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COVID-19 vaccine-associated peripheral and central neuroimmunological disorders have been well described. We present the case of a 56 year old male who developed α3-ganglionic AChR antibody positive Autoimmune Autonomic Ganglionopathy (AAG) after completion of a two-dose course of mRNA (Comirnaty) vaccination for COVID19.A previously hypertensive 56 year old male presented with the subacute onset of severe constipation, urinary retention, erectile dysfunction, sudomotor failure, sicca symptoms, non-reactive pupils and severe orthostatic hypotension shortly after receiving the second dose of an mRNA vaccine against COVID19. Autonomic testing revealed severe cardiovagal, adrenergic and sudomotor impairment, and tonic 'half-mast' pupils with evidence of sympathetic and parasympathetic denervation. Pathological α3-ganglionic ACHR antibodies were positive in serum as detected by a new flow cytometric immunomodulation assay. Malignancy was excluded. The patient was diagnosed with severe, treatment-refractory acute AAG.While autonomic dysfunction has been previously reported post-COVID19 vaccination, to our knowledge this is the first reported case of antibody-positive AAG in this setting. The severity of this case is in marked contrast to the existing literature on idiopathic antibody-positive autoimmune pandysautonomia.

Background: The development of a nurse-led approach to managing epilepsy in adults with an intellectual disability offers the potential of improved outcomes and lower costs of care. We undertook a cluster randomised trial to assess the impact on costs and outcomes of the provision of intellectual disability nurses working to a designated epilepsy nurse competency framework. Here, we report the impact of the intervention on costs. Method: Across the UK, 8 sites randomly allocated to the intervention recruited 184 participants, 9 sites allocated to treatment as usual recruited 128 participants. Cost and outcome data were collected mainly by telephone interview at baseline and after six months. Total costs at six months were compared from the perspective of health & social services, and society, with adjustments for pre-specified participant and cluster characteristics at baseline including costs. Missing data was imputed using Multiple Imputation. Uncertainty was quantified by bootstrapping. Results: The intervention was associated with lower per participant costs from a health & social services perspective of -£357 (2014/15 GBP) (95% CI -£986, £294) and from a societal perspective of -£631 (95% CI -£1,473, £181). Results were not sensitive to the exclusion of accommodation costs. Conclusions: Our findings suggest that the competency framework is unlikely to increase the cost of caring for people with epilepsy and intellectual disability and may reduce costs., This paper presents independent research commissioned by the National Institute for Health Research (NIHR) under its Health Technology Assessment Programme (Grant 10/104/16 PI Dr H Ring). During the time that this research was carried out, H Ring also received support from the NIHR Collaboration for Leadership in Applied Health Research and Care (CLAHRC) East of England at Cambridgeshire and Peterborough NHS Foundation Trust.

Background The Clinical Practice Research Datalink (CPRD) was used to evaluate the overall costs to the National Health Service, including healthcare utilisation, of prescribing emollients in UK primary care for dry skin and atopic eczema (DS&E). Methods Primary care patients in the UK were identified using the CPRD and their records were interrogated for the 2 years following first diagnosis of DS&E. Data from patients with (n = 45,218) and without emollient prescriptions (n = 9780) were evaluated. Multivariate regression models were used to compare healthcare utilisation and cost in the two matched groups (age, sex, diagnosis). Two sub-analyses of the Emollient group were performed between matched groups receiving (1) a colloidal oatmeal emollient (Aveeno-First) versus non-colloidal oatmeal emollients (Aveeno-Never) and (2) Aveeno prescribed first-line (Aveeno-First) versus prescribed Aveeno later (Aveeno-Subsequently). Logistic regression models calculated the odds of prescription with either potent / very potent topical corticosteroids (TCS) or skin-related antimicrobials. Results Costs per patient were £125.80 in Emollient (n = 7846) versus £128.13 in Non-Emollient (n = 7846) matched groups (p = 0.08). The Emollient group had fewer visits/patient (2.44 vs. 2.66; p

Background This study aimed to (i) investigate the factors that influence donor and recipient decision making in adult-to-adult living donor liver transplantation (AALDLT); (ii) quantify the level of risk that would be acceptable to potential donors; and (iii) determine from whom an individual would be willing to receive a donation. Methods A self-administered questionnaire using hypothetical scenarios centred on AALDLT was created and administered to participants recruited from the waiting room of an orthopaedic outpatient clinic at a teaching hospital in Sydney (n = 105). The questionnaire asked participants to consider scenarios in which they either (i) were a potential donor for a family member or close friend or (ii) themselves required a liver transplant. Results Ninety-five (90%) participants expressed an in-principal willingness to consider living organ donation. The factors most important in deciding to be living liver donors were the probability of a good outcome for the recipient, the likelihood of the potential recipient's survival until a deceased donor liver became available and the risk of donor death. Donor death was also rated as the least acceptable donor outcome. Participants expressed a willingness to receive a donation from all proposed donor groups equally. Conclusions The acceptability of hypothetical living organ donation was very high in the population group studied. Participants were also willing to accept significantly higher risks of complications from organ donation than they would actually be exposed to. Clinicians should feel encouraged to discuss the risks and benefits of living donation frankly with patients and their families.

Background In adults with intellectual disability (ID) and epilepsy there are suggestions that improvements in management may follow introduction of epilepsy nurse-led care. However, this has not been tested in a definitive clinical trial and results cannot be generalised from general population studies as epilepsy tends to be more severe and to involve additional clinical comorbidities in adults with ID. This trial investigates whether nurses with expertise in epilepsy and ID, working proactively to a clinically defined role, can improve clinical and quality of life outcomes in the management of epilepsy within this population, compared to treatment as usual. The trial also aims to establish whether any perceived benefits represent good value for money. Methods/design The EpAID clinical trial is a two-arm cluster randomised controlled trial of nurse-led epilepsy management versus treatment as usual. This trial aims to obtain follow-up data from 320 participants with ID and drug-resistant epilepsy. Participants are randomly assigned either to a ‘treatment as usual’ control or a ‘defined epilepsy nurse role’ active arm, according to the cluster site at which they are treated. The active intervention utilises the recently developed Learning Disability Epilepsy Specialist Nurse Competency Framework for adults with ID. Participants undergo 4 weeks of baseline data collection, followed by a minimum of 20 weeks intervention (novel treatment or treatment as usual), followed by 4 weeks of follow-up data collection. The primary outcome is seizure severity, including associated injuries and the level of distress manifest by the patient in the preceding 4 weeks. Secondary outcomes include cost-utility analysis, carer strain, seizure frequency and side effects. Descriptive measures include demographic and clinical descriptors of participants and clinical services in which they receive their epilepsy management. Qualitative study of clinical interactions and semi-structured interviews with clinicians and participants’ carers are also undertaken. Discussion The EpAID clinical trial is the first cluster randomised controlled trial to test possible benefits of a nurse-led intervention in adults with epilepsy and ID. This research will have important implications for ID and epilepsy services. The challenges of undertaking such a trial in this population, and the approaches to meeting these are discussed. Trial registration International Standard Randomised Controlled Trial Number: ISRCTN96895428 version 1.1. Registered on 26 March 2013. Electronic supplementary material The online version of this article (doi:10.1186/s13063-016-1429-7) contains supplementary material, which is available to authorized users.

The need to forecast unplanned care activity is entwined with local healthcare economies need to reduce it. An analysis of the available data shows that it directly limits the type of approach that can be used to forecast this type of demand. It is proposed that local healthcare economies start with an approach that works by profiling individual-level data. The use of a pure numerical approach is considered to complement the other two, if there is the willingness among local healthcare economies to use it. Three laws for unplanned care demonstrate the need to question whether any of the approaches funded by local healthcare economies will reduce the levels of unplanned care, and contribute to financial savings.

Unplanned care (accident and emergency attendances and emergency admissions) may be defined as three separate, but connected laws. The need for local healthcare economies to reduce the total levels of unplanned care in a financial year means that they require an approach to determine where they should be focusing their efforts and why. The three laws offer this, as they can be used to explain unplanned care and to dispel any number of viewpoints that fall outside of them. They are based on a set way of collecting and analysing unplanned care data that distinguishes between the unique individuals that experience, for example an accident and emergency attendance and the number of subsequent repeat attendances by individual.

Each local healthcare economy faces a challenge. The rising numbers of accident and emergency (A&E) attendances and emergency hospital admissions (unplanned care) are neither affordable, nor desirable. The current financial climate has only increased this challenge. Local healthcare economies now not only need to reduce the total number of each from one financial year to the next, but to do this in an absence of ideas and approaches that work. Data analysis from NHS Wakefield District has been used to inform a new paradigm on how the total levels of unplanned care are viewed and understood. The analysis shows that local healthcare economies should embrace at least two main findings, if they are to reduce the totals. The first is to work from the basis that the totals for unplanned care in any financial year are driven by the number who experience them, rather than by the number who have more than one unplanned event in a year. The second specifically concerns emergency admissions. Individuals who experience an admission in a financial year are unlikely to have experienced one in those before it.

This study aimed to (i) investigate the factors that influence donor and recipient decision making in adult-to-adult living donor liver transplantation (AALDLT); (ii) quantify the level of risk that would be acceptable to potential donors; and (iii) determine from whom an individual would be willing to receive a donation.A self-administered questionnaire using hypothetical scenarios centred on AALDLT was created and administered to participants recruited from the waiting room of an orthopaedic outpatient clinic at a teaching hospital in Sydney (n = 105). The questionnaire asked participants to consider scenarios in which they either (i) were a potential donor for a family member or close friend or (ii) themselves required a liver transplant.Ninety-five (90%) participants expressed an in-principal willingness to consider living organ donation. The factors most important in deciding to be living liver donors were the probability of a good outcome for the recipient, the likelihood of the potential recipient's survival until a deceased donor liver became available and the risk of donor death. Donor death was also rated as the least acceptable donor outcome. Participants expressed a willingness to receive a donation from all proposed donor groups equally.The acceptability of hypothetical living organ donation was very high in the population group studied. Participants were also willing to accept significantly higher risks of complications from organ donation than they would actually be exposed to. Clinicians should feel encouraged to discuss the risks and benefits of living donation frankly with patients and their families.

A method of robust feature-detection is proposed for visual tracking with a pan-tilt head. Even with good foreground models, the tracking process is liable to be disrupted by strong features in the background. Previous researchers have shown that the disruption can be somewhat suppressed by the use of image-subtraction. Building on this idea, a more powerful statistical model of background intensity is proposed in which a Gaussian mixture distribution is fitted to each of the pixels on a ‘virtual’ image plane. A fitting algorithm of the ‘Expectation-Maximisation’ type proves to be particularly effective here. Practical tests with contour tracking show marked improvement over image subtraction methods. Since the burden of computation is off-line, the online tracking process can run in real-time, at video field-rate.

A method is proposed of robust feature-detection for visual tracking. Frequently strong background clutter competes with foreground features and may succeed in pulling a tracker off target. This effect may be avoided by modelling the appearance of the foreground object (the target). The model consists of probability density functions of intensity along curve normals—a form of statistical template. The model can then be located by the use of a dynamic programming algorithm—even in the presence of substantial image distortions. Practical tests with contour tracking show marked improvement over simple feature detection techniques.