Completion of fit notes by GPs: a mixed methods study

Aims: The aim of this study was to investigate the completion of fit notes by UK general practitioners (GPs). A series of actual fit notes issued to employed patients were examined, and their GPs’ reflections and experiences of fit note completion explored. Methods: A mixed-methods design was used. Data were collected from copies of 94 fit notes issued to employed patients by 11 GPs, and from 86 questionnaires completed by these GPs reflecting on the fit notes they had issued. Face-to-face interviews were then conducted with each GP. Results: Fit note completion is not meeting expectations for a number of reasons. These include the following: limited knowledge and awareness of the guidance in fit note completion; problems with the fit note format; lack of mandatory training in completing fit notes; lack of incentive to change practice; incomplete implementation of the electronic fit note; GPs’ lack of confidence in, and doubts about the appropriateness of performing this role. Conclusion: If UK GPs are to continue their contractual responsibility for completing fit notes, further consideration of their education and training needs is urgently required. Weaknesses in the design and format of the fit note and the availability of the electronic version also need to be addressed

Differential expression of VEGF-Axxx isoforms is critical for development of pulmonary fibrosis

RATIONALE Fibrosis after lung injury is related to poor outcome, and idiopathic pulmonary fibrosis (IPF) can be regarded as an exemplar. Vascular endothelial growth factor (VEGF)-A has been implicated in this context, but there are conflicting reports as to whether it is a contributory or protective factor. Differential splicing of the VEGF-A gene produces multiple functional isoforms including VEGF-Aa and VEGF-Ab, a member of the inhibitory family. To date there is no clear information on the role of VEGF-A in IPF. OBJECTIVES To establish VEGF-A isoform expression and functional effects in IPF. METHODS We used tissue sections, plasma, and lung fibroblasts from patients with IPF and control subjects. In a bleomycin-induced lung fibrosis model we used wild-type MMTV mice and a triple transgenic mouse SPC-rtTATetoCreLoxP-VEGF-Ato conditionally induce VEGF-A isoform deletion specifically in the alveolar type II (ATII) cells of adult mice. MEASUREMENTS AND MAIN RESULTS IPF and normal lung fibroblasts differentially expressed and responded to VEGF-Aa and VEGF-Ab in terms of proliferation and matrix expression. Increased VEGF-Ab was detected in plasma of progressing patients with IPF. In a mouse model of pulmonary fibrosis, ATII-specific deficiency of VEGF-A or constitutive overexpression of VEGF-Ab inhibited the development of pulmonary fibrosis, as did treatment with intraperitoneal delivery of VEGF-Ab to wild-type mice. CONCLUSIONS These results indicate that changes in the bioavailability of VEGF-A sourced from ATII cells, namely the ratio of VEGF-Aa to VEGF-Ab, are critical in development of pulmonary fibrosis and may be a paradigm for the regulation of tissue repair

Impact of interventions to reduce sugar-sweetened beverage intake in children and adults: a protocol for a systematic review and meta-analysis

Background: Sugar-sweetened beverages (SSBs) have been stressed as relevant targets of public health interventions considering the negative outcomes derived from their excessive intake. Though the evidence from published literature grows to support a cause-and-effect association of SSBs with obesity and other diseases, little is known on the effectiveness that strategies alone or as part of multi-component programmes have had to influence this particular dietary behaviour across all ages. Therefore, this review and meta-analysis aim to evaluate the effect that interventions have had to decrease their consumption or increase water intake in children and adults so as to guide the design of future programmes and inform policy making. Methods: Included studies in this review will be randomised controlled trials and quasi-experimental interventions (with a control group) that have reported baseline and post-intervention intakes of SSBs or water and that have been published from 1990 in any language. A thorough search will be performed in MEDLINE, EMBASE, Scopus, Web of Science, Cochrane's central register of controlled trials, and the Global Health Library. Two independent reviewers will conduct initial screening of potentially included articles and will later extract data to analyse domains of intervention design and delivery (with emphasis on behaviour change techniques used as rationale), as well as results in changes on consumption patterns and behavioural determinants. Internal and external validity of each study will also be appraised. A meta-analysis will be performed if a sufficient number of studies are available, and if not, a narrative review will be conducted instead. Discussion: The results from this review aim to strengthen public health initiatives tackling obesity through improvements in non-alcoholic drinking patterns. As a subject of growing attention globally, this review will help determine which strategies available are the most effective in different contexts. Knowledge gained from this work will also aid resource allocation in future research and government agendas

Increased CSF levels of aromatic amino acids in hip fracture patients with delirium suggests higher monoaminergic activity

textabstractBackground: To examine whether delirium in hip fracture patients was associated with changes in the levels of amino acids and/or monoamine metabolites in cerebrospinal fluid (CSF) and serum. Methods: In this prospective cohort study, 77 patients admitted with an acute hip fracture to Oslo University Hospital, Norway, were studied. The concentrations of amino acids in CSF and serum were determined by high performance liquid chromatography. The patients were assessed daily for delirium by the Confusion Assessment Method (pre-operatively and post-operative day 1-5 (all) or until discharge (delirious patients)). Pre-fracture dementia status was decided by an expert panel. Serum was collected pre-operatively and CSF immediately before spinal anesthesia. Results: Fifty-three (71 %) hip fracture patients developed delirium. In hip fracture patients without dementia (n = 39), those with delirium had significantly higher CSF levels of tryptophan (40 % higher), tyrosine (60 % higher), phenylalanine (59 % higher) and the monoamine metabolite 5-hydroxyindoleacetate (23 % higher) compared to those without delirium. The same amino acids were also higher in CSF in delirious patients with dementia (n = 38). The correlations between serum and CSF amino acid levels were poor. Conclusion: Higher CSF levels of monoamine precursors in hip fracture patients with delirium suggest a higher monoaminergic activity in the central nervous system during delirium in this patient group

Testing for an effect of a mindfulness induction on child executive functions

Several sessions of mindfulness practice can exert positive gains for child executive functions (EF); however, the evidence for effects of a mindfulness induction, on EF for adults, is mixed and this effect has not been tested in children. The immediate effect of an age appropriate 3-min mindfulness induction on EF of children aged 4–7 years was tested. Participants (N = 156) were randomly assigned to a mindfulness induction or dot-to-dot activity comparison group before completing four measures of EF. A composite score for EF was calculated from summed z scores of the four EF measures. A difference at baseline in behavioural difficulties between the mindfulness induction and comparison group meant that data was analysed using a hierarchical regression. The mindfulness induction resulted in higher average performance for the composite EF score (M = 0.12) compared to the comparison group (M = − 0.05). Behavioural difficulties significantly predicted 5.3% of the variance in EF performance but participation in the mindfulness or comparison induction did not significantly affect EF. The non-significant effect of a mindfulness induction to exert immediate effects on EF fits within broader evidence reporting mixed effects when similar experimental designs have been used with adults. The findings are discussed with consideration of the extent to which methodological differences may account for these mixed effects and how mindfulness inductions fit within broader theoretical and empirical understanding of the effects of mindfulness on EF

Visual attention and action: How cueing, direct mapping, and social interactions drive orienting

Despite considerable interest in both action perception and social attention over the last 2 decades, there has been surprisingly little investigation concerning how the manual actions of other humans orient visual attention. The present review draws together studies that have measured the orienting of attention, following observation of another’s goal-directed action. Our review proposes that, in line with the literature on eye gaze, action is a particularly strong orienting cue for the visual system. However, we additionally suggest that action may orient visual attention using mechanisms, which gaze direction does not (i.e., neural direct mapping and corepresentation). Finally, we review the implications of these gaze-independent mechanisms for the study of attention to action. We suggest that our understanding of attention to action may benefit from being studied in the context of joint action paradigms, where the role of higher level action goals and social factors can be investigated

Executive function and IQ predict mathematical and attention problems in very preterm children

Objective of this study was to examine the impact of executive function (EF) on mathematical and attention problems in very preterm (gestational age ≤ 30 weeks) children. Participants were 200 very preterm (mean age 8.2 ± 2.5 years) and 230 term children (mean age 8.3 ± 2.3 years) without severe disabilities, born between 1996 and 2004. EFs assessed included verbal fluency, verbal working memory, visuospatial span, planning, and impulse control. Mathematics was assessed with the Dutch Pupil Monitoring System and parents and teachers rated attention problems using standardized behavior questionnaires. The impact of EF was calculated over and above processi

25-hydroxyvitamin D is lower in deprived groups, but is not associated with carotid intima media thickness or plaques: results from pSoBid

Objective: The association of the circulating serum vitamin D metabolite 25-hydroxyvitamin D (25OHD) with atherosclerotic burden is unclear, with previous studies reporting disparate results. <p/>Method: Psychological, social and biological determinants of ill health (pSoBid) is a study of participants aged 35–64 years from Glasgow who live at extremes of the socioeconomic spectrum. Vitamin D deficiency was defined as 25OHD < 25nmol/L, as per convention. Cross-sectional associations between circulating 25OHD concentrations and a range of socioeconomic, lifestyle, and biochemistry factors, as well as carotid intima media thickness (cIMT) and plaque presence were assessed in 625 participants. <p/>Results: Geometric mean levels of circulating 25OHD were higher among the least deprived (45.6 nmol/L, 1-SD range 24.4–85.5) versus most deprived (34.2 nmol/L, 1-SD range 16.9–69.2; p < 0.0001). In the least deprived group 15% were “deficient” in circulating 25OHD versus 30.8% in the most deprived (χ2p < 0.0001). Log 25OHD was 27% lower among smokers (p < 0.0001), 20% higher among the physically active versus inactive (p = 0.01), 2% lower per 1 kg/m2 increase in body mass index (BMI) (p < 0.0001), and showed expected seasonal variation (χ2p < 0.0001). Log 25OHD was 13% lower in the most versus least deprived independent of the aforementioned lifestyle confounding factors (p = 0.03). One unit increase in log 25OHD was not associated with atherosclerotic burden in univariable models; cIMT (effect estimate 0.000 mm [95% CI −0.011, 0.012]); plaque presence (OR 0.88 [0.75, 1.03]), or in multivariable models. <p/>Conclusion: There is no strong association of 25OHD with cIMT or plaque presence, despite strong evidence 25OHD associates with lifestyle factors and socioeconomic deprivation

Prognostic model to predict postoperative acute kidney injury in patients undergoing major gastrointestinal surgery based on a national prospective observational cohort study.

Background: Acute illness, existing co-morbidities and surgical stress response can all contribute to postoperative acute kidney injury (AKI) in patients undergoing major gastrointestinal surgery. The aim of this study was prospectively to develop a pragmatic prognostic model to stratify patients according to risk of developing AKI after major gastrointestinal surgery. Methods: This prospective multicentre cohort study included consecutive adults undergoing elective or emergency gastrointestinal resection, liver resection or stoma reversal in 2-week blocks over a continuous 3-month period. The primary outcome was the rate of AKI within 7 days of surgery. Bootstrap stability was used to select clinically plausible risk factors into the model. Internal model validation was carried out by bootstrap validation. Results: A total of 4544 patients were included across 173 centres in the UK and Ireland. The overall rate of AKI was 14·2 per cent (646 of 4544) and the 30-day mortality rate was 1·8 per cent (84 of 4544). Stage 1 AKI was significantly associated with 30-day mortality (unadjusted odds ratio 7·61, 95 per cent c.i. 4·49 to 12·90; P < 0·001), with increasing odds of death with each AKI stage. Six variables were selected for inclusion in the prognostic model: age, sex, ASA grade, preoperative estimated glomerular filtration rate, planned open surgery and preoperative use of either an angiotensin-converting enzyme inhibitor or an angiotensin receptor blocker. Internal validation demonstrated good model discrimination (c-statistic 0·65). Discussion: Following major gastrointestinal surgery, AKI occurred in one in seven patients. This preoperative prognostic model identified patients at high risk of postoperative AKI. Validation in an independent data set is required to ensure generalizability

Brain-behavior correlates of rhythmic timing and auditory-motor synchronization in children with developmental coordination disorder: an EEG study

Vulnerabilities in motor control and sensorimotor timing are hallmarks of developmental coordination disorder (DCD). Although the positive effects of rhythmic entrainment on motor performance have been demonstrated in adults with movement disorders, interactions between auditory and motor systems have not been well characterized in children with DCD. We employed neuropsychological tests, caregiver reports, adaptive psychophysical procedures, finger-tapping paradigms, and electroencephalography (EEG) recordings to determine whether children with DCD have auditory-perceptual difficulties, whether rhythmic auditory cues can improve their motor performance, and whether extensive musical training contributes to enhanced auditory-motor abilities. Thirty-four children aged 7–11 years participated, including children with DCD and typically developing children with and without musical training. As hypothesized, children with DCD exhibited difficulties in rhythmic timing in both auditory-perceptual and motor tasks, especially compared to typically developing children with musical training. Notably, rhythmic auditory stimuli significantly improved motor performance across groups, which was linked to increased beta power and reduced functional connectivity in the ipsilateral fronto-central network compared to unpaced movements. Moreover, children with musical training consistently outperformed their DCD and TD peers across tasks and showed greater interhemispheric connectivity during auditory-motor synchronization, suggesting that rhythmic skills can be enhanced through practice. Our findings provide compelling evidence for the use of individually tailored auditory/rhythm-based interventions in children with DCD and highlight the positive effects of music education on auditory-motor development. Given the strong association between rhythm perception and movement, future studies should continue to investigate the link between auditory and motor skills to identify the profiles of children who are most likely to benefit from such interventions