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Objective The objective of this study is to determine research priorities for the management of major trauma, representing the shared priorities of patients, their families, carers and healthcare professionals.Design/setting An international research priority-setting partnership.Participants People who have experienced major trauma, their carers and relatives, and healthcare professionals involved in treating patients after major trauma. The scope included chest, abdominal and pelvic injuries as well as major bleeding, multiple injuries and those that threaten life or limb.Methods A multiphase priority-setting exercise was conducted in partnership with the James Lind Alliance over 24 months (November 2021–October 2023). An international survey asked respondents to submit their research uncertainties which were then combined into several indicative questions. The existing evidence was searched to ensure that the questions had not already been sufficiently answered. A second international survey asked respondents to prioritise the research questions. A final shortlist of 19 questions was taken to a stakeholder workshop, where consensus was reached on the top 10 priorities.Results A total of 1572 uncertainties, submitted by 417 respondents (including 132 patients and carers), were received during the initial survey. These were refined into 53 unique indicative questions, of which all 53 were judged to be true uncertainties after reviewing the existing evidence. 373 people (including 115 patients and carers) responded to the interim prioritisation survey and 19 questions were taken to a final consensus workshop between patients, carers and healthcare professionals. At the final workshop, a consensus was reached for the ranking of the top 10 questions.Conclusions The top 10 research priorities for major trauma include patient-centred questions regarding pain relief and prehospital management, multidisciplinary working, novel technologies, rehabilitation and holistic support. These shared priorities will now be used to guide funders and teams wishing to research major trauma around the globe.

Introduction Technology-facilitated, self-directed upper limb (UL) rehabilitation, as an adjunct to conventional care, could enhance poststroke UL recovery compared with conventional care alone, without imposing additional resource burden. The proposed pilot randomised controlled trial (RCT) aims to assess whether stroke survivors will engage in self-directed UL training, explore factors associated with intervention adherence and evaluate the study design for an RCT testing the efficacy of a self-directed exer-gaming intervention for UL recovery after stroke.Methods and analysis This is a multicentre, internal pilot RCT; parallel design, with nested qualitative methods. The sample will consist of stroke survivors with UL paresis, presenting within the previous 30 days. Participants randomised to the intervention group will be trained to use an exergaming device and will be supported to adopt this as part of their self-directed rehabilitation (ie, without formal support/supervision) for a 3-month period. The primary outcome will be the Fugl Meyer Upper Extremity Assessment (FM-UE) at 6 months poststroke. Secondary outcomes are the Action Research Arm Test (ARAT), the Barthel Index and the Modified Rankin Scale. Assessment time points will be prior to randomisation (0–1 month poststroke), 3 months and 6 months poststroke. A power calculation to inform sample size required for a definitive RCT will be conducted using FM-UE data from the sample across 0–6 months time points. Semistructured qualitative interviews will examine factors associated with intervention adoption. Reflexive thematic analysis will be used to code qualitative interview data and generate key themes associated with intervention adoption.Ethics and dissemination The study protocol (V.1.9) was granted ethical approval by the Health Research Authority, Health and Care Research Wales, and the London- Harrow Research Ethics Committee (ref. 21/LO/0054) on 19 May 2021. Trial results will be submitted for publication in peer-reviewed journals, presented at national and international stroke meetings and conferences and disseminated among stakeholder communities.Trial registration number NCT04475692

Access to burn camps and clubs is cited as an essential element for children following a burn injury. In the Northern Regional Burns Service, this takes the form of a club run by a multidisciplinary team, offering residential camps and family day trips. In this service evaluation, Group Concept Mapping was used to evaluate the perception of the club by staff, children and families. Opportunistic sampling was used to seek responses to the following prompts: “The challenges for children and families after a burn injury are…” and “The role of The Grafters Club is…”. The results indicate that participants perceived the club to be effective at addressing body image and confidence issues for the children but highlighted an unmet parental expectation that the club would also facilitate the sharing of experiences, normalisation of emotional reactions, and processing of guilt and other psychological distress for parents. When taken concurrently with pre-existing evidence in the literature base, it is proposed that a club model of psychosocial support for children and families could provide an accessible and informal opportunity for parental support that may be less subject to barriers perceived with traditional formal psychological support.

Systematically implementing personalised care has far reaching benefits to individuals, communities and health and social care systems. If done well, personalised care can result in better health outcomes and experiences, more efficient use of health services and reduced health inequalities. Despite these known benefits, implementation of personalised care has been slow. Evaluation is an important step towards achieving the ambition of universally delivered personalised care. There are currently few comprehensive assessments or tools that are designed to understand the implementation of personalised care at a service or system level, or the cultural, practical and behavioural factors influencing this. The aim of this paper is to describe the development and testing of a system-wide evaluation tool. The tool offers a process through which healthcare systems can better understand the current delivery of personalised care and the factors influencing this. With a focus on implementation, the development of the tool was informed by the Consolidated Framework for Implementation Research, and its content is structured using behaviour change theory (COM-B Theory of Behaviour Change Model). The tool consists of four mirrored surveys, which were developed using an iterative exploratory design. This included a series of testing cycles, in which its structure and content were continually refined. To date, it has been used by 24 clinical services, involving 397 service users, 313 front-line practitioners, 73 service managers and 40 commissioners. These services have used the evaluation process to initiate quality improvement, targeted at one of the more aspects of personalised care. The use of the COM-B model increases the likelihood of those improvements being sustained, through identification of the core factors that enable or limit personalised care behaviours among healthcare staff. We have shown this process to be applicable in a wide range of settings, thus it potentially has broad applicability as a tool for cultural change and quality improvement. The next stage of this work will focus on implementation and evaluation, to fully understand if and how the tool can be used to drive improvements in personalised care delivery.

Abstract Background Women's experiences of pregnancy, birth and motherhood extend beyond healthcare provision and the immediate postpartum. Women's social, cultural and political environments shape the positive or negative effects of their experiences through this transition. However, there is limited research concerning the factors that women identify as being protective or promotive of maternal well‐being in the perinatal period and motherhood transition. Objective To explore women's views on the factors within healthcare, social, cultural, organizational, environmental and political domains that do or can work well in creating positive perinatal experiences. Design, Setting and Participants A qualitative descriptive study with embedded public and participant involvement (PPI). Participants were 24 women who were maternity care service users giving birth in Ireland. Results Three themes were developed. The first theme, ‘tone of care’, related to women's interactions with and attitudes of healthcare professionals in setting the tone for the care they experienced. The second theme, ‘postpartum presence and support’, concerned the professional postpartum supports and services that women found beneficial in the motherhood transition. The final theme, ‘flexibility for new families’ addresses social and organizational issues around parents returning to paid employment. Discussion and Conclusion Women suggested multiple avenues for promoting positive perinatal experiences for women giving birth in Ireland, which may be implemented at healthcare and policy levels. Women identified that maternal health education focuses on supporting informed decision‐making processes as a positive and worry‐alleviating resource. Additionally, women valued being met by healthcare professionals who regard women as the decision makers in their care experience. Exchanges in which healthcare professionals validate and encourage women in their mothering role and actively involve their partners as caregivers left lasting positive impressions. Extended and professional postpartum support was a common issue, and phone lines or drop‐in clinics were suggested as invaluable and affirming assets where women could access personalized support with healthcare professionals who had the knowledge and skills to genuinely approach women's concerns. Social and organizational considerations involved supporting parents to balance their responsibilities as new or growing families in the return to work. Public or Patient Contribution Maternity care service users were involved in the interviews and manuscript preparation.

In recent decades, increasing numbers of families with children are living in apartments in Australian cities; negotiating family life in dwellings not designed for their specific needs. This paper describes indirect participatory design research, involving architects and researchers acting as intermediates of end users, identifying how architects see that apartment design guidelines could be reconciled with the needs of families with children. Architects in Victoria, Australia, participated in a design workshop that elicited their views on child and family needs elucidated by research with families, explored Australian and international apartment design guidelines in relation to families, and which asked in light of this evidence – what needs to change in design guidelines to inform family-friendly apartment designs? Findings reveal important similarities and critical differences between architects’ and users’ views on apartment design for families with children. The paper concludes by discussing how these differences might be reconciled to ensure future apartment designs that suit a more diverse mix of households, including families with children. The challenges are also highlighted of using indirect participatory design when direct participatory design is not possible, including sacrificing the design consensus arising from architects and end users working together.

BackgroundUpper limb (UL) recovery after stroke is strongly dependent upon rehabilitation dose. Rehabilitation technologies present pragmatic solutions to dose enhancement, complementing therapeutic activity within conventional rehabilitation, connecting clinicians with patients remotely, and empowering patients to drive their own recovery. To date, rehabilitation technologies have been poorly adopted. Understanding the barriers to adoption may shape strategies to enhance technology use and therefore increase rehabilitation dose, thus optimizing recovery potential. ObjectiveWe examined the usability, acceptability, and adoption of a self-directed, exercise-gaming technology within a heterogeneous stroke survivor cohort and investigated how stroke survivor characteristics, technology usability, and attitudes toward technology influenced adoption. MethodsA feasibility study of a novel exercise-gaming technology for self-directed UL rehabilitation in early subacute stroke survivors (N=30) was conducted in an inpatient, acute hospital setting. Demographic and clinical characteristics were recorded; participants’ performance in using the system (usability) was assessed using a 4-point performance rating scale (adapted from the Barthel index), and adherence with the system was electronically logged throughout the trial. The technology acceptance model was used to formulate a survey examining the acceptability of the system. Spearman rank correlations were used to examine associations between participant characteristics, user performance (usability), end-point technology acceptance, and intervention adherence (adoption). ResultsThe technology was usable for 87% (n=26) of participants, and the overall technology acceptance rating was 68% (95% CI 56%-79%). Participants trained with the device for a median of 26 (IQR 16-31) minutes daily over an enrollment period of 8 (IQR 5-14) days. Technology adoption positively correlated with user performance (usability) (ρ=0.55; 95% CI 0.23-0.75; P=.007) and acceptability as well as domains of perceived usefulness (ρ=0.42; 95% CI 0.09-0.68; P=.03) and perceived ease of use (ρ=0.46; 95% CI 0.10-0.74; P=.02). Technology acceptance decreased with increased global stroke severity (ρ=−0.56; 95% CI −0.79 to −0.22; P=.007). ConclusionsThis technology was usable and acceptable for the majority of the cohort, who achieved an intervention dose with technology-facilitated, self-directed UL training that exceeded conventional care norms. Technology usability and acceptability were determinants of adoption and appear to be mediated by stroke severity. The results demonstrate the importance of selecting technologies for stroke survivors on the basis of individual needs and abilities, as well as optimizing the accessibility of technologies for the target user group. Facilitating changes in stroke survivors’ beliefs and attitudes toward rehabilitation technologies may enhance adoption. Further work is needed to understand how technology can be optimized to benefit those with more severe stroke.

BackgroundThe Implicit Learning in Stroke study was a pilot cluster randomised controlled trial, investigating the use of different motor learning strategies in acute stroke rehabilitation. Participating Stroke Units (n = 8) were from the South East/West regions of the UK, with the experimental intervention (implicit learning) being delivered by clinical teams. It required therapists to change how they gave instructions and feedback to patients during rehabilitation. This paper reports the processes underpinning implementation of the implicit learning intervention. The evaluation aimed to i) understand how therapists made sense of, engaged with and interpreted the effects of the intervention; ii) compare this to the experience reported by patients; iii) extrapolate learning of broader relevance to the design and conduct of research involving complex interventions in stroke rehabilitation.MethodsQualitative evaluation, with data collected through focus groups with clinical staff (n = 20) and semi structured interviews with people with stroke (n = 19). Mixed inductive and theory driven analysis, underpinned by Normalisation Process Theory.ResultsHow therapists made sense of and experienced the intervention impacted how it was implemented. The intervention was delivered by individual therapists, and was influenced by their individual values, beliefs and concerns. However, how teams worked together to build a shared (team) understanding, also played a key role. Teams with a more "flexible" interpretation, reported the view that the intervention could have benefits in a wide range of scenarios. Those with a more fixed, "rule based" interpretation, found it harder to implement, and perceived the benefits to be more limited. Therapists' concerns that the intervention may impair therapeutic relationships and patient learning were not reflected in how patients experienced it.ConclusionsChanging practice, whether in a research study or in the "real world", is complex. Understanding the process of implementation is crucial to effective research delivery. Implementation frameworks facilitate understanding, and subsequently the systematic and iterative development of strategies for this to be addressed. How teams (rather than individuals) work together is central to how complex interventions are understood and implemented. It is possible that new complex interventions work best in contexts where there are 'flexible' cultures. Researchers should consider, and potentially measure this, before they can effectively implement and evaluate an intervention.Trial registrationClinical Trials - NCT03792126.

Abstract Background For the Syilx Okanagan Nation in Canada, salmon has vital nutritional, cultural, and spiritual significance. Yet, the Okanagan Sockeye salmon population came to near extinction, resulting in a drastic decline in salmon consumption from high historical levels. Thus, restoring and protecting salmon is crucial to Syilx well-being and way of life. A Syilx-led food sovereignty initiative re-established the Okanagan Sockeye salmon population, which has resulted in a rise in fish harvesting. The aim of this study was to assess whether engaging with this initiative was associated with health, well-being, and cultural connectedness (i.e., degree to which one is integrated in their culture) among Syilx adults. Eating Okanagan Sockeye salmon was conceptualized as a proxy for engaging with this Indigenous food sovereignty initiative. Methods 265 Syilx adults completed a survey including a traditional food frequency questionnaire and questions on health status (e.g., BMI, self-assessed physical health), well-being (e.g., life satisfaction, stress levels), and cultural connectedness (e.g., sense of belonging, importance of cultural practices). Participants were divided into 3 groups based on their wild salmon eating during the year prior to the survey: (1) adults who ate Okanagan Sockeye salmon, (2) adults who ate salmon but did not usually know the species of the salmon they ate, or who solely ate salmon that were not Okanagan Sockeye; and (3) adults who did not eat any salmon. Results A statistically significant gradient was observed for enhanced well-being and cultural connectedness, with individuals in group 1 having better indicators than those in group 2, and adults in groups 1 and 2 having better indicators than adults in group 3. No differences were observed in physical health outcomes between the three groups. Conclusion Findings suggest that the initiative to re-establish Okanagan Sockeye salmon in the Okanagan River system may have led to better well-being and cultural connectedness among Syilx adults. This study highlights the importance of Indigenous food sovereignty as a way to enhance well-being and cultural connectedness among First Nations in Canada. Findings also reinforce the importance of assessing health and well-being in a wholistic way in Indigenous health research.

Abstract Background Optimal parental preconception health benefits reproductive outcomes. However, preconception health promotion is not routinely offered in primary health care settings to people of reproductive age. The aim was to gauge the planned preconception health behaviours and attitudes towards being asked about pregnancy intention by a general practitioner (GP) among people of reproductive age in Australia. Method The research was conducted on a single wave of Australia’s first and only probability-based online panel, Life in Australia™. Members of the Life in Australia™ panel are Australian residents aged 18 years or over. All active members between the ages of 18 and 45 years were eligible to participate. Eligible panel members were invited to complete a survey about fertility and childbearing. Data were collected from 18 February to 4 March 2019. Results In all 965 female and male members of Life in Australia™ aged between 18 and 45 years were invited to complete the survey. Of these, 716 (74.2%) agreed. Most respondents indicated that if they were planning to have a child they would try to optimise their preconception health by adopting a healthier diet (80%), seeing a GP for a health check-up (78%), reducing alcohol consumption (78% of those consuming alcohol), getting fitter (73%), and stopping smoking (70% of smokers). Three in four (74%) stated that they would not mind if their GP asked them about their pregnancy intentions. Conclusion Findings suggests that routinely asking people of reproductive age about their pregnancy intentions and advising those who are planning pregnancy about what they can do to ensure optimal preconception health would be acceptable to most people and may improve reproductive outcomes.

Objective To determine research priorities for the management of complex fractures, which represent the shared priorities of patients, their families, carers and healthcare professionals.Design/setting A national (UK) research priority setting partnership.Participants People who have experienced a complex fracture, their carers and relatives, and relevant healthcare professionals and clinical academics involved in treating patients with complex fractures. The scope includes open fractures, fractures to joints broken into multiple pieces, multiple concomitant fractures and fractures involving the pelvis and acetabulum.Methods A multiphase priority setting exercise was conducted in partnership with the James Lind Alliance over 21 months (October 2019 to June 2021). A national survey asked respondents to submit their research uncertainties which were then combined into several indicative questions. The existing evidence was searched to ensure that the questions had not already been sufficiently answered. A second national survey asked respondents to prioritise the research questions. A final shortlist of 18 questions was taken to a stakeholder workshop, where a consensus was reached on the top 10 priorities.Results A total of 532 uncertainties, submitted by 158 respondents (including 33 patients/carers) were received during the initial survey. These were refined into 58 unique indicative questions, of which all 58 were judged to be true uncertainties after review of the existing evidence. 136 people (including 56 patients/carers) responded to the interim prioritisation survey and 18 questions were taken to a final consensus workshop between patients, carers and healthcare professionals. At the final workshop, a consensus was reached for the ranking of the top 10 questions.Conclusions The top 10 research priorities for complex fracture include questions regarding rehabilitation, complications, psychological support and return to life-roles. These shared priorities will now be used to guide funders and teams wishing to research complex fractures over the coming decade.

Background: Care home residents are mainly inactive, leading to increased dependency and low mood. Although exercise classes may increase activity, a more sustainable model is to engage staff and residents in increasing routine activity. Objectives: The objectives were to develop and preliminarily test strategies to enhance the routine physical activity of care home residents to improve their physical, psychological and social well-being through five overlapping workstreams. Design: This trial had a mixed-methods research design to develop and test the feasibility of undertaking an evaluative study consisting of gaining an understanding of the opportunities for and barriers to enhancing physical activity in care homes (workstream 1); testing physical activity assessment instruments (workstream 2); developing an intervention through a process of intervention mapping (workstream 3); refining the provisional intervention in the care home setting and clarifying outcome measurement (workstream 4); and undertaking a cluster randomised feasibility trial of the intervention [introduced via three facilitated workshops at baseline (with physiotherapist input), 2 weeks (with artist input) and 2 months], with embedded process and health economic evaluations (workstream 5). Setting: The trial was set in 12 residential care homes differing in size, location, ownership and provision in Yorkshire, UK. Participants: The participants were elderly residents, carers, managers and staff of care homes. Intervention: The intervention was MoveMore, designed for the whole home, to encourage and support the movement of residents in their daily routines. Main outcome measures: The main outcome measures related to the feasibility and acceptability of implementing a full-scale trial in terms of recruitment and retention of care homes and residents, intervention delivery, completion and reporting of baseline data and outcomes (including hours of accelerometer wear, hours of sedentary behaviour and hours and type of physical activity), and safety and cost data (workstream 5). Results: Workstream 1 – through a detailed understanding of life in a care home, a needs assessment was produced, and barriers to and facilitators of activity were identified. Key factors included ethos of care; organisation, management and delivery of care; use of space; and the residents’ daily routines. Workstream 2 – 22 (73.3%) out of 30 residents who wore a hip accelerometer had valid data (≥ 8 hours on ≥ 4 days of the week). Workstream 3 – practical mechanisms for increasing physical activity were developed, informed by an advisory group of stakeholders and outputs from workstreams 1 and 2, framed by the process of intervention mapping. Workstream 4 – action groups were convened in four care homes to refine the intervention, leading to further development of implementation strategies. The intervention, MoveMore, is a whole-home intervention involving engagement with a stakeholder group to implement a cyclical process of change to encourage and support the movement of residents in their daily routines. Workstream 5 – 12 care homes and 153 residents were recruited to the cluster randomised feasibility trial. Recruitment in the care homes varied (40–89%). Five care homes were randomised to the intervention and seven were randomised to usual care. Predetermined progression criteria were recruitment of care homes and residents (green); intervention delivery (amber); and data collection and follow-up – 52% of residents provided usable accelerometer data at 9 months (red), > 75% of residents had reported outcomes at 9 months (green, but self-reported resident outcomes were red), 26% loss of residents to follow-up at 9 months [just missing green criterion (no greater than 25%)] and safety concerns (green). Limitations: Observations of residents’ movements were not conducted in private spaces. Working with care home residents to identify appropriate outcome measures was challenging. Take-up of the intervention was suboptimal in some sites. It was not possible to make a reliably informed decision on the most appropriate physical activity end point(s) for future use in a definitive trial. Conclusions: A whole-home intervention was developed that was owned and delivered by staff and was informed by residents and staff. The feasibility of conducting a cluster randomised controlled trial was successfully tested: the target numbers of care homes and residents were recruited, demonstrating that it is possible to recruit care home residents to a cluster randomised trial, although this process was time-consuming and resource heavy. A large data set was collected, which provided a comprehensive picture of the environment, residents and staff in care homes. Extensive quantitative and qualitative work comprehensively explored a neglected area of health and social care research. Completion of ethnographic work in a range of settings enabled the production of an in-depth picture of life in care homes that will be helpful for other researchers considering organisational change in this setting. Future work: The content and delivery of the intervention requires optimisation and the outcome measurement requires further refinement prior to undertaking a full trial evaluation. Consideration could be given to a recommended, simplified, core outcome set, which would facilitate data collection in this population. Trial registration: Current Controlled Trials ISRCTN16076575. Funding: This project was funded by the National Institute for Health Research (NIHR) Programme Grant for Applied Research programme and will be published in full in Programme Grant for Applied Research; Vol. 9, No. 9. See the NIHR Journals Library website for further project information.

Lysyl oxidase is able to remodel the extracellular matrix and its expression correlates with poor prognosis. Here the authors show that this protein modulates trapping of the epidermal growth factor receptor at the cell surface, causing persistent signalling activation and tumour progression.

We examined the feasibility of linear programming (LP) to develop diets that were economical, included traditional (cultural, non-market) foods and met the dietary reference intakes (DRI) in a Canadian Indigenous population. Diet optimisation using LP is a mathematical technique that can develop food-based dietary guidelines for healthy eating in Indigenous populations where food insecurity, availability and cost are important considerations. It is a means of developing nutritionally optimal food combinations that are based on economical and culture-specific foods. Observed food consumption data were derived using 24-h food recalls from the First Nations Food, Nutrition and Environment Study. The LP models were constructed to develop diets meeting DRI, cost and food constraints. Achieving the recommended food intake was not feasible in a model meeting all nutrient requirements. Models that met most nutrient requirements at reduced cost were designed for men and women, separately. In women, it was necessary to increase energy intake to meet most nutrient requirements. Nutrient requirements could not be met for fibre, linoleic and linolenic acids, vitamin D, Ca and K in both sexes, P in women, and Mg and vitamin A in men. Using LP to develop optimal diets for First Nations people, we found simultaneous achievement of all DRI was difficult, suggesting that supplementation might be necessary which goes against recommendations for individuals to meet their nutrient needs through healthy eating patterns. Additionally, to make diets feasible, programmes to reduce market food costs and to support First Nations people in traditional food harvesting are recommended.

Background: Indigenous peoples have traditionally relied on foods hunted and gathered from their immediate environment. The Eastern James Bay Cree people consume wild game and birds, and these are believed to provide health as well as cultural benefits. Objective: To determine the fatty acid (FA) composition of traditional game and bird meats hunted in the Eastern James Bay area. Design: Harvested traditional game and birds were analysed for FA composition. A total of 52 samples from six wildlife species were collected in the areas of Chisasibi, Waswanipi and Mistissini, of which 35 were from birds (white partridge and Canada goose) and 17 were from land animals (beaver, moose, caribou and black bear). Results: Alpha-linolenic acid (ALA) was the most common n-3 polyunsaturated fatty acid (PUFA) in all samples except for the black bear flesh, in which it was docosapentaenoic acid (DPAn-3). In white partridge, beaver and caribou flesh, PUFAs (mainly n-6) were the most common category of fats while in goose, moose and black bear flesh, monounsaturated fatty acids (MUFAs) predominated. In all species, saturated fatty acids (SFAs) were the second most important FAs. It would appear that in the land animals and birds that were analysed, the SFA content was lower and the PUFA content was higher than store-bought meats giving them a more heart-healthy profile. Conclusions: These results showed that the FA composition of game species consumed by the James Bay Cree population is consistent with a beneficial diet and that traditional foods should continue to be promoted among the Cree people to provide better physical health as well as social and spiritual benefits.

Stroke disease in Ghana has been of increasing concern since the mid to late 20th century, in association with the increasing westernisation of diet and lifestyle [1]. Two thirds of world-wide mortality cases from stroke occur in sub-Saharan Africa [2], and in the Ghanaian capital city region of Accra, stroke is now attributed as the second largest cause of death [1]. The burden of stroke in sub-Saharan Africa is significant [3]. Experts recommend a three-prong approach to dealing with the burden of non-communicable disease (NCD): epidemiological surveillance; primary prevention (preventing disease in healthy populations); and secondary prevention (preventing complications and improving quality of life in affected communities) [4]. This paper outlines the development of a specialist stroke service in Accra, Ghana. This work therefore broadly relates to the secondary prevention aspect, achieved through the development of a dedicated and specialised stroke service. Whilst this project took place in Ghana, the learning could be applied to the development of a stroke service in any resource poor setting, such as South Sudan. Indeed, because the focus is on establishing the fundamentals of organised stroke care, the principles are also entirely relevant to more developed health care systems.

The Eeyouch are a First Nations (Cree) population that live above 49.6°N latitude in Eeyou Istchee in northern Quebec. Eeyouch rely on traditional foods (TF) hunted, fished or gathered from the land. The overarching aim of this study was to achieve an understanding of the factors associated with TF intake among Eeyouch. Data were from 465 women and 330 men who participated in the Nituuchischaayihtitaau Aschii Multi-Community Environment-and-Health (E&H) study. The relationship between TF consumption and dietary, health, sociodemographic and food sovereignty (i.e. being a hunter or receiving Income Security to hunt, trap or fish) variables was examined using linear and logistic regression. Analyses were stratified by sex because of the male/female discrepancy in being a hunter. Among respondents, almost all (99.7%) consumed TF, 51% were hunters and 10% received Income Security. Higher intake of TF was associated with lower consumption of less nutritious ultra-processed products (UPP). In women, TF intake increased with age, hunting and receiving Income Security, but decreased with high school education. In men, TF intake increased with age and speaking only Cree at home. The findings suggest that increased food sovereignty would result in improved diet quality among Eeyouch through increased TF intake and decreased UPP intake.

To describe exposure to methylmercury among Cree, focusing on women of childbearing age, we used data from 2 studies. Multiple regression was employed to examine associations between blood and hair mercury concentrations and consumption of locally harvested fish. Approximately 9.9% of non-pregnant women aged 15–44 y and 3.9% of pregnant women required follow-up according to Health Canada’s blood mercury guidance value of 40 nmol/L. 8% of hair mercury observations in the non-pregnant women and 2.5% among pregnant women exceeded the equivalent threshold of 10 nmol/g. The geometric mean blood mercury concentration was 12.7 nmol/L in 1,429 persons aged 8 and over, and 17.7 nmol/L in adults aged 18 and older. The proportion of hair mercury concentrations greater than 12.5 nmol/g decreased in all age-sex groups when comparing the 2002–2009 data to published values for 1993–1994. Among women of childbearing age, local fish consumption was associated with increased blood and hair mercury concentrations. While over 90% of women of childbearing age in this population have acceptable levels of mercury, ongoing intake of mercury suggests that their consumption of fish with known high mercury content be minimised. Reducing consumption of fish known to be high in mercury content needs to be balanced with promoting ongoing connection to Cree culture and land-based activities that are also important determinants of health.

An amendment to this paper has been published and can be accessed via a link at the top of the paper.

Polycystic ovary syndrome (PCOS) is the most common cause of anovulatory infertility in women of reproductive age. Lifestyle change is considered the first line treatment for the management of infertile anovulatory women with PCOS, and weight loss for those who are overweight or obese. First line medical ovulation induction therapy to improve fertility outcomes is letrozole, whilst other less efficacious ovulation induction agents, such as clomiphene citrate, metformin, and metformin combined with clomiphene citrate, may also be considered. Metformin combined with clomiphene citrate is more effective than clomiphene citrate alone. In obese women with PCOS, clomiphene citrate could be used in preference to metformin alone whilst clomiphene citrate could be added to metformin alone in order to improve reproductive outcome in all women with PCOS. Gonadotrophins, which are more effective than clomiphene citrate in therapy naïve women with PCOS, can be considered a first line therapy in the presence of ultrasound monitoring, following counselling on the cost and the potential risk of multiple pregnancy.

In clomiphene-citrate-resistant anovulatory women with polycystic ovary syndrome (PCOS) and no other infertility factors, either metformin combined with clomiphene citrate or gonadotrophins could be used as a second-line pharmacological therapy, although gonadotrophins are more effective. Gonadotrophins could also be used as a second-line pharmacological therapy in anovulatory women with PCOS and clomiphene-citrate-failure. Laparoscopic ovarian surgery can also be used as a second-line therapy for ovulation induction in anovulatory women with clomiphene-citrate-resistant PCOS and no other infertility factors. The usefulness of letrozole as a second-line pharmacological treatment for ovulation induction in clomiphene-citrate-resistant women with PCOS requires further research. In terms of improving fertility, both pharmacological anti-obesity agents and bariatric surgery should be considered an experimental therapy in anovulatory women with PCOS and no other infertility factors. Where first- or second-line ovulation induction therapies have failed, in vitro fertilization (IVF)/ intracytoplasmic sperm injection (ICSI) could be offered as a third-line therapy in women with PCOS in the absence of an absolute indication for IVF/ICSI. For women with PCOS undergoing IVF/ICSI treatment, the gonadotropin-releasing hormone (GnRH) antagonist protocol is preferred and an elective frozen embryo transfer strategy could be considered. In assisted conception units with sufficient expertise, in-vitro maturation (IVM) of oocytes could be offered to women with PCOS.

This article reports on how photo elicitation interviewing (PEI) was experienced by eight participants in a qualitative phenomenological study of suburban lived experiences. Adopting a respondent-controlled approach, participants were required to photograph at least 10 aspects of their suburb that they perceived to be good and problematical and then explain the meaning of their images as part of a follow-up interview. This discussion also involved in-depth reflection on the photography exercise itself, with analysis revealing that taking photographs was perceived to be a purposeful exercise that offered a range of benefits. It gave a new perspective and appreciation for the community, while also helping to ensure their meanings were conveyed to the interviewers. The photography task was not without challenges. While some of these challenges influenced the images captured, the findings of this study highlight the importance for qualitative researchers who use PEI to not only consider the benefits and limitations for the research but also give due consideration to the experiences of the participant photographers.

The social and legal acceptability of third-party reproduction varies around the world. In Australia, gamete and embryo donation and surrogacy are permitted within the regulatory framework set out by federal and state governments. The aim of this paper is to describe the social context and regulatory framework for third-party reproduction in Australia. This is a review of current laws and regulations related to third-party reproduction in Australia. Although subtle between-state differences exist, third-party reproduction is by and large a socially acceptable and legally permissible way to form a family throughout Australia. The overarching principles that govern the practice of third-party reproduction are altruism; the right of donorconceived people to be informed of their biological origins; and the provision of comprehensive counselling about the social, psychological, physical, ethical, financial and legal implications of third-party reproduction to those considering donating or receiving gametes or embryos and entering surrogacy arrangements. These principles ensure that donors are not motivated by financial gain, donor offspring can identify and meet with the person or persons who donated gametes or embryos, and prospective donors and recipients are aware of and have carefully considered the potential consequences of third-party reproduction. Australian state laws and federal guidelines prohibit commercial and anonymous third-party reproduction; mandate counselling of all parties involved in gamete and embryo donation and surrogacy arrangements; and require clinics to keep records with identifying and non- identifying information about the donor/s to allow donor-conceived offspring to trace their biological origins.

PURPOSE: Large changes in spectacle prescription can increase falls risk in older people. We investigated the effect of induced astigmatism (a common cause of distorted or blurred vision in older people) on locomotor stepping patterns to determine whether the orientation of astigmatic changes could have differential effects on gait safety when negotiating steps and stairs. METHODS: 10 older adults (mean age 76.0±6.4 years) walked up to and stepped onto a raised block whilst wearing their spectacle prescription and when blurred with ±3.00D cylinders at axes 45°, 90°, 135° and 180°. Gait measurements included foot placement before the block, toe clearance over the block edge and foot placement on the block. RESULTS: Induced astigmatism with axes at 90°, providing magnification in the horizontal meridian only, caused no change in stepping pattern. Induced astigmatism with axes at 180° caused foot placement changes in the anterior or posterior direction according to whether magnification was positive or negative in the vertical meridian (block perceived higher or lower respectively). Induced astigmatism with axes oblique at 45° and 135° (causing the block to be perceived as a parallelogram sloping downwards either to the right or left) caused gait changes in the anterior and posterior, vertical and lateral directions. Changes in lateral foot placement appeared to be an attempt to maintain constant foot clearance levels over the block edge by stepping over the perceived 'lower' side of the 'sloping' block. CONCLUSIONS: Astigmatic changes with oblique axes had the greatest effect on gait. Clinicians, including optometrists, physiotherapists, occupational therapists and nurses should counsel older patients about the effects of astigmatism on gait safety. Furthermore, partial prescribing of astigmatic corrections should be considered to reduce the risk of falling.