Peter Williams

Background: First Contact Physiotherapy Practitioners (FCPPs) are embedded within general practice, providing expert assessment, diagnosis and management plans for patients with musculoskeletal disorders (MSKDs), without the prior need for GP consultation. Aim: To determine the clinical effectiveness and costs of FCPP-led compared to GP-led models of care. Design and Setting: Multiple site case study design. UK GP practices. Method: General Practice sites were recruited representing three models: 1. GP-led care; 2. FCPPs who could not prescribe/inject (Standard (St)); 3. FCPPs who could prescribe/inject (Additional Qualifications (AQ)). Patient participants from each site completed clinical outcome data at baseline, 3 and 6 months. The primary outcome was the SF-36v.2 Physical Component Score (PCS). Healthcare usage was collected for 6 months. Results: N=426 adults were recruited from 46 practices across the UK. Non-inferiority analysis showed no significant difference in physical function (SF36-PCS) across all three arms at 6 months (p=0.999). At 3 months a significant difference in numbers improving was seen between arms: 54.7% GP consultees; 72.4% FCPP-St, 66.4% FCPP-AQ; (p=0.037). No safety issues were identified. Following initial consultation, a greater proportion of patients received medication (including opioids) in the GP-led arm (44.7%) compared with FCPP-St (17.5%) and FCPP-AQ (22.8%); (p

Families with children with disabilities can feel isolated during school holidays and concerns exist that they face greater difficulties than families of children without disabilities in finding enriching activities for their child. In the context of national policies that encourage integrated play, local service commissioners in England require evidence on what sort of short breaks parents and children prefer. The parents of 99 children with disabilities and 43 children without disabilities attending various holiday play schemes in summer 2010 completed mailed questionnaires. Parents of children with disabilities reported more difficulty getting information, less choice of schemes and further distances to travel than parents of children without disabilities. Although 72% of parents of children without disabilities and 55.5% of parents of children with disabilities stated integrated schemes would be suitable for their child, open text comments provided weaker support. Variety of provision is required to meet all needs and preferences.

Background Multidisciplinary rehabilitation is recommended for Parkinson's disease, but evidence suggests that benefit is not sustained. Objectives (1) Implement a specialist domiciliary rehabilitation service for people with Parkinson's and carers. (2) Provide continuing support from trained care assistants to half receiving the rehabilitation. (3) Evaluate the clinical effectiveness of the service, and the value added by the care assistants, compared with usual care. (4) Assess the costs of the interventions. (5) Investigate the acceptability of the service. (6) Deliver guidance for commissioners. Design Pragmatic three-parallel group randomised controlled trial. Setting Community, county of Surrey, England, 2010–11. Participants People with Parkinson's, at all stages of the disease, and live-in carers. Interventions Groups A and B received specialist rehabilitation from a multidisciplinary team (MDT) – comprising Parkinson's nurse specialists, physiotherapists, occupational therapists, and speech and language therapists – delivered at home, tailored to individual needs, over 6 weeks (about 9 hours’ individual therapy per patient). In addition to the MDT, participants in group B received ongoing support for a further 4 months from a care assistant trained in Parkinson's (PCA), embedded in the MDT (1 hour per week per patient). Participants in control group (C) received care as usual (no co-ordinated MDT or ongoing support). Main outcome measures Follow-up assessments were conducted in participants’ homes at 6, 24 and 36 weeks after baseline. Primary outcomes: Self-Assessment Parkinson's Disease Disability Scale (patients); the Modified Caregiver Strain Index (carers). Secondary outcomes included: for patients, disease-specific and generic health-related quality of life, psychological well-being, self-efficacy, mobility, falls and speech; for carers, strain, stress, health-related quality of life, psychological well-being and functioning. Results A total of 306 people with Parkinson's (and 182 live-in carers) were randomised [group A, n = 102 (n = 61); group B, n = 101 (n = 60); group C, n = 103 (n = 61)], of whom 269 (155) were analysed at baseline, pilot cohort excluded. Attrition occurred at all stages. A per-protocol analysis [people with Parkinson's, n = 227 (live-in carers, n = 125)] [group A, n = 75 (n = 45); group B, n = 69 (n = 37); group C, n = 83 (n = 43)] showed that, at the end of the MDT intervention, people with Parkinson's in groups A and B, compared with group C, had reduced anxiety (p = 0.02); their carers had improved psychological well-being (p = 0.02). People with Parkinson's in groups A and B also had marginally reduced disability (primary outcome, p = 0.09), and improved non-motor symptoms (p = 0.06) and health-related quality of life (p = 0.07), compared with C. There were significant differences in change scores between week 6 (end of MDT) and week 24 (end of PCA for group B) in favour of group B, owing to worsening in group A (no PCA support) in posture (p = 0.001); non-motor symptoms (p = 0.05); health-related quality of life (p = 0.07); and self-efficacy (p = 0.09). Carers in group B (vs. group A) reported a tendency for reduced strain (p = 0.06). At 36 weeks post recruitment, 3 months after the end of PCA support for group B, there were few differences between the groups. Participants reported learning about Parkinson's, and valued individual attention. The MDT cost £833; PCA support was £600 extra, per patient (2011 Great British pounds). Conclusions Further research is needed into ways of sustaining benefits from rehabilitation including the use of care assistants.

Background There is a high prevalence of health problems among single people who are homeless. Specialist primary health care services for this population have been developed in several locations across England; however, there have been very few evaluations of these services. Objectives This study evaluated the work of different models of primary health care provision in England to determine their effectiveness in engaging people who are homeless in health care and in providing continuity of care for long-term conditions. It concerned single people (not families or couples with dependent children) staying in hostels, other temporary accommodation or on the streets. The influence on outcomes of contextual factors and mechanisms (service delivery factors), including integration with other services, were examined. Data from medical records were collated on participants’ use of health care and social care services over 12 months, and costs were calculated. Design and setting The evaluation involved four existing Health Service Models: (1) health centres primarily for people who are homeless (Dedicated Centres), (2) Mobile Teams providing health care in hostels and day centres, (3) Specialist GPs providing some services exclusively for patients who are homeless and (4) Usual Care GPs providing no special services for people who are homeless (as a comparison). Two Case Study Sites were recruited for each of the specialist models, and four for the Usual Care GP model. Participants People who had been homeless during the previous 12 months were recruited as ‘case study participants’; they were interviewed at baseline and at 4 and 8 months, and information was collected about their circumstances and their health and service use in the preceding 4 months. Overall, 363 participants were recruited; medical records were obtained for 349 participants. Interviews were conducted with 65 Case Study Site staff and sessional workers, and 81 service providers and stakeholders. Results The primary outcome was the extent of health screening for body mass index, mental health, alcohol use, tuberculosis, smoking and hepatitis A among participants, and evidence of an intervention if a problem was identified. There were no overall differences in screening between the models apart from Mobile Teams, which scored considerably lower. Dedicated Centres and Specialist GPs were more successful in providing continuity of care for participants with depression and alcohol and drug problems. Service use and costs were significantly higher for Dedicated Centre participants and lower for Usual Care GP participants. Participants and staff welcomed flexible and tailored approaches to care, and related services being available in the same building. Across all models, dental needs were unaddressed and staff reported poor availability of mental health services. Limitations There were difficulties recruiting mainstream general practices for the Usual Care GP model. Medical records could not be accessed for 14 participants of this model. Conclusions Participant characteristics, contextual factors and mechanisms were influential in determining outcomes. Overall, outcomes for Dedicated Centres and for one of the Specialist GP sites were relatively favourable. They had dedicated staff for patients who were homeless, ‘drop-in’ services, on-site mental health and substance misuse services, and worked closely with hospitals and homelessness sector services. Funding This project was funded by the National Institute for Health and Care Research (NIHR) Health and Social Care Delivery Research programme (HSDR 13/156/03) and will be published in full in Health and Social Care Delivery Research ; Vol. 11, No. 16. See the NIHR Journals Library website for further project information.

Purpose To describe trends and explore factors associated with quality of life (QoL) and psychological morbidity and assess breast cancer (BC) health service use over a 12-month period for patients joining the supported self-management (SSM)/ patient-initiated follow-up ( PIFU) pathway. Methods Participants completed questionnaires at baseline, 3, 6, 9 and 12 months that measured QoL (FACT-B, EQ 5D-5L), self-efficacy (GSE), psychological morbidity (GHQ-12), roles and responsibilities ( PRRS) and service use (cost diary). Results 99/110 patients completed all timepoints; 32% (35/110) had received chemotherapy. The chemotherapy group had poorer QoL; FACT-B total score mean differences were 8.53 ( 95% CI: 3.42 to 13.64), 5.38 (95% CI: 0.17 to 10.58) and 8.00 (95% CI: 2.76 to 13.24) at 6, 9 and 12 months, respectively. The odds of psychological morbidity (GHQ12 >= 4) were 5.5-fold greater for those treated with chemotherapy. Financial and caring burdens (PRRS) were worse for this group (mean difference in change at 9 months 3.25 (95% CI: 0.42 to 6.07)). GSE and GHQ-12 scores impacted FACT-B total scores, indicating QoL decline for those with high baseline psychological morbidity. Chemotherapy patients or those with high psychological morbidity or were unable to carry out normal activities had the highest service costs. Over the 12 months, 68.2% participants phoned/emailed breast care nurses, and 53.3% visited a hospital breast clinician. Conclusion The data suggest that chemotherapy patients and/or those with heightened psychological morbidity might benefit from closer monitoring and/or supportive interventions whilst on the SSM/PIFU pathway. Reduced access due to COVID-19 could have affected service use.

Background: Increasing numbers of nurses, pharmacists and allied health professionals across the world have prescribing rights for medicines: over 90,000 of the eligible United Kingdom workforce are qualified as non-doctor prescribers. In order to inform future developments, it is important to understand the benefits and impact of prescribing by allied health professionals including physiotherapists and podiatrists.

Objective Hospice at Home (HAH) services aim to enable patients to be cared for and die at home, if that is their choice and achieve a ‘good death’. A national survey, in 2017, aimed to describe and compare the features of HAH services and understand key enablers to service provision. Methods: Service managers of adult HAH services in the ‘Hospice UK’ and National Association for Hospice at Home directories within England were invited to participate. Information on service configuration, referral, staffing, finance, care provision and enablers to service provision were collected by telephone interview. Results: Of 128 services invited, 70 (54.7%) provided data. Great diversity was found. Most services operated in mixed urban/rural (74.3%) and mixed deprivation (77.1%) areas and provided hands-on care (97.1%), symptom assessment and management (91.4%), psychosocial support (94.3%) and respite care (74.3%). Rapid response (within 4 hours) was available in 65.7%; hands-on care 24 hours a day in 52.2%. Charity donations were the main source of funding for 71.2%. Key enablers for service provision included working with local services (eg, district nursing, general practitioner services), integrated health records, funding and anticipatory care planning. Access to timely medication and equipment was critical. Conclusion: There is considerable variation in HAH services in England. Due to this variation it was not possible to categorise services into delivery types. Services work to supplement local care using a flexible approach benefitting from integration and funding. Further work defining service features related to patient and/or carer outcomes would support future service development.

OBJECTIVES: Young onset dementia is associated with distinctive support needs but existing research on service provision has been largely small scale and qualitative. Our objective was to explore service use, cost and satisfaction across the UK. METHODS: Information about socio-demographic characteristics, service use and satisfaction were gathered from people with young onset dementia (YOD) and/or a family member/supporter via a national survey. RESULTS: Two hundred and thirty-three responses were analysed. Diagnosis was most commonly received through a Memory Clinic or Neurology. The type of service delivering diagnosis impacted on post-diagnostic care. Those diagnosed in specialist YOD services were more likely to receive support within the first 6 weeks and receive ongoing care in the service where they were diagnosed. Ongoing care management arrangements varied but generally care was lacking. Around 42% reported no follow-up during 6-weeks after diagnosis; over a third reported seeing no health professional within the previous 3 months; just over a third had a key worker and just under a third had a care plan. Satisfaction and quality of care were highest in specialist services. Almost 60% of family members spent over 5 h per day caring; median costs of health and social care, 3 months, 2018, were £394 (interquartile range £389 to 640). CONCLUSIONS: Variation across diagnostic and post-diagnostic care pathways for YOD leads to disparate experiences, with specialist young onset services being associated with better continuity, quality and satisfaction. More specialist services are needed so all with YOD can access age-appropriate care.

In autosomal recessive dystrophic Epidermolysis bullosa, repeat blistering results in finger webbing and severe contractures of the hands. The aim of this study was to codesign patient-reported outcome indicators for hand therapy with patients, carers and clinicians, and use these to proof-of-concept test a novel dressing glove for recessive dystrophic Epidermolysis bullosa, with cost analysis. Qualitative interviews and focus groups with patients and carers generated content for the indicators. Validity and reliability were established through expert review, piloting and consensus between patients, carers and clinicians. The indicators were self-reported by patients before and while wearing the dressing glove in an N-of-1 study. Time for dressing changes and use of conventional products were also self-reported. A total of 11 indicators were initially generated from the thematic analysis. Expert review, piloting and consensus involved six patients, five carers and eight clinicians (total n=19). Participants agreed 14 indicators, covering hand skin condition (n=4), webbing between the digits (n=4), experiences of wearing and changing dressings (n=2), hand function (n=2), wrist function (n=1) and hand pain (n=1). In Phase 3, 12 patients scored indicators before wearing the gloves and four patients completed scoring while wearing the gloves. Statistically significant improvements between pre-glove and with-glove periods were found for most participants' experience scores. Skin appearance also improved for most participants. The indicators generated useful data, differentiation between scores and participants demonstrating proof-of-concept for patients with recessive dystrophic Epidermolysis bullosa who could wear the dressing gloves. The indicators are being used in routine practice, supporting clinical follow up, commercialisation and regulatory governance of the dressing glove.

Introduction: Nutrition is one of many factors influencing a child’s learning abilitiy. Objectives: This study aims to assess parents’ views on the effect of food on children’s ability to learn in four European countries (England, Germany, Hungary, Spain). Method. Design: Parents of children aged 4 to 10 years were recruited through state elementary schools. Participants were asked to sort 18 cards representing possible determinants of learning (in 6 categories: 4 food related, 3 educational, 2 physical, 4 social, 2 psychological, 3 biological) according to their views about strength of effect. Determinants were identified from the literature. Effects were scored: 0=none; 1=moderate; 2=strong. Results: 201 parents took part. There were no significant differences among countries in age, gender, number of children of participants. Higher proportions of parents in England and Germany had received university education than in the other countries (p=0.015); significantly fewer parents in Spain were in employment (p

Background This study aimed to determine the impact of preoperative exposure to intravenous contrast for CT and the risk of developing postoperative acute kidney injury (AKI) in patients undergoing major gastrointestinal surgery. Methods This prospective, multicentre cohort study included adults undergoing gastrointestinal resection, stoma reversal or liver resection. Both elective and emergency procedures were included. Preoperative exposure to intravenous contrast was defined as exposure to contrast administered for the purposes of CT up to 7 days before surgery. The primary endpoint was the rate of AKI within 7 days. Propensity score-matched models were adjusted for patient, disease and operative variables. In a sensitivity analysis, a propensity score-matched model explored the association between preoperative exposure to contrast and AKI in the first 48 h after surgery. Results A total of 5378 patients were included across 173 centres. Overall, 1249 patients (23 center dot 2 per cent) received intravenous contrast. The overall rate of AKI within 7 days of surgery was 13 center dot 4 per cent (718 of 5378). In the propensity score-matched model, preoperative exposure to contrast was not associated with AKI within 7 days (odds ratio (OR) 0 center dot 95, 95 per cent c.i. 0 center dot 73 to 1 center dot 21; P = 0 center dot 669). The sensitivity analysis showed no association between preoperative contrast administration and AKI within 48 h after operation (OR 1 center dot 09, 0 center dot 84 to 1 center dot 41; P = 0 center dot 498). Conclusion There was no association between preoperative intravenous contrast administered for CT up to 7 days before surgery and postoperative AKI. Risk of contrast-induced nephropathy should not be used as a reason to avoid contrast-enhanced CT.

Background Many people prefer to die at home when the time comes. Hospice at home services aim to support patients to achieve this. A range of hospice at home services exist; some services have been evaluated, but there has been limited evidence synthesis. Objectives The main objective was to find out what models of hospice at home services work best, for whom and in what circumstances. Other objectives supported this aim, including an analysis of the health economic costs of hospice at home models. Design The study was an overarching, non-interventional, realist evaluation comprising three phases. Phase 1 was a survey of hospice at home services. Phase 2 involved 12 case studies, grouped into four models on the basis of size and 24 hours per day, 7 days per week (24/7), operations, from which quantitative and health economics data were gathered. Qualitative interview data from bereaved carers, commissioners and providers were analysed to generate context–mechanism–outcome configurations. Phase 3 comprised stakeholder consensus meetings. Setting Hospice at home services across England. Participants A total of 70 hospice at home managers responded to the survey. A total of 339 patient and family/informal carer dyads were recruited; 85 hospice at home providers and commissioners were interviewed. A total of 88 stakeholders participated in consensus meetings. Main outcome measures The quality of dying and death of patients was assessed by bereaved carers (using the Quality of Dying and Death questionnaire). A patient’s use of services was collected using the Ambulatory and Home Care Record. Results Hospice at home services varied; two-thirds were mainly charitably funded, and not all operated 24/7. Most patients (77%) had cancer. Hospice at home services overall provided care that was likely to deliver ‘a good death’, and 73% of patients died in their preferred place. Six context–mechanism–outcome configurations captured factors relevant to providing optimum hospice at home services: (1) sustainability (of the hospice at home service); (2) volunteers (use of, in the hospice at home service); (3) integration and co-ordination (with the wider health and social care system); (4) marketing and referral (of the hospice at home service); (5) knowledge, skills and ethos (of hospice at home staff); and (6) support directed at the carer at home. Key markers of a good service included staff who had time to care, providing hands-on care; staff whose knowledge and behaviour promoted supportive relationships and confidence through the process of dying; and services attending to the needs of the informal carer. Areas of potential improvement for most hospice at home services were the use of volunteers in hospice at home, and bereavement care. Limitations The study had the following limitations – heterogeneity of hospice at home services, variations in numbers and patient clinical statuses at recruitment, a low Quality of Dying and Death questionnaire response rate, and missing data. Only patients with an informal carer involved on a daily basis were eligible for the study. Conclusions Hospice at home services delivered high-quality care and a ‘good death’, with the majority of patients dying in their stated preferred place. Hospice at home providers can improve their impact by focusing on the features identified that deliver the best patient outcomes. Commissioners can facilitate patient preference and reduce the number of hospital deaths by working with hospice at home services to secure their financial sustainability and increase the numbers and range of patients admitted to hospice at home services. Future research Future research should explore the use of volunteers in the hospice at home setting and evaluate approaches to bereavement support. Funding This project was funded by the National Institute for Health and Care Research (NIHR) Health and Social Care Delivery Research programme and will be published in full in Health and Social Care Delivery Research ; Vol. 10, No. 24. See the NIHR Journals Library website for further project information.

Although the impact of diet on physical health is an important public health issue, less attention has been devoted to the relationship between nutrition and children's mental development. The views of parents and teachers about the extent to which diet affects physical and mental development of children were compared in four European countries. An online questionnaire (developed in English and translated) was circulated through a market research agency. Participants were parents or teachers of children aged 4-10 years without learning or behavioural issues. Questionnaires were returned by 1606 parents (401 in England, Germany and Hungary; 403 in Spain) and 403 teachers (100 in each country, except for 103 in Hungary). Teachers were older than parents (35·3 % v. 18·3 % over 45 years; P

Background Measuring service use and costs is an important aspect of service delivery evaluation. In end-of-life care, there is heavy reliance on care by family/friends (informal carers) and this should be reflected in the total cost of care alongside formal services. The Ambulatory and Home Care Record, developed in Canada, is both comprehensive in coverage and validated for collecting data on formal and informal caring. This study aimed to adapt and pilot the Ambulatory and Home Care Record questionnaire for use in the UK within a study evaluating a new palliative care service. The objectives were to test if family carers could be recruited and assess acceptability and usability of data gathered. Methods Single cohort pilot study using a structured telephone questionnaire carried out every other week. Family carers of patients newly added to the palliative care register or referred to hospice services in the South East of England were invited to participate by mail. Volunteers remained in the study for a maximum of six interviews or until the patient died. Results In total, 194 carers were invited by mail to participate in the study, of which 23 (11.8%) completed at least one interview and 16 (8.2%) completed all possible interviews. Recruitment to the study was lower than anticipated, but most participants seemed to find the interviews acceptable. The modified questionnaire produced usable and relevant data for an economic evaluation of formal and informal caring costs. Conclusions Modifications are needed to the process of recruitment as a postal recruitment strategy did not have a high response rate. The Ambulatory and Home Care Record has proved a viable tool for use in the UK setting, with a few minor modifications, and will be used in a larger study comparing hospice models.

Purpose: To compare patient-triggered follow-up (PTFU) for curatively treated colorectal cancer against traditional outpatient follow-up (OPFU). Methods: Questionnaires were mailed at four time points over one-year post-treatment to two prospectively-recruited cohorts: A, patients entering follow-up and receiving OPFU pre-implementation of PTFU; B, patients entering follow-up (FU) and receiving either OPFU (B1) or PTFU (B2) post-implementation of PTFU. Bi-variate tests were used to compare patient characteristics and outcomes eight months after entering follow-up (generic and cancer-specific quality of life (QoL), satisfaction). Regression analysis explored associations between follow-up model and outcomes. Resource implications and costs of models were compared. Results: Patients in Cohort B1 were significantly more likely to have received chemotherapy (p

Background: Demand for diagnostic assessment in children with possible autism has recently increased significantly. Services are under pressure to deliver timely and high-quality diagnosis, following National Institute and Care Excellence multidisciplinary assessment guidelines. This UK National Health Service study aimed to answer: how many hours of health professional time are required to deliver autism diagnostic assessment, and how much does this cost?. Method: Case notes of 20 children (1–16 yrs.) from 27 NHS trusts, assessed through an autism diagnostic pathway in the previous year, were examined retrospectively. Data included: hours of professional time, diagnostic outcome. Assessment costs calculated using standardised NHS tariffs. Results: 488 children (aged 21–195 months, mean 82.9 months, SD 39.36) from 22 Child Development Services (CDS), four Child and Adolescent Mental Health Services (CAMHS) and one tertiary centre; 87% were either under 5 (36%) or 5 to 11 years (51%). Children seen by CDS were younger than CAMHS (mean (SD) 6.10 (2.72) vs. 10.39 (2.97) years, p 

BACKGROUND/OBJECTIVES: Infant feeding decisions made by new parents have significant health implications. The study aimed to investigate: influences on infant feeding decisions; characteristics of mothers reporting reliance on alternative information sources; associations between reliance on different sources and intentions to exclusively breastfeed and introduce complementary foods later; and subsequent breastfeeding and weaning behaviours. SUBJECTS/METHODS: First-time mothers in five European countries (England, Finland, Germany, Hungary, Spain) completed questionnaires about the importance of 17 influences on infant feeding choices at birth and 8 months later, during 2007–2008. Use of individual sources and reliance on four categories (family and friends, health professionals, written materials, audio-visual media) were compared between countries. Associations between information sources used and mother characteristics, feeding intentions and behaviours were investigated using appropriate statistical tests. RESULTS: In all, 2071 first-time mothers provided baseline data; 78% at 8 months. Variation exists between countries in the influence of different sources on feeding decisions of first-time mothers. Across all countries, the most important influences at both time points were books, partner and antenatal midwife. Mothers in higher income quintiles and remaining at school beyond age 16 years reported greater reliance on written sources (P

Background: The programming concept suggests that poor early nutrition causes an array of medical problems later in life. Public health messages about the implications of programming may not be reaching parents and influencing infant feeding behaviors. Objective: The views of new mothers were sought about the extent to which lifelong health is influenced by diet as an infant, rather than by genetic predispositions or lifestyles and behaviors. Design: A questionnaire survey of first-time mothers was undertaken in 5 European countries. Results: A convenience sample of 2071 mothers from England (438), Finland (426), Germany (414), Hungary (389), and Spain (404) self-completed the questionnaire. High proportions of mothers agreed that how an infant is fed affects his or her health over the first year (95.8%) and in subsequent years (88.5%), but the effect of infant feeding decisions on the development of long-term conditions was the least-cited underlying reason. Diet as an infant was rated an extremely/very important influence on adult health by 64% of mothers, equivalent to environmental pollution (63%), but by fewer mothers than were diet and physical activity in childhood/adolescence (79%, 84%) and adulthood (81%, 83%), genetics/inheritance (70%), and exposure to cigarette smoke (81%). Inter- and intracountry differences were observed. Conclusions: Mothers in this study consider diet as an infant to be a less important influence on lifelong health than many lifestyle, behavioral, and environmental factors and genetics. Further dissemination of the implications of programming to consumers may be warranted.

Objective: Typically, attention focuses on how nutrition affects physical health. The present study investigated the importance that parents attach to the impact of diet on mental performance when choosing food for their child. Design: Questionnaire. Setting: Four European countries. Subjects: Parents of children aged 4–10 years (n 1574): England (n 397), Germany (n 389), Hungary (n 398) and Spain (n 390). Results: Most parents (80–85 %) considered the effect of food on four elements of mental performance (child’s ability to learn, attention, behaviour, mood) to be moderately, very, extremely (v. slightly, not at all) important in food choices; over 90% considered healthiness of food and making food appealing to their child important; 79·8% cost; 76·8% convenience. Belief that food affects mental performance was 57·4% (ability to learn), 60·5% (attention); less than 40% of parents agreed they were aware which foods had an effect. Parents with lower general interest in healthy eating were less likely to consider the effect of food on mental performance elements as important. Respondents from Germany were more likely to rate mental performance as important (except behaviour); those in Hungary less likely. The most important influence on parents’ decisions about feeding their child was their own experience, except Spain, where family/friends/ health professionals were more important. Conclusions: Nutrition affects brain development and cognitive functioning. Low prioritisation of the effect of food on mental performance indicates potential for educating parents.

Objectives: Evidence of how health-related quality of life (HRQOL) changes following laparoscopic and open colorectal surgery in the first 6 weeks of postoperative recovery is needed to inform cost-effectiveness evaluations. Methods: Pragmatic prospective cohort study design. Consecutive patients requiring elective colorectal surgery were allocated to either laparoscopic or open surgery by administrative staff in a district general hospital in England, 2006-2007. Patients completed two validated, generic measures of HRQOL at baseline (preoperatively) and on multiple occasions in the first 6 weeks postsurgery using diaries (EuroQol five-dimensional [EQ-5D] questionnaire: 16 times; short-form 36 health survey [SF-36]: 4 times; HRQOL was compared between groups at each time point, and overall using repeated-measures analysis. Results: Of 201 consecutive patients recruited, 32 (15.1%) were unable to complete diaries. Of the remaining 169 patients, 120 (71%) returned completed diaries at 28 days and 105 (62.1%) at 42 days. There was no difference in preoperative HRQOL scores between surgical groups, but the postoperative EQ-5D questionnaire and SF-36 scores were significantly higher in the laparoscopic group (EQ-5D questionnaire P = 0.005, SF-36 P = 0.007). Subgroup analysis showed that patients with a stoma have worse HRQOL than those without. HRQOL did not differ between the laparoscopic and open stoma patients. Conclusions: This study presents unique prospective data demonstrating that laparoscopic surgery confers HRQOL benefits for patients in the early recovery period following colorectal surgery, compared with open surgery. Consideration of these data in the context of a cost-effectiveness analysis will be reported separately. © 2013 International Society for Pharmacoeconomics and Outcomes Research (ISPOR).

Aims: To identify and describe infant feeding policy documents in Hungary and compare them to the documents of other four European countries (England, Finland, Germany and Spain). The question was also addressed how the phenomenon of nutritional programming was represented in the documents. Subjects: Policy documents on infant feeding were identified and analyzed in the five European countries by using uniform methods for searching and coding. Results: Twenty-six documents were identified: 4 in England, 2 in Finland, 9 in Germany, 6 in Hungary and 5 in Spain. Altogether 203 statements linked to references were identified: benefits of breast-feeding in general (24%), protection against infections (32%), long-term advantages like the prevention of diabetes (31%) or allergy (12%). Considerable variations were found within and between countries in the evaluation of the duration and character of the positive effects. The majority of the statements in the Hungarian documents referred either to the role of breast-feeding in infection protection (n = 8), or to long-term protective effects (n = 13). Conclusion: Policy documents in the study countries varied both in their extent and in the description of the long-term effects of infant nutrition. Majority of the documents failed to contain evidence based discussion of the phenomenon of early nutritional programming.

Objectives: To estimate the proportion of cancer outpatients who visit a Complementary and Alternative Medicine (CAM) unit that is located within a conventional cancer treatment centre; to compare the characteristics of CAM unit visitors with those of all outpatients; to monitor the demand for 20 CAM therapies delivered by professionals, and the use of the CAM unit for waiting, gathering information and informal support from volunteer staff. Design: Prospective, observational, over a six month period. Setting: CAM unit within a NHS cancer treatment centre. Main outcome measures: Utilisation of the CAM unit for 20 complementary therapies, and for waiting, gathering information, informal support; characteristics of CAM users compared with those of all cancer outpatients attending the cancer centre; predictors of CAM therapy use and frequent use. Results: 761 (95% of those approached) people were recruited, 498 (65.4%) cancer patients, 202 (26.5%) relatives, 37 (4.8%) friends/carers, 24 (3.2%) staff. Women predominated (n = 560, 73.6%). Of all outpatients attending the cancer centre, 498 (15.8%) visited the CAM unit, 290 (9.2%) accessed therapies. Compared to all outpatients, those visiting the CAM unit were: younger (mean 63.7 vs. 58.4 years), more likely to be female (57.9% vs. 78.7%), have breast (14.8% vs. 51.9%), gynaecotogical (5.0% vs. 9.1%) cancer, live in local postal district (57.3% vs. 61.6%). Significant predictors of therapy use and frequent visits were being a patient, female, higher education, living closer to the cancer centre. Conclusions: Despite easy access to CAM therapies, a relatively small number of people regularly used them, whilst a larger number selectively tried a few. The integrated CAM unit meets a demand for information and informal support. The findings inform emerging policy on integrating CAM and conventional cancer treatment to address psychosocial needs of people with cancer. More research is needed on why people do not use integrated CAM services and how charges affect demand. (C) 2008 Published by Elsevier Ltd.

[...]this is of great research interest and public health concern as vitamin D deficiency has been shown to have key implications for long-term health outcomes in humans(2). Most (78%) used vitamin D supplements to manage vitamin D deficiency, commonly D3 (57%), meeting clinical recommendations. The findings identify urgent need for HCP nutrition education to help attenuate vitamin D deficiency prevalence.

Abstract Background Increasing numbers of nurses, pharmacists and allied health professionals across the world have prescribing rights: over 90,000 of the eligible United Kingdom workforce are qualified as non-doctor prescribers. In order to inform future developments, it is important to understand the benefits and impact of prescribing by allied health professionals including physiotherapists and podiatrists. Aim: to compare outcomes of Physiotherapist and Podiatrist Independent Prescriber (PP-IP) patients with those of Physiotherapist and Podiatrist non-prescribers (PP-NPs). Outcome measures included patient satisfaction, ease of access to services, quality of life and cost implications. Design: a quasi-experimental, post-test control group design Methods: Using mixed methods outcomes were compared between 7 sites where care was provided from a PP-IP (3 podiatrist and 4 physiotherapist IPs) and 7 sites from a PP-NP (3 podiatrist and 4 physiotherapist NPs). Patients were followed up for 2 months (2015-2016). Results: 489 patients were recruited: n=243 IP sites, and n=246 NP sites. Independent prescribing was found to be highly acceptable, and equivalent in terms of quality of life (p>0.05) and patient satisfaction (p≤0.05) compared to care provided by NPs. PP-IP care delivery was found to be more resource intensive than NP-PP, with longer consultation duration for IPs (around 6.5 mins), and a higher proportion of physiotherapy patients discussed with medical colleagues (around 9.5 minutes). Conclusion This study provides new knowledge that PP-IPs provide high levels of care. PP-IP care delivery was found to be more resource intensive. Further research is required to explore cost effectiveness. A more focussed exploration within each profession using targeted outcome measures would enable a more robust comparison, inform future developments around the world and help ensure non-doctor prescribing is recognised as an effective way to alleviate shortfalls in the global workforce.

Background Online gaming motivations are differently associated with career interests. However, very little is known about online gaming behaviour based on the actual games played and how career interests are reflected in what people play. Hence, we investigated the actual gaming behaviour of individuals from an extensive secondary data set to further support gamers’ future career planning and professional training. Methods The study comprised 16,033 participants playing a different number of games on Steam. Our study was based on the 800 most played games only and included participants where we had access to gender and job details. We employed a secondary data analysis approach by using an existing data set (O’Neill et al., 2016), looking into the actual gaming behaviour of Steam users and additional administrative data (i.e., job details and gender) provided by Game Academy Limited. We used logistic regression on the participants’ top ten games, allowing us to investigate any possible associations between different professions, gender, and the games played. Results We found that IT professionals and engineers played puzzle-platform games, allowing for enhanced spatial skills. Managers showed an interest in action roleplay games where organisational and planning skills can be improved. Finally, engineers were associated with strategy games that required problem-solving and spatial skills. There were apparent gender differences too: females preferred playing single-player games, whereas males played shooting games. Conclusion Our study found that online gaming behaviour varied between different job categories, allowing the participants to gain different soft skills. The soft skills gained could assist gamers with training that leads to a particular career path. The reasons for these findings and suggestions for future research will be discussed.

Objective: To explore the impact of price manipulation and healthy eating information on intended food choices Design: Health information was provided to a random half of subjects (vs. information on Saudi agriculture). Each subject chose from the same lunch menu, containing two healthy and two unhealthy entrees, deserts and beverages, on five occasions. Reference case prices were 5, 3 and 2 Saudi Arabian Reals (SARs). Prices of healthy and unhealthy items were manipulated up (taxed) and down (subsidised) by 1 SAR in four menu variations (random order); subjects were given a budget enabling full choice within any menu. The number of healthy food choices were compared with different price combinations, and between information groups. Linear regression modelling explored the effect of relative prices of healthy / unhealthy options and information on number of healthy choices controlling for dietary behaviours and hunger levels. Setting: University campus, Saudi Arabia, 2013 Subjects: 99 women students Results: In the reference case, 49.5% of choices were for healthy items. When the price of healthy items was reduced, 58.5% of selections were healthy; 57.2% when the price of unhealthy items rose. In regression modelling, reducing the price of healthy items and increasing the price of unhealthy items increased the number of healthy choices by 5% and 6% respectively. Students reporting a less healthy usual diet selected significantly fewer healthy items. Providing healthy eating information was not a significant influence. Conclusion: Price manipulation offers potential for altering behaviours to combat rising youth obesity in Saudi Arabia.

Background:Hospice-at-home aims to enable patients approaching end-of-life to die at home and support their carers. A wide range of different service models exists but synthesised evidence on how best to support family carers to provide sustainable end-of-life care at home is limited. Aim:To explore what works best to promote family carers’ experiences of hospice-at-home. Design:Realist evaluation with mixed methods. This paper focuses on qualitative interviews with carers (to gain their perspective and as proxy for patients) and service providers from 12 case study sites in England. Interviews were coded and programme theories were refined by the research team including two public members. Setting/participants:Interviews with carers (involved daily) of patients admitted to hospice-at-home services (n = 58) and hospice-at-home staff (n = 78). Results:Post bereavement, 76.4% of carers thought that they had received as much help and support as they needed and most carers (75.8%) rated the help and support as excellent or outstanding. Of six final programme theories capturing key factors relevant to providing optimum services, those directly relevant to carer experiences were: integration and co-ordination of services; knowledge, skills and ethos of hospice staff; volunteer roles; support directed at the patient–carer dyad. Conclusions:Carers in hospice-at-home services identified care to be of a higher quality than generic community services. Hospice staff were perceived as having ‘time to care’, communicated well and were comfortable with dying and death. Hands-on care was particularly valued in the period close to death.

Background/Objectives: Several factors affect the mental performance of children. The importance that parents attribute to food-related determinants, compared with genetic, socio-economic and school environment, was investigated. Subjects/Methods: Parents of school children (aged 4–11) were recruited through state primary schools in four European countries. Interviews were conducted in which participants were asked to sort 18 cards representing possible determinants of four elements of mental performance (attention, learning, mood and behaviour) according to perceived strength of effect. Determinants were identified from the literature and grouped in six categories: food-related, school environment, physical, social, psychological and biological. Effects were scored: 0=none; 1=moderate; and 2=strong. Views were compared between and within countries. Results: Two hundred parents took part (England: 53; Germany: 45; Hungary: 52; Spain: 50). Differences existed between countries in the proportions reporting university education and being in employment. Taking all countries together, parents consider the food category (mean 1.33) to have a lower impact on a child’s mental performance than physical (activity and sleep, 1.77), psychological (mood and behaviour, 1.69) and school environment (1.57). Social (1.12) and biological (0.91) determinants were ranked lower than food. Of determinants in the food category, parents thought regularity of meals had more influence on mental performance (1.58) than what a child eats now (1.36), food at school (1.35), nutrition as a baby/infant (1.02). Conclusion: Scope exists to improve parental awareness of the repercussions of their dietary choices for the mental performance of their children.

Introduction: Diet is one of many factors influencing a child’s mental performance. but little is known about the beliefs. attitudes and knowledge of parents. and how these affect food choices. A survey of parents of children aged 4-10 years was conducted in four European countries (England. Germany. Hungary. Spain) to explore their views about the effect of diet on children’s attention and ability to learn. Objectives: Diet is one of many factors influencing a child’s mental performance. but little is known about the beliefs. attitudes and knowledge of parents. and how these affect food choices. A survey of parents of children aged 4-10 years was conducted in four European countries (England. Germany. Hungary. Spain) to explore their views about the effect of diet on children’s attention and ability to learn. Method/Design: A questionnaire was designed. translated and piloted in the four countries. Parents of children in mainstream education and without diagnosed pathologies such as Attention Deficit Hyperactivity Disorder were recruited through online panels accessed by a market research company. Background information was collected on respondents’ personal characteristics (household composition and demography. socioeconomic status. education. ethnicity). The questionnaire explored views on the relationship between diet and physical and mental development. attention and ability to learn. and how such considerations affected food choices. Results: 1604 parents completed the questionnaire (401 in England. Germany and Hungary. 403 in Spain); 61% female (range 54% Spain – 68% England). Most respondents had completed higher education (range 66% England – 39% Hungary). Almost one half were current smokers (range 42% England – 52% Germany). Many parents thought that a child’s ability to learn was very much . extremely dependent on diet (71% overall. range 64% Spain – 78% Hungary). but smaller proportions reported that they considered this (very much. extremely) when providing food for their child (51% overall. range 47% England and Hungary – 55 % Germany). Differences between views and reported behaviours of parents were smaller for other aspects of mental performance. Conclusions: Parents may belief that diet affects mental performance but other factors. such as providing variety and overall healthiness of diet. may be more important in the food choices they make for their children.

Objectives To explore the supportive care needs of cancer survivors, the characteristics of patients with high levels of unmet need, changes in unmet need after treatment ends and differences in unmet needs of breast, colorectal and testicular survivors. Methods The method used was a prospective longitudinal mailed survey. Unmet needs, measured by 25-item modified Cancer Survivors Unmet Needs survey at baseline (immediately post-treatment) and 8 months later, were analysed descriptively. Results Of 434 breast, 186 colorectal and 75 testicular patients responding at baseline, 56.2%, 65.6% and 50.7%, respectively, had no unmet needs, the top decile having >= 10 (breast) or seven (colorectal and testicular) different needs and seven different unmet needs. The most frequently reported unmet need (all groups) was fear of cancer recurrence. Unmet needs fell significantly at 8 months for breast patients. Some patients reported new needs. Needs were lowest amongst colorectal survivors and differed between the three groups. Higher levels of unmet needs (breast and colorectal) were associated with having had chemotherapy. Conclusion Most survivors reported few unmet needs, but a small proportion have persisting or emerging needs. Routine or regular monitoring of unmet needs is required so that healthcare professionals can deliver personalised care based on individual needs, preferences and circumstances.

Background: The role of named midwife for teenagers was implemented in Royal Surrey County Hospital NHS Foundation Trust in order to improve outcomes for teenage mothers and their babies. The role comprised a dedicated midwife-led teenage antenatal clinic, antenatal and postnatal home visits and tailored antenatal education. Aims: This project monitored the outcomes of teenage mothers following implementation of the role, to assess improvements in outcomes. Methods: During this service development project, 31 teenage mothers aged ≤ 19 years received midwifery care and their obstetric outcomes were monitored. These outcomes were compared with 52 teenage mothers who had previously given birth. Findings: Comparing teenagers who gave birth in February–August 2014 with those who gave birth in the same period in 2013, there was an increase in the rate of spontaneous vaginal deliveries, a decrease in instrumental deliveries and increase in induction of labour; however, induction of labour for intrauterine growth restriction decreased. The rate of caesarean section increased but remained lower than in the general population. An increase in birth weight and intention to breastfeed were also observed. Conclusions: This project indicates that the role of a dedicated midwife for teenagers has a place in the care of teenage mothers.

Palliative care remains suboptimal in end-stage liver disease.

There is much epidemiological evidence suggesting a reduced risk of development of type 2 diabetes (T2D) in habitual coffee drinkers, however to date there have been few longer term interventions, directly examining the effects of coffee intake on glucose and lipid metabolism. Previous studies may be confounded by inter-individual variation in caffeine metabolism. Specifically, the rs762551 single nucleotide polymorphism (SNP) in the CYP1A2 gene has been demonstrated to influence caffeine metabolism, with carriers of the C allele considered to be of a “slow” metaboliser phenotype. This study investigated the effects of regular coffee intake on markers of glucose and lipid metabolism in coffee-naïve individuals, with novel analysis by rs762551 genotype. Participants were randomised to either a coffee group (n=19) who consumed 4 cups/day instant coffee for 12 weeks or a control group (n=8) who remained coffee/caffeine free. Venous blood samples were taken pre- and post13 intervention. Primary analysis revealed no significant differences between groups. Analysis of the coffee group by genotype revealed several differences. Prior to coffee intake, the AC genotype (“slow” caffeine metabolisers, n=9) displayed higher baseline glucose and non esterified fatty acids (NEFA) than the AA genotype (“fast” caffeine metabolisers, n=10, p