15N-DNA stable isotope probing reveals niche differentiation of ammonia oxidizers in paddy soils.

Chemoautotrophic canonical ammonia oxidizers (ammonia-oxidizing archaea (AOA) and ammonia-oxidizing bacteria (AOB)) and complete ammonia oxidizers (comammox Nitrospira) are accountable for ammonia oxidation, which is a fundamental process of nitrification in terrestrial ecosystems. However, the relationship between autotrophic nitrification and the active nitrifying populations during 15N-urea incubation has not been totally clarified. The 15N-labeled DNA stable isotope probing (DNA-SIP) technique was utilized in order to study the response from the soil nitrification process and the active nitrifying populations, in both acidic and neutral paddy soils, to the application of urea. The presence of C2H2 almost completely inhibited NO3--N production, indicating that autotrophic ammonia oxidation was dominant in both paddy soils. 15N-DNA-SIP technology could effectively distinguish active nitrifying populations in both soils. The active ammonia oxidation groups in both soils were significantly different, AOA (NS (Nitrososphaerales)-Alpha, NS-Gamma, NS-Beta, NS-Delta, NS-Zeta and NT (Ca. Nitrosotaleales)-Alpha), and AOB (Nitrosospira) were functionally active in the acidic paddy soil, whereas comammox Nitrospira clade A and Nitrosospira AOB were functionally active in the neutral paddy soil. This study highlights the effective discriminative effect of 15N-DNA-SIP and niche differentiation of nitrifying populations in these paddy soils. KEY POINTS: • 15N-DNA-SIP technology could effectively distinguish active ammonia oxidizers. • Comammox Nitrospira clade A plays a lesser role than canonical ammonia oxidizers. • The active groups in the acidic and neutral paddy soils were significantly different.

Formation of a conceptual framework during the development of a patient-reported outcome measure for early gastrointestinal recovery: phase I of the PRO-diGi study.

AIM: Patients admitted to hospital for abdominal surgery often experience gastrointestinal dysfunction. Many studies have reported outcomes following gastrointestinal dysfunction, yet there is no unified definition of recovery or a validated patient-reported outcome measure (PROM). The first stage of PROM development requires formation of a conceptual framework to identify key themes to patients. The aim of this study was to utilize semistructured interviews to identify core themes and concepts relevant to patients to facilitate development of a conceptual framework. METHOD: Adult patients admitted to hospital for major gastrointestinal, urological or gynaecological surgery, in an emergency or elective setting, were eligible to participate. Patients treated nonoperatively for small bowel obstruction were also eligible. Interviews were conducted by telephone, audio-recorded, transcribed, coded and analysed using NVivo software by two researchers and reviewed by lay members of the steering group. Interviews continued until data saturation was reached. Ethical approval was gained prior to interviews (21/WA/0231). RESULTS: Twenty nine interviews were completed (17 men, median age 64 years) across three specialties (20 gastrointestinal, six gynaecological, three urological). Two overarching themes of 'general recovery' and 'gastrointestinal symptoms' were identified. General recovery included three themes: 'life impact', 'mental impact', including anxiety, and 'physical impact', including fatigue. Gastrointestinal symptoms included three themes: 'abdominal symptoms' such as pain, 'diet and appetite' and 'expulsory function', such as stool frequency. A total of 18 gastrointestinal symptoms were identified during patient recovery-many of which lasted several weeks following discharge. CONCLUSION: This study reports a range of gastrointestinal and nongastrointestinal symptoms experienced by patients during early gastrointestinal recovery. Identified symptoms have been synthesized into a conceptual framework to enable development of a definitive PROM for early gastrointestinal recovery.

Dietary tryptophan-rich protein hydrolysate can acutely impact physiological and psychological measures of mood and stress in healthy adults.

BACKGROUND: Tryptophan is the precursor to the mood regulating neurotransmitter serotonin. Its brain bioavailability from food can be dependent on the dietary source. Egg protein hydrolysate (EPH), a dietary supplement rich in tryptophan, has previously shown to acutely impact cognition, mood and stress benefits at 2 g dose. No data exist on the acute effects of lower doses in a food matrix. METHODS: This exploratory study tested the acute effects of low-doses EPH (0.5, 1 g) in a food matrix on cognition, mood and stress. The study employed a double-blinded randomized controlled parallel design in 45 participants with three arms. The effects of the interventions were measured after a multi-task cognitive stressor on blood biomarkers, self-reported mood states, performances of attention, autonomic parameters and, emotional reactivity responses from electroencephalographic recording. RESULTS: As compared to the reference, the 1 g EPH dose increased tryptophan bioavailability from baseline, and, both doses improved heart rate variability parameters related to parasympathetic activation while showing differences in the late neural response to negative versus neutral emotions. Post-hoc analyses indicated a gender difference in the baseline tryptophan bioavailability and further examination suggested the change in mood rating depends on the interaction between gender and change from baseline of tryptophan bioavailability. CONCLUSIONS: Overall, this study suggests that low levels of tryptophan rich EPH in a food matrix positively impact mood or stress in acute settings and adds to the body of evidence linking tryptophan and dietary sources thereof with these benefits. Confirmatory randomized controlled trials are needed to confirm these findings.Trial registration number: CER-VD N°2019-00218.

Analytical profile of the lysergamide 1cP-AL-LAD and detection of impurities.

The development of novel lysergamides continues to occur, based on both the needs of psychedelic medicine and commercial interest in new recreational substances. The present study continues the authors' research on novel lysergamides and describes the analytical profile of 1-cyclopropanoyl-AL-LAD (IUPAC name: 1-(cyclopropanecarbonyl)-N,N-diethyl-6-(prop-2-en-1-yl)-9,10-didehydroergoline-8ß-carboxamide; 1cP-AL-LAD), using various chromatographic, mass spectrometric, and spectroscopic methods. Analysis of a powdered sample of 1cP-AL-LAD, obtained from an online vendor, by high performance liquid chromatography-electrospray ionization-quadrupole time-of-flight mass spectrometry in full scan/AutoMS/MS mode revealed the detection of 17 impurities based on high-resolution tandem mass spectral data; tentative determination of their identity was based on mass spectral grounds alone, though detection of AL-LAD and 1P-AL-LAD was confirmed using available reference standards. Other tentative compound identifications included 1-acetyl-AL-LAD and several other substances potentially reflecting oxidation of the N6 -allyl group as well as other positions on the ergoline ring system. These data may assist those interested in the chemistry of lysergamides. Finally, 1cP-AL-LAD was also detected in samples of "blotters" sold online for recreational use.

Clinical associations with carriage of pulmonary Stenotrophomonas maltophilia.

BACKGROUND: Stenotrophomonas maltophilia causes opportunistic respiratory infections and is associated with declining lung function in patients with cystic fibrosis (CF). Risk factors for carrying S. maltophilia remain unclear. METHODS: We conducted a retrospective study of patients yielding ⩾1 respiratory S. maltophilia isolate at the Oxford University Hospitals Trust between 2014 and 2019 and a cohort study of S. maltophilia carriage in CF patients attending annual review in 2018. RESULTS: Seven hundred and forty isolates were identified from 238 patients (median 1.0 isolate/patient). Predisposing conditions included invasive ventilation (29.8%), CF (25.6%) and non-CF bronchiectasis (24.4%). The rates of Stenotrophomonas isolates and co-trimoxazole resistance were stable over time. About 10.8% of isolates were co-trimoxazole-resistant, with resistance more common in CF than in other diagnoses (29.5% vs 5.8%, p < 0.001). No clinical features were significantly associated with S. maltophilia carriage in the CF population. DISCUSSION: We present new insight into the epidemiology of Stenotrophomonas colonisation/infection and identify increased co-trimoxazole resistance in CF isolates.

Duplication and nonregistration of COVID-19 systematic reviews: Bibliometric review.

Objectives: This study examines the conduct of systematic reviews during the early stages of the COVID-19 pandemic, including compliance to protocol registration and duplication of reviews on similar topics. The methodological and reporting quality were also explored. Methods: A cross-sectional, bibliometric study was undertaken of all systematic review manuscripts on a COVID-19 intervention published between January 1st and June 30th, 2020. Protocol registration on a publicly accessible database was recorded. Duplication was determined by systematically recording the number of reviews published on each topic of analysis. Methodological quality and reporting quality were assessed using the AMSTAR-2 and PRISMA 2009 instruments, respectively. Results: Thirty-one eligible systematic reviews were identified during the inclusion period. The protocol of only four (12.9%) studies was registered on a publicly accessible database. Duplication was frequent, with 15 (48.4%) of the 31 included studies focusing on either hydroxychloroquine (and/or chloroquine) or corticosteroids. Only one study (3.2%) was of "high" methodological quality, four (12.9%) were "low" quality, and the remainder (n = 26, 83.9%) were of "critically low" quality. The median completeness of reporting was 20 out of 27 items (74.1%) with a range of 5-26 (interquartile range: 14-23). Conclusion: Systematic reviews during the early stages of the COVID-19 pandemic were uncommonly registered, frequently duplicated, and mostly of low methodological quality. In contrast, the reporting quality of manuscripts was generally good but varied substantially across published reports. There is a need for heightened stewardship of systematic review research, particularly during times of medical crisis where the generation of primary evidence may be rapid and unstable.

Effects of different carbon sources on methane production and the methanogenic communities in iron rich flooded paddy soil.

Various carbon sources as substrates and electron donors can produce methane via different metabolic pathways. In particular, the methane produced by rice cultivation has a severe impact on climate change. However, how Fe3+, the most abundant oxide in paddy soil, mediates the methanogenesis of different carbon sources is unknown. In this study, we investigated the effect of four carbon sources with different chain lengths (acetate, glucose, nonanoate, and starch) on CH4 production and associated methanogens in iron-rich paddy soil over 90 days of anaerobic incubation. We found that glucose and starch were the more preferential substrates for liberating methane compared to acetate, and the rate was also faster. Nonanoate was unable to support methane production. Methanosarcinales and Methanobacteriales were the most predominant methanogenic archaea as shown by 16S rRNA gene sequencing, though their abundance changed over time. Additionally, a significantly higher content of iron-reducing bacteria was observed in the glucose and starch treatments, and it was significantly positively correlated with the copy number of the methanogenic mcrA gene. Together, we confirmed the methanogenic capacity of different carbon sources and their related microorganisms. We also showed that iron oxides play a central role in regulating methane emissions from paddy soils and need more attention to be paid to them.

Postoperative nonsteroidal anti-inflammatory drugs in relation to recurrence, survival and anastomotic leakage after surgery for colorectal cancer.

AIM: The aim of this work was to investigate whether nonsteroidal anti-inflammatory drugs (NSAIDs) could be beneficial or harmful when used perioperatively for colorectal cancer patients, as inflammation may affect occult disease and anastomotic healing. METHOD: This is a protocol-based retrospective cohort study on colorectal cancer patients operated on between 2007 and 2012 at 21 hospitals in Sweden. NSAID exposure was retrieved from postoperative analgesia protocols, while outcomes and patient data were retrieved from the Swedish Colorectal Cancer Registry. Older or severely comorbid patients, as well as those with disseminated or nonradically operated tumours were excluded. Multivariable regression with adjustment for confounders was performed, estimating hazard ratios (HRs) for long-term outcomes and odds ratios (ORs) for short-term outcomes, including 95% confidence intervals (CIs). RESULTS: Some 6945 patients remained after exclusion, of whom 3996 were treated at hospitals where a NSAID protocol was in place. No association was seen between NSAIDs and recurrence-free survival (HR 0.97, 95% CI 0.87-1.09). However, a reduction in cancer recurrence was detected (HR 0.83, 95% CI 0.72-0.95), which remained significant when stratifying into locoregional (HR 0.68, 95% CI 0.48-0.97) and distant recurrences (HR 0.85, 95% CI 0.74-0.98). Anastomotic leakage was less frequent (HR 0.69%, 95% CI 0.51-0.94) in the NSAID-exposed, mainly due to a risk reduction in colo-rectal and ileo-rectal anastomoses (HR 0.47, 95% CI 0.33-0.68). CONCLUSION: There was no association between NSAID exposure and recurrence-free survival, but an association with reduced cancer recurrence and the rate of anastomotic leakage was detected, which may depend on tumour site and anastomotic location.

Diagnosis of cystic fibrosis in adulthood and eligibility for novel CFTR modulator therapy.

BACKGROUND: Cystic fibrosis (CF) is an autosomal recessive condition that primarily manifests as a chronic respiratory disease. CF is usually diagnosed in early childhood or through newborn screening although in a small but important group, diagnosis is not made until adulthood. Highly effective cystic fibrosis transmembrane conductance regulator (CFTR) modulator therapies are now available for most genetic causes of CF highlighting the importance of identifying people with late presentations of CF. AIM: We aimed to identify the clinical characteristics of people diagnosed with CF in adulthood and their resulting eligibility for novel CFTR modulator therapies. DESIGN: Retrospective single-centre cohort study. METHODS: Patients diagnosed with CF at age 18 years or older were identified from a patient database. Paper and electronic medical records were reviewed and clinical, microbiological and radiological data at diagnosis were recorded. RESULTS: Nineteen patients were identified. Median age at diagnosis was 38 years (range: 19-71) and 9 (47%) were female. All patients had a history of chronic respiratory symptoms and 18/19 (94%) had radiological evidence of bronchiectasis. All patients had two pathogenic CFTR mutations identified with 16/19 (84%) compound heterozygotes for the F508del mutation. The majority of patients had a CFTR genotype considered eligible for CFTR modulator therapy (84% and 89% according to European and US licences, respectively). CONCLUSIONS: Adult patients with unexplained chronic bronchiectasis should be thoroughly investigated for CF. A low index of suspicion will help to identify adults with undiagnosed CF who are likely to benefit from CFTR modulator therapy.

Separating the wheat from the chaff: Observations on the analysis of lysergamides LSD, MIPLA, and LAMPA.

Lysergic acid diethylamide (LSD) is a potent psychoactive substance that has attracted great interest in clinical research. As the pharmacological exploration of LSD analogs continues to grow, some of those analogs have appeared on the street market. Given that LSD analogs are uncontrolled in many jurisdictions, it is important that these analogs be differentiated from LSD. This report presents the analysis of blotters found to contain the N-methyl-N-isopropyl isomer of LSD (MIPLA), and techniques to differentiate it from LSD and the N-methyl-N-propyl isomer (LAMPA) under routine conditions. Gas chromatography (GC)-solid phase infrared spectroscopy was particularly helpful. GC-electron ionization-tandem mass spectrometry of the m/z 72 iminium ion also provided sufficient information to distinguish the three isomers on mass spectral grounds alone, where chromatographic separation proved challenging. Derivatization with 2,2,2-trifluoro-N,N-bis (trimethylsilyl)acetamide (BSTFA) also led to improved GC separation. Liquid chromatography single quadrupole mass spectrometry (LC-Q-MS) and in-source collision-induced dissociation allowed for the differentiation between MIPLA and LAMPA based on distinct m/z 239 ion ratios when co-eluting. An alternative LC-MS/MS method improved the separation between all three lysergamides, but LSD was found to co-elute with iso-LSD. However, a comparison of ion ratios recorded for transitions at m/z 324.2 > 223.2 and m/z 324.2 > 208.2 facilitated their differentiation. The analysis of two blotters by LC-Q-MS revealed the presence of 180 and 186 µg MIPLA per blotter. These procedures may be used to avoid inadvertent misidentification of MIPLA or LAMPA as LSD.

Post-operative ileus: definitions, mechanisms and controversies.

Post-operative ileus (POI) is a syndrome of impaired gastrointestinal transit which occurs following abdominal surgery. There are few effective targeted therapies for ileus, and research has been limited by inconsistent definitions and an incomplete understanding of the underlying pathophysiology. Despite considerable effort, there remains no widely-adopted definition of ileus, and recent work has identified variation in outcome reporting is a major source of heterogeneity in clinical trials. Outcomes should be clearly-defined, clinically-relevant, and reflective of the underlying biology, impacts on hospital resources and quality of life. Further collaborative efforts will be needed to develop consensus definitions and a core outcome set for postoperative gastrointestinal recovery. Investigation into the pathophysiology of POI has been hindered by use of low-resolution techniques and difficulties linking cellular mechanisms to dysmotility patterns and clinical symptoms. Recent evidence has suggested the common assumption of post-operative GI paralysis is incorrect, and that the distal colon becomes hyperactive following surgery. The post-operative inflammatory response is important in the pathophysiology of ileus, but the time course of this in humans remains unclear, with the majority of evidence coming from animal models. Future work should investigate dysmotility patterns underlying ileus, and identify biomarkers which may be used to diagnose, monitor and stratify patients with ileus.

Can aged biochar offset soil greenhouse gas emissions from crop residue amendments in saline and non-saline soils under laboratory conditions?

Applying biochar in association with crop residues might optimize costs and effectiveness in the reclamation of saline soils. Here, we explored the potential effects of biochar in association with crop residue amendments on soil greenhouse gas (GHG) emissions, and microbial communities. Previously, we found that soil N2O emission significantly increased with increasing salinity levels followed by cotton straw addition. In the present study, microcosm experiments were performed to investigate the interaction of salinity (0 and 1.2% salt) with the aging of biochar following soil amendments over an incubation period of 80 days. The results indicated that N2O emissions were approximately 5-10 times higher in saline soils than in non-saline soils, and the cumulative N2O emissions following two straw amendments treatment were the highest of all the treatments. Salinity increased the contribution of nitrification to soil N2O emissions stimulated by the cotton straw amendments, and aged biochar performed better in decreasing soil N2O emissions in saline soils than in non-saline soils. In addition, aged biochar increased soil C mineralization and CO2 emissions under saline conditions. Soil CO2 and N2O emissions were affected by both soil abiotic and biotic factors under non-saline and saline conditions. Moreover, much more specific but fewer microbial groups survived and utilized crop residues under saline than non-saline conditions, and aged biochar decreased salt stress in soil microorganisms. These findings indicated that aged biochar and crop residues together would be an optimal way to address soil C storage and mitigate N2O emissions under saline conditions.

Experiencing a virtual patient to practice patient counselling skills.

INTRODUCTION: Virtual patients (VPs) are a safe and standardised method of simulating clinical environments but few studies have explored health care professional's experiences of learning via a VP. This study explored how users experienced and used a VP that aimed to teach the user to deliver non-vitamin K oral anticoagulant patient education. METHODS: The study used semi-structured interviews with pharmacists and pre-registration trainees from a wider research study. Interview topics were based on key areas concerning VP use. Interviews were audio-recorded and transcribed verbatim before being analysed using the framework approach to thematic analysis. Ethical approval was granted by Keele University. RESULTS: There was variation in the type and nature of use of the VP and in the reported learning, which included reinforcement of knowledge, an opportunity to promote reflection, and acquisition and application of knowledge to clinical, patient-facing interactions. The VP was seen as an adjunct to other education and training. The majority of users indicated that they used the VP more than once. Some users seemed to have gamified their learning with a drive to achieve perfect feedback rather than true engagement with the learning, whereas for others the learning appeared to be deep with a reflective focus. CONCLUSIONS: The VP offered an educational use as experiential learning, although the users experienced the VP differently; commonly the VP facilitated learning via reinforcement of pre-existing knowledge. The users reported that the VP had value as an adjunct to other education and training resources.

Epidemiology of Mycobacterium abscessus in England: an observational study.

BACKGROUND: Mycobacterium abscessus has emerged as a significant clinical concern following reports that it is readily transmissible in health-care settings between patients with cystic fibrosis. We linked routinely collected whole-genome sequencing and health-care usage data with the aim of investigating the extent to which such transmission explains acquisition in patients with and without cystic fibrosis in England. METHODS: In this retrospective observational study, we analysed consecutive M abscessus whole-genome sequencing data from England (beginning of February, 2015, to Nov 14, 2019) to identify genomically similar isolates. Linkage to a national health-care usage database was used to investigate possible contacts between patients. Multivariable regression analysis was done to investigate factors associated with acquisition of a genomically clustered strain (genomic distance <25 single nucleotide polymorphisms [SNPs]). FINDINGS: 2297 isolates from 906 patients underwent whole-genome sequencing as part of the routine Public Health England diagnostic service. Of 14 genomic clusters containing isolates from ten or more patients, all but one contained patients with cystic fibrosis and patients without cystic fibrosis. Patients with cystic fibrosis were equally likely to have clustered isolates (258 [60%] of 431 patients) as those without cystic fibrosis (322 [63%] of 513 patients; p=0·38). High-density phylogenetic clusters were randomly distributed over a wide geographical area. Most isolates with a closest genetic neighbour consistent with potential transmission had no identifiable relevant epidemiological contacts. Having a clustered isolate was independently associated with increasing age (adjusted odds ratio 1·14 per 10 years, 95% CI 1·04-1·26), but not time spent as an hospital inpatient or outpatient. We identified two sibling pairs with cystic fibrosis with genetically highly divergent isolates and one pair with closely related isolates, and 25 uninfected presumed household contacts with cystic fibrosis. INTERPRETATION: Previously identified widely disseminated dominant clones of M abscessus are not restricted to patients with cystic fibrosis and occur in other chronic respiratory diseases. Although our analysis showed a small number of cases where person-to-person transmission could not be excluded, it did not support this being a major mechanism for M abscessus dissemination at a national level in England. Overall, these data should reassure patients and clinicians that the risk of acquisition from other patients in health-care settings is relatively low and motivate future research efforts to focus on identifying routes of acquisition outside of the cystic fibrosis health-care-associated niche. FUNDING: The National Institute for Health Research, Health Data Research UK, The Wellcome Trust, The Medical Research Council, and Public Health England.

Improving uptake of Fracture Prevention drug treatments: a protocol for Development of a consultation intervention (iFraP-D).

INTRODUCTION: Prevention of fragility fractures, a source of significant economic and personal burden, is hindered by poor uptake of fracture prevention medicines. Enhancing communication of scientific evidence and elicitation of patient medication-related beliefs has the potential to increase patient commitment to treatment. The Improving uptake of Fracture Prevention drug treatments (iFraP) programme aims to develop and evaluate a theoretically informed, complex intervention consisting of a computerised web-based decision support tool, training package and information resources, to facilitate informed decision-making about fracture prevention treatment, with a long-term aim of improving informed treatment adherence. This protocol focuses on the iFraP Development (iFraP-D) work. METHODS AND ANALYSIS: The approach to iFraP-D is informed by the Medical Research Council complex intervention development and evaluation framework and the three-step implementation of change model. The context for the study is UK fracture liaison services (FLS), which enact secondary fracture prevention. An evidence synthesis of clinical guidelines and Delphi exercise will be conducted to identify content for the intervention. Focus groups with patients, FLS clinicians and general practitioners and a usual care survey will facilitate understanding of current practice, and investigate barriers and facilitators to change. Design of the iFraP intervention will be informed by decision aid development standards and theories of implementation, behaviour change, acceptability and medicines adherence. The principles of co-design will underpin all elements of the study through a dedicated iFraP community of practice including key stakeholders and patient advisory groups. In-practice testing of the prototype intervention will inform revisions ready for further testing in a subsequent pilot and feasibility randomised trial. ETHICS AND DISSEMINATION: Ethical approval was obtained from North West-Greater Manchester West Research Ethics Committee (19/NW/0559). Dissemination and knowledge mobilisation will be facilitated through national bodies and networks, publications and presentations. TRIAL REGISTRATION NUMBER: researchregistry5041.

Impact of the introduction of falls risk assessment toolkit on falls prevention and psychotropic medicines' utilisation in Walsall: an interrupted time series analysis.

OBJECTIVE: To determine the impact of the introduction of a falls risk assessment toolkit (FRAT) in a UK medical centre on the number and cost of non-elective admissions for falls and psychotropic medication utilisation. DESIGN: Interrupted time series analysis quantifying the number and cost of non-elective admissions for falls and primary care use data for Rushall Medical Centre before and after the implementation of FRAT at July 2017. SETTING: Data on the monthly number and cost of non-elective admissions for falls and number of referrals and assessment to the falls service were provided by Walsall Clinical Commissioning Group. Primary care prescribing cost and volume data for Rushall Medical Centre was derived from the Openprescribing.net website for prescriptions dispensed between April 2015 and November 2018. PRIMARY AND SECONDARY OUTCOME MEASURES: The number and cost of non-elective admissions for falls and number of referrals and assessment to the falls service, and the volume of utilisation of psychotropic medicines. RESULTS: Following the implementation of FRAT at Rushall Medical Centre in July 2017, the number of non-elective admissions for falls decreased at a rate of 0.414 admissions per month (p<0.033, 95% CI -0.796 to -0.032). The utilisation of psychotropic medications (alimemazine, citalopram, escitalopram, fluoxetine, mirtazapine, olanzapine and risperidone) decreased. The expenditure on psychotropic medications prescribed/used at Rushall Medical Centre decreased by at least £986 per month (p<0.001, 95% CI -2067 to -986). CONCLUSIONS: The implementation of FRAT at Rushall Medical Centre was associated with a reduction in the number of non-elective admissions for falls. Assessment of these patients together with deprescribing of psychotropic medications resulted in a reduction in the number of non-elective admissions for falls and associated costs.

Non-invasive, vagus nerve stimulation to reduce ileus after colorectal surgery: protocol for a feasibility trial with nested mechanistic studies.

INTRODUCTION: Ileus is a common and distressing condition characterised by gut dysfunction after surgery. While a number of interventions have aimed to curtail its impact on patients and healthcare systems, ileus is still an unmet challenge. Electrical stimulation of the vagus nerve is a promising new treatment due to its role in modulating the neuro-immune axis through a novel anti-inflammatory reflex. The protocol for a feasibility study of non-invasive vagus nerve stimulation (nVNS), and a programme of mechanistic and qualitative studies, is described. METHODS AND ANALYSIS: This is a participant-blinded, parallel-group, randomised, sham-controlled feasibility trial (IDEAL Stage 2b) of self-administered nVNS. One hundred forty patients planned for elective, minimally invasive, colorectal surgery will be randomised to four schedules of nVNS before and after surgery. Feasibility outcomes include assessments of recruitment and attrition, adequacy of blinding and compliance to the intervention. Clinical outcomes include bowel function and length of hospital stay. A series of mechanistic substudies exploring the impact of nVNS on inflammation and bowel motility will inform the design of the final stimulation schedule. Semistructured interviews with participants will explore experiences and perceptions of the intervention, while interviews with patients who decline participation will explore barriers to recruitment. ETHICS AND DISSEMINATION: The protocol has been approved by the Tyne and Wear South National Health Service (NHS) Research Ethics Committee (19/NE/0217) on 2 July 2019. Feasibility, mechanistic and qualitative findings will be disseminated to national and international partners through peer-reviewed publications, academic conferences, social media channels and stakeholder engagement activities. The findings will build a case for or against progression to a definitive randomised assessment as well as informing key elements of study design. TRIAL REGISTRATION NUMBER: ISRCTN62033341.

Shared Decision-Making With a Virtual Patient in Medical Education: Mixed Methods Evaluation Study.

BACKGROUND: Shared decision-making (SDM) is a process in which clinicians and patients work together to select tests, treatments, management, or support packages based on clinical evidence and the patient's informed preferences. Similar to any skill, SDM requires practice to improve. Virtual patients (VPs) are simulations that allow one to practice a variety of clinical skills, including communication. VPs can be used to help professionals and students practice communication skills required to engage in SDM; however, this specific focus has not received much attention within the literature. A multiple-choice VP was developed to allow students the opportunity to practice SDM. To interact with the VP, users chose what they wanted to say to the VP by choosing from multiple predefined options, rather than typing in what they wanted to say. OBJECTIVE: This study aims to evaluate a VP workshop for medical students aimed at developing the communication skills required for SDM. METHODS: Preintervention and postintervention questionnaires were administered, followed by semistructured interviews. The questionnaires provided cohort-level data on the participants' views of the VP and helped to inform the interview guide; the interviews were used to explore some of the data from the questionnaire in more depth, including the participants' experience of using the VP. RESULTS: The interviews and questionnaires suggested that the VP was enjoyable and easy to use. When the participants were asked to rank their priorities in both pre- and post-VP consultations, there was a change in the rank position of respecting patient choices, with the median rank changing from second to first. Owing to the small sample size, this was not analyzed for statistical significance. The VP allowed the participants to explore a consultation in a way that they could not with simulated or real patients, which may be part of the reason that the VP was suggested as a useful intervention for bridging from the early, theory-focused years of the curriculum to the more patient-focused ones later. CONCLUSIONS: The VP was well accepted by the participants. The multiple-choice system of interaction was reported to be both useful and restrictive. Future work should look at further developing the mode of interaction and explore whether the VP results in any changes in observed behavior or practice.