedics scored low across all domains of the SAAPPQ for working with both problem and dependent drinkers. Not having suitable counseling materials (77%), not enough training (72%) and no facilities or time to deal with prevention (69%) were key barriers. Conclusions At this present time, levels of commitment, motivation, satisfaction, legitimacy and adequacy are low in front-line paramedics when working with patients with alcohol-related injury and illness. However, they are open to finding ways to provide interventions if they are adequately trained and have appropriate referral pathways open to them.

Background Management of fistulating perianal Crohn's disease (fpCD) is a significant challenge for a colorectal surgeon. A recent survey of surgical practice in this condition showed variation in management approaches. As a result we set out to devise recommendations for practice for UK colorectal surgeons. Methods Results from a national survey were used to devise a set of potential consensus statements. Consultant colorectal surgeons were invited to participate in the exercise via the previous survey and the mailing list of the professional society. Iterative voting was performed on each statement using a 5-point Likert scale and electronic voting, with opportunity for discussion and refinement between each vote. Consensus was defined as agreement >80%. Results Seventeen surgeons and two patient representatives voted upon 51 statements. Consensus was achieved on 39 items. Participants advocated a patient centred approach by a colorectal specialist, within strong multidisciplinary team-working. The use of anti-TNFα therapy is advocated. Where definitive surgical techniques are considered, they should be carefully selected to avoid adverse impact on function. Ano- and rectovaginal fistulae should be managed by specialists in fistulating disease. Stoma or proctectomy could be discussed earlier in a patient's treatment pathway to improve choice, as they may improve quality of life. Discussion This consensus provides principles and guidance for best practice in managing patients with fistulating perianal Crohn's Disease. This article is protected by copyright. All rights reserved.

Anti-CD154mAb is a powerful co-stimulation blockade agent that is efficacious in preventing rejection, even in xenogeneic settings. It has been used in the majority of successful long-term pig-to-non-human primate islet transplantation models. However, its clinical use was halted as a result of thromboembolic complications that were also observed in preclinical and clinical organ transplantation models. An anti-CD154mAb was administered to 14 streptozotocin-induced diabetic cynomolgus monkey recipients of porcine islets, some of which received the agent for many months. Monkeys were monitored for complications, and blood monitoring was carried out frequently. After euthanasia, multiple biopsies of all organs were examined for histological features of thromboembolism. Anti-CD154mAb prevented rejection of genetically engineered pig islets in all monkeys. No significant complications were attributable specifically to anti-CD154mAb. There was no evidence of thromboembolism in multiple histological sections from all major organs, including the brain. Our data suggest that in diabetic monkeys with pig islet grafts, anti-CD154mAb would appear to be an effective and safe therapy, and is not associated with thromboembolic complications.

Background: UK society is ageing. Older people who drink alcohol, drink more than those from previous generations, drink more frequently than other age groups and are more likely to drink at home and alone. Alcohol problems in later life however are often under-detected and under-reported meaning older people experiencing alcohol problems have high levels of unmet need. Methods: This study sought to identify existing services within South of Tyne, North East England to capture the extent of service provision for older drinkers and identify any gaps. The Age UK definition of ‘older people’ (aged 50 and over) was used. Services were contacted by telephone, managers or their deputy took part in semi-structured interviews. Findings: Forty six service providers were identified. Only one provided a specific intervention for older drinkers. Others typically provided services for age 18+. Among providers, there was no definitive definition of an older person. Data collection procedures within many organisations did not enable them to confirm whether older people were accessing services. Where alcohol was used alongside other drugs, alcohol use could remain unrecorded. Conclusion: To enable alcohol services to meet the needs of older people, greater understanding is needed of the patterns of drinking in later life, the experiences of older people, the scale and scope of the issue and guidance as to the most appropriate action to take. An awareness of the issues related to alcohol use in later life also needs to be integrated into commissioning of other services that impact upon older people.

The delivery of brief interventions (BIs) in health care settings to reduce problematic alcohol consumption is a key preventive strategy for public health. However, evidence of effectiveness beyond primary care is inconsistent. Patient populations and intervention components are heterogeneous. Also, evidence for successful implementation strategies is limited. In this article, recent literature is reviewed covering BI effectiveness for patient populations and subgroups, and design and implementation of BIs. Support is evident for short-term effectiveness in hospital settings, but long-term effects may be confounded by changes in control groups. Limited evidence suggests effectiveness with young patients not admitted as a consequence of alcohol, dependent patients, and binge drinkers. Influential BI components include high-quality change plans and provider characteristics. Health professionals endorse BI and feel confident in delivering it, but training and support initiatives continue to show no significant effects on uptake, prompting calls for systematic approaches to implementing BI in health care.

Background\ud Concurrent alcohol and medication use can result in significant problems especially in mid to later life. Alcohol is often used instead of medication for a number of health-related conditions. This novel qualitative study explored concurrent alcohol and medication use, as well as the use of alcohol for medicinal purposes, in a sample of individuals in mid to later life.\ud \ud Methods\ud Twenty-four interviews (12 men/12 women, ages 51–90 years) and three focus groups (n = 27, 6 men/21 women, ages 50–95 years) from three branches of Age UK and two services for alcohol problems in North East England.\ud \ud Results\ud Older people in this study often combined alcohol and medication, frequently without discussing this with their family doctor. However, being prescribed medication could act as a motivating factor to stop or reduce alcohol consumption. Participants also used alcohol to self-medicate, to numb pain, aid sleep or cope with stress and anxiety. Some participants used alcohol to deal with depression although alcohol was also reported as a cause of depression. Women in this study reported using alcohol to cope with mental health problems while men were more likely to describe reducing their alcohol consumption as a consequence of being prescribed medication.\ud \ud Conclusions\ud As older people often combine alcohol and medication, health professionals such as family doctors, community nurses, and pharmacists should consider older patients’ alcohol consumption prior to prescribing or dispensing medication and should monitor subsequent drinking. In particular, older people should be informed of the dangers of concurrent alcohol and medication use.

PURPOSE To determine if the discomfort associated with pterygium is different for men and women. METHODS Subjects were selected from patients attending a clinic in Guanajuato, Mexico, which has a high prevalence of pterygium. Discomfort was determined using a Spanish version of an English questionnaire designed to evaluate symptoms in dry eye patients. Questions were asked regarding seven sensations of discomfort, and five environmental sources of irritation that were not present in the original questionnaire: smoke, cigarette smoke, dust, wind, and sun. Most of the subjects had limited reading skills so the questionnaire was administered orally. Two subsamples are reported. In the first subsample, the interviewer was a male interviewer and the subsample was made up of 28 matched pairs of subjects selected from a total of 110 subjects (one man and one woman in each pair with the same age and pterygium stage). In the second subsample, the interviewer was a female interviewer and made up of 16 matched pairs selected from a total of 70 subjects. Pterygium staging was based on a scale in which progression was staged on a scale of one to five. The data was analyzed statistically using the Mann-Whitney U test (two-tailed). RESULTS The subjects had an age range of 41 to 82 years. The pterygium stages ranged from localized minor disturbances of the nasal conjunctiva (one on the scale) to compound pterygium (five on the scale). The difference in ocular surface discomfort between men and women was statistically significant for both the male interviewer (P < 0.001) and the female interviewer (P < 0.01). CONCLUSIONS Women with pterygium report more discomfort than men. It is likely that men and women with other sources of ocular surface discomfort also respond differently to pain.

This article reports on a study of the views of Scottish teachers concerning the delivery of arts subjects within the 5–14 curriculum. Data were gathered through focus group interviews with primary, secondary and primary head teachers, and a questionnaire survey of 232 teachers in 10 Scottish LEAs. Research issues included the balance of the curriculum; assessment; the specialist knowledge required to teach each subject with confidence; how the arts were valued by parents and schools; and the benefits which may accrue to pupils and the school through participation in the arts. This article compares findings from primary teachers with those from secondary teachers. While differences were apparent in terms of confidence with teaching and assessing the arts, and how they felt arts subjects were valued, all participants strongly endorsed the benefits of arts education, particularly in terms of pupils' personal development. The implications of these findings are discussed in relation to current literature.

Group musical improvisation is a unique psychological phenomenon. Cognitive literature on jazz musicians argues that creativity in improvisation is constrained by stylistic conventions and facility with existing musical elements. However the expanding field of free improvisation is predicated on avoiding idiomatic expectations and familiar material. To model musical improvisation in its widest sense, 15 diverse free improvisers were video recorded performing in trios, and interviewed in-depth while reviewing the recording. Improvisers chose on an iterative basis whether to maintain what they were doing or change, either to initiate a new direction or to respond to another improviser. Responses were subjectively understood to adopt, augment or contrast the contributions of others. These choices were based on evaluative dimensions of texture, rate of initiatives, and degrees of novelty and diversity, as well as structural and practical concerns and experience of enjoyment. Improvisers did not perceive consistent agency for themselves while improvising, and their evaluations were influenced by constructions of the social context. Results highlight that new material is generated at a variable rate by any one individual during this collaborative creativity, and indicate that constraints on choices to cope with high cognitive demands are subjective and situation-specific rather than objective.

This paper describes how a soft contact lens can be used to harvest cells from the surface of the corneal epithelium. The procedure is called contact lens cytology (CLC). Cells were removed from a soft contact lens by irrigation and stained with acridine orange. Two methods for the measurement of cell size are described. First, cell size was measured using a computer-assisted technique, which calculated the area of the cell from its outline. The second method was simpler in that it required only a single measurement of the longest dimension of the cell (the cell length). To test the validity of this simpler method, cell area was compared with cell length in 185 cells. The resulting correlation (r = 0.92) suggests that the size of shed cells can be described adequately using cell length in place of the more time-consuming measurement of cell area. A mathematical relation can be used to convert cell length to cell area so that results from experimenters using different measures of size can be compared. When a large pool of cells collected by CLC was divided into four aliquots and cell length measured by two observers on two different days, there were no significant differences between observers or days. Thus, the technique does not depend on one observer, and it is unaffected by a 24-h delay in measurement. Cells were harvested from the corneal epithelium of normal human subjects. The number of cells collected from any single removal of the contact lens had a range of 10 to 175 cells, and a mean of 66.8 +/- 40.4 (N = 46). Cell length was measured and plotted as frequency histograms for both eyes of each subject. The range in cell length was from 10 to 80 microns. The mean cell length for individual subjects had a low of 26.5 +/- 9.0 microns and a high of 44.2 +/- 10.2 microns, with a grand mean for all right eyes of 36.0 +/- 5.1 microns, and a grand mean for all left eyes of 34.6 +/- 5.2 microns. The mean for all eyes was 35.3 +/- 5.1 microns. Composite histograms were created with the combined data from the 23 right eyes (N = 1310 cells), and the 23 left eyes (N = 1765 cells). Individual histograms and the composite histograms were not normally distributed. Peaks in the distributions suggest the presence of different subpopulations of cells, lending support to the hypothesis that there is more than one mechanism for cell shedding.

Ideas about the role of fathers in the separated family have changed over the last few decades. The prevalent legal construct of 'co-parenting' implies that children should be able to maintain contact with a non-resident parent, usually the father, if they wish, except in cases where there has been abuse or violence. Research in several disciplines has sought to explain the processes of contact by examining the behaviour of separated fathers, their relationships within the family, and the separated family as a whole. Quantitative studies have explored levels of involvement, the father-child relationship and the inter-parental relationship as factors affecting children's outcomes, while an expanding body of qualitative work has sought to map the practice of co-parenting through identifying the diversity of separated parenthood and the perspectives of non-resident fathers in particular. The contributions of these diverse approaches to current debates on non-resident fathers are reviewed in this article.

The collaborative processes of jazz improvising are of considerable academic interest as a unique form of creativity. While recent work highlights the utility of interviewing practitioners with the aim of gaining an authoritative view, there is still a need for research to apprehend the gamut of what can be constituted as “jazz”. A previous study has shown how understandings of the music arising in focus group interviews with jazz improvisers are shaped by the need to establish identities (MacDonald and Wilson, 2005; Wilson and MacDonald, 2005). This paper reports on a further series of semi-structured individual interviews with 10 (6 male and 4 female) professional UK jazz musicians on the theme of jazz and musical identity. Specifically, the interviews investigated the social and psychological implications of the collaborative nature of this music. Discursive analysis of the interview transcripts shows how understandings of the music were constructed in relation to identity positions for the speaker. Identity as a jazz musician was negotiated with other individual identities; the relationship between gendered identities and identity as a jazz musician is examined as an instance of how conflict between these identities may allow hegemonic influences to operate. These findings are discussed in relation to current debates in identity theory, and implications for music education.

Views about jazz, and being a jazz musician, were gathered from current Scottish practitioners. Jazz is a uniquely interactive creative practice, dependent on shared practices and meanings. These are inseparable from social and cultural contexts; however, research on musicians’ views has been concentrated on individuals in the USA. This study therefore uses focus group interviewing to access group musical identities in the UK. Reflexive issues of the research procedure are also addressed. Maintaining swing feel and a balance of collective and individual practices emerged as important. Eclectic professional practice created a demanding lifestyle; in this context, the group aspect of jazz is integral to related musical identities. Diverse discourses highlighted the constructed nature of these identities; focus groups are thus a useful method for this field. Consideration of the interview circumstances suggests how these function, and has implications for subsequent research.

Purpose. To assess the response of human corneas to minor irritancy using cell counts from contact lens cytology. Methods. Three potential irritants were investigated: 0.01% benzalkonium chloride (BAC), surface exposure produced by voluntarily holding the eye open (EXP), and irrigation of the corneal surface (IRR). One of the two eyes was randomly selected to be tested and the other eye served as a control. Following the treatment corneal surface cells were collected from soft contact lenses with four insertions and removals. Cells were counted using fluorescent staining of acridine orange and Hoechst. Ten normal human subjects took part in each experiment. Results. Nucleated cell counts increased significantly (p 0.05). Cell structures without nuclei were always present (cell ghosts), and they were counted separately. These structures showed green fluorescent staining from acridine orange, but no nuclear staining with Hoechst. The number of cell ghosts inc...

Purpose – The purpose of this paper is to examine the prevalence of alcohol use disorders (AUDs) amongst young people in the criminal justice system (CJS) in the North East of England and to compare the ability of the Alcohol Use Disorders Identification Test (AUDIT) to the Youth Justice Board ASSET tool in identifying alcohol-related need in Youth Offending Team (YOT) clients. Design/methodology/approach – A validated screening tool (AUDIT) was used to identify alcohol-related health risk or harm. Findings from AUDIT were compared with those of the standard criminogenic risk screening tool used in CJS (ASSET). An anonymous cross-sectional questionnaire was administered during a one-month period in 2008. The questionnaires were completed by 11-17-year-old offenders who were in contact with three YOTs, one Youth Offending Institution and one Secure Training Estate. Findings – In total, 429 questionnaires were completed out of a possible 639 (67 per cent). The majority (81 per cent) of the young offenders were identified as experiencing alcohol-related health risk or harm and 77 per cent scored within a possibly alcohol-dependent range. In total, 77 (30 per cent) of young people completing both assessments were identified as having an AUD by AUDIT but not identified as needing alcohol-related treatment using ASSET. Research limitations/implications – This research was confined to one geographical area of England, however, the results show that even in this area of high drinking by young people the levels of AUDs amongst young people in the CJS are very high. Social implications – There are major social implications to this research. It is imperative for changes to be made to the care pathways in place in the UK for young people coming through the CJS with alcohol-related issues. Originality/value – This paper adds to the evidence base by using well-validated tools to measure alcohol use amongst young people in the CJS in the UK.

Purpose: To determine whether apoptosis contributes to regeneration of the corneal epithelium following erosion and following ultraviolet irradiation. Methods: Central corneal erosions were made on one eye of 16 rats. One eye of another set of 16 rats was exposed to UVB irradiation. The rats were killed at time intervals varying from 12 hours to 7 days after treatment. Enucleated eyes were fixed in buffered formaldehyde and evaluated by terminal deoxynucleotidyl transferase-mediated deoxyuridinetriphosphate (dUTP) nick-end labelling (TUNEL) and morphology. The total number of cells and the number of TUNEL positive cells were counted in perpendicular sections using light microscopy. Results: Following central erosion the total epithelial cell number was restored by day 3. During the first 5 days, TUNEL positive cells were observed only in small numbers, but an increase occurred by days 6 and 7. After UVB, an increase in TUNEL positive cells was noted for at least 3 days, and by day 7 there was a small increase of TUNEL positive cells. This differed from the results seen in control animals. Conclusions: The present study indicates that after injury, apoptosis occurs in two distinct phases. There is an initial early phase of apoptosis which subsides at about the time the cell mass is being restored and after damaged cells have been removed. A later phase of apoptosis occurs suggests it has a homeostatic role which contributes to the regulation of the cell population.

With quadrotor use seeing extensive growth in recent years, the autonomous control of these Unmanned Aerial Vehicles (UAVs) is an increasing relevant and intersting field. In this paper a linear state-space approach at designing a stable hover controller in the presence of disturbances is presented along with simulation of control system performance. Additionally the design of a tracking system, for linear inertial position and yaw, is presented with simulation results. The gain matrix developed for this control system is independent of the specific quadrotor parameters, meaning that this same gain matrix can be used on a wide variety of quadrotors without modification. The hover and tracking controllers designed in this paper proved to perform well in simulation under perturbation disturbances and normally distributed disturbances on the UAVs linear speeds and angular speeds., 8 pages, 10 figures

Background Return to employment is one of the key goals of joint replacement surgery in the working-age population. There is limited quantitative and qualitative research focusing on return to work after hip and knee replacement. It remains unclear why certain groups of patients are not able to achieve sufficient functional improvement to allow productive return to work while others can. Very little is known about the individual patient and employer perspectives in this regard.Aims To review current evidence for the factors influencing employment outcomes in patients undergoing hip and knee replacement.Methods Original articles and reviews in Medline, Embase and PsycINFO from 1987 to 2013 were included in the analysis.Results Age, patient motivation, employment before surgery and type of job were found to be important factors in determining return to work following hip and knee replacement.Conclusions There is a need for further qualitative work on how and why these factors influence employment outcomes.