The Veteran Friendly Practice accreditation programme: a mixed-methods evaluation.

BACKGROUND: The Royal College of General Practitioners (RCGP) Veteran Friendly Practice Accreditation Programme launched in 2019, aiming to allow practices to better identify, treat, and refer veterans, where appropriate, to dedicated NHS services. AIM: To evaluate the effectiveness of the accreditation programme, focusing on benefits for the veteran, the practice, and the delivery of the programme itself. DESIGN & SETTING: The study evaluated the views of veteran-friendly accredited GP practices across England. METHOD: A mixed-methods study was undertaken, which collected data via an online survey from 232 accredited primary healthcare (PHC) staff and 15 semi-structured interviews with PHC veteran leads. Interviews were analysed using modified grounded theory. RESULTS: The study found 99% (n = 228) of responders would recommend the programme, 78% (n = 180) reported improved awareness, and 84% (n = 193) a better understanding of veterans' needs. Seventy-two per cent (n = 166) identified benefits for veterans who were engaging more with PHC but participants felt more time was needed, largely owing to the COVID-19 pandemic, to fully assess the impact of the programme on help-seeking behaviour. Challenges included identifying veterans already registered, promoting the accreditation process, and ensuring all PHC staff were kept up to date with veteran issues. CONCLUSION: The programme has increased signposting to veteran-specific services and resulted in greater understanding of the NHS priority referral criteria for veterans. Recording of veteran status has improved and there was evidence of a better medical record coding system in PHC practices. These findings add to the limited empirical evidence exploring veteran engagement in PHC, and demonstrate how accreditation results in better treatment and identification of veterans.

UK military veteran-friendly GP practices.

About 5% of the UK population are military veterans and have specific medical needs sometimes different from the general population. Veterans may be reluctant to seek help or talk about their problems, which means they do not always access care, support and treatments that are available. Others may face difficulty getting the right help. Veterans may think 'civilians' do not understand military culture or know about options for help and services that are available. Experience has shown that general practitioners (GPs) would like more help and support when looking after veterans. The Royal College of General Practitioners has developed the 'Veteran Friendly GP Practice Accreditation Programme', which involves a simple online process of accreditation where practices are required to meet the specified criteria and provide evidence that they are supportive of veterans' healthcare. The aim is to improve healthcare provided to veterans and their families by GPs working in primary healthcare.

Chemical Imaging of Human Fingermark by X-ray Photoelectron Spectroscopy (XPS).

X-ray photoelectron spectroscopy (XPS) is a widely used technique to characterize the surface chemistry of materials. It plays a crucial role in accessing qualitative and quantitative information and in detecting the presence of chemical functional groups on the surface of any material. The forensic methods available to detect and identify elements and organic/inorganic compounds are often destructive, so evidence cannot be re-analyzed. However, XPS allows rapid analysis of samples without damaging them. Recently, an increasing number of forensic researchers have begun to study certain chemical information on fingermarks. In this study, the authors aimed to present the applicability and power of XPS imaging in fingermark analysis which can also provide specific information about the fingermark chemical composition. Herein, monochromated X-ray (Al Kα) spot size was fixed at 50 µm. XPS mapping resulted in the acquisition of spectra at each pixel, in an array of 41 × 30 pixels with a step size of 50 µm. Then, a simple discussion has been made about how the scanned surface spectrum and basic snapshot spectra are used to identify different components at a fingertip of a scanned surface area (~3 mm2 ). Hence, a fingermark pattern contaminated with caffeine, TiO2 , and Pb/PbO deposited on the silicon wafer can be chemically mapped and visualized by XPS using principal component analysis (PCA). Thus, the present study showed the possible applicability of XPS for the identification of illicit drugs of abuse, gunshot residue, and skin care products on latent fingermark by mimicking a crime scene evidence.

Educating nurses to deliver optimum care to military veterans and their families.

The aim of the project was to help prepare the future nursing workforce to provide optimum care for the Armed Forces Community. Structured evidenced-based educational sessions were designed and then delivered at two Universities in England. This educational model included a flipped approach, didactic classroom teaching, blended learning, and information technology. Educational sessions were provided to 468 first year Bachelor of Nursing undergraduate students in 2017 and 2018. A mixed methods evaluation included a quasi-experiential design with pre and post-test data followed by research interviews conducted by student nurses and analysed using a modified Grounded Theory. Post session evaluation demonstrated a significant improvement in students' knowledge. 93% agreed that the training was useful, 95% felt that nurses should be aware of the healthcare needs of the Armed Forces Community, and 89% indicated that the subject matter should be included in the undergraduate curriculum. A qualitative theoretical model was built from four major clusters: the military community; student's identity, clinical engagement, and future practice. These educational sessions are being introduced into a growing number of United Kingdom Universities to create future nursing leaders with a better insight into the large and diverse Armed Forces Community.

Finding the Forgotten: Motivating Military Veterans to Register with a Primary Healthcare Practice.

Introduction: In the UK, primary healthcare practices choose from a series of Read codes to detail certain characteristics onto a patient's medical documentation. One of these codes is for military veterans indicating a history relating to military service. However, veterans are poor at seeking help, with research indicating that this code is only applied in 7.9% of cases. Clinical staff have a clear role in motivating veterans to declare their ex-Forces status or register with a primary healthcare center. The aim of this study was to motivate veterans to notify primary healthcare staff of their armed forces status or register with a general practitioner, and to improve primary healthcare staff's understanding of veterans' health and social care issues. Materials and Methods: Data were provided by four primary healthcare centers' containing 40,470 patients in Lancashire, England during 2017. Pre- and post-patient medical record Read Code searches were conducted either side of a 6-wk intervention period centered on an advertising campaign. The data identified those veterans with the military specific Read code attached to their medical record and their age, gender, marital status and mental health disorders. Further information was gathered from interviews with eight members of staff, some of whom had completed an e-learning veteran healthcare academic module. The study was approved by the University of Chester's Research Ethics Committee. Results: The pre-intervention search indicated that 8.7% (N = 180) of veterans were registered and had the correct military specific code applied to their medical record. Post-intervention, this figure increased by nearly 200% to N = 537. Mental health disorders were present in 28% (N = 152) of cases, including 15% (N = 78) with depression. Interviews revealed the primary healthcare staff's interpretation of the factors that motivated patients to declare their ex-Forces status and the key areas for development. Conclusion: The primary healthcare staff took ownership and responsibility for this initiative. They were creative in introducing new ways of engaging with the local armed forces community. Many veterans' and staff were unaware of veterans' entitlement to priority medical services, or the wider provisions available to them. It is probable that veterans declaring their military status within primary healthcare, or registering with a general practitioner for the first time is likely to increase. Another review will be undertaken after 12 mo, which will provide a better indication of success. There remains however an ongoing need to reach out to those veterans who never access a primary healthcare practice. This paper adds to the limited international empirical evidence undertaken to explore help-seeking behavior in an armed forces community. The positive outcomes of increased awareness and staff commitment provide a template for improvement across the UK, and will potentially stimulate similar initiatives with international colleagues.

Characterizing the outcomes of metastatic papillary renal cell carcinoma.

Outcomes of metastatic papillary renal cell carcinoma (pRCC) patients are poorly characterized in the era of targeted therapy. A total of 5474 patients with metastatic renal cell carcinoma (mRCC) in the International mRCC Database Consortium (IMDC) were retrospectively analyzed. Outcomes were compared between clear cell (ccRCC; n = 5008) and papillary patients (n = 466), and recorded type I and type II papillary patients (n = 30 and n = 165, respectively). Overall survival (OS), progression-free survival (PFS), and overall response rate (ORR) favored ccRCC over pRCC. OS was 8 months longer in ccRCC patients and the hazard ratio of death was 0.71 for ccRCC patients. No differences in PFS or ORR were detected between type I and II PRCC in this limited dataset. The median OS for type I pRCC was 20.0 months while the median OS for type II was 12.6 months (P = 0.096). The IMDC prognostic model was able to stratify pRCC patients into favorable risk (OS = 34.1 months), intermediate risk (OS = 17.0 months), and poor-risk groups (OS = 6.0 months). pRCC patient outcomes were inferior to ccRCC, even after controlling for IMDC prognostic factors. The IMDC prognostic model was able to effectively stratify pRCC patients.

Advanced processing and simulation of MRS data using the FID appliance (FID-A)-An open source, MATLAB-based toolkit.

PURPOSE: To introduce a new toolkit for simulation and processing of magnetic resonance spectroscopy (MRS) data, and to demonstrate some of its novel features. METHODS: The FID appliance (FID-A) is an open-source, MATLAB-based software toolkit for simulation and processing of MRS data. The software is designed specifically for processing data with multiple dimensions (eg, multiple radiofrequency channels, averages, spectral editing dimensions). It is equipped with functions for importing data in the formats of most major MRI vendors (eg, Siemens, Philips, GE, Agilent) and for exporting data into the formats of several common processing software packages (eg, LCModel, jMRUI, Tarquin). This paper introduces the FID-A software toolkit and uses examples to demonstrate its novel features, namely 1) the use of a spectral registration algorithm to carry out useful processing routines automatically, 2) automatic detection and removal of motion-corrupted scans, and 3) the ability to perform several major aspects of the MRS computational workflow from a single piece of software. This latter feature is illustrated through both high-level processing of in vivo GABA-edited MEGA-PRESS MRS data, as well as detailed quantum mechanical simulations to generate an accurate LCModel basis set for analysis of the same data. RESULTS: All of the described processing steps resulted in a marked improvement in spectral quality compared with unprocessed data. Fitting of MEGA-PRESS data using a customized basis set resulted in improved fitting accuracy compared with a generic MEGA-PRESS basis set. CONCLUSIONS: The FID-A software toolkit enables high-level processing of MRS data and accurate simulation of in vivo MRS experiments. Magn Reson Med 77:23-33, 2017. © 2015 Wiley Periodicals, Inc.

Feasibility of cardiovascular magnetic resonance derived coronary wave intensity analysis.

BACKGROUND: Wave intensity analysis (WIA) of the coronary arteries allows description of the predominant mechanisms influencing coronary flow over the cardiac cycle. The data are traditionally derived from pressure and velocity changes measured invasively in the coronary artery. Cardiovascular magnetic resonance (CMR) allows measurement of coronary velocities using phase velocity mapping and derivation of central aortic pressure from aortic distension. We assessed the feasibility of WIA of the coronary arteries using CMR and compared this to invasive data. METHODS: CMR scans were undertaken in a serial cohort of patients who had undergone invasive WIA. Velocity maps were acquired in the proximal left anterior descending and proximal right coronary artery using a retrospectively-gated breath-hold spiral phase velocity mapping sequence with high temporal resolution (19 ms). A breath-hold segmented gradient echo sequence was used to acquire through-plane cross sectional area changes in the proximal ascending aorta which were used as a surrogate of an aortic pressure waveform after calibration with brachial blood pressure measured with a sphygmomanometer. CMR-derived aortic pressures and CMR-measured velocities were used to derive wave intensity. The CMR-derived wave intensities were compared to invasive data in 12 coronary arteries (8 left, 4 right). Waves were presented as absolute values and as a % of total wave intensity. Intra-study reproducibility of invasive and non-invasive WIA was assessed using Bland-Altman analysis and the intraclass correlation coefficient (ICC). RESULTS: The combination of the CMR-derived pressure and velocity data produced the expected pattern of forward and backward compression and expansion waves. The intra-study reproducibility of the CMR derived wave intensities as a % of the total wave intensity (mean ± standard deviation of differences) was 0.0 ± 6.8%, ICC = 0.91. Intra-study reproducibility for the corresponding invasive data was 0.0 ± 4.4%, ICC = 0.96. The invasive and CMR studies showed reasonable correlation (r = 0.73) with a mean difference of 0.0 ± 11.5%. CONCLUSION: This proof of concept study demonstrated that CMR may be used to perform coronary WIA non-invasively with reasonable reproducibility compared to invasive WIA. The technique potentially allows WIA to be performed in a wider range of patients and pathologies than those who can be studied invasively.

Acquisition of 3D temperature distributions in fluid flow using proton resonance frequency thermometry.

PURPOSE: Proton resonance frequency thermometry is well established for monitoring small temperature changes in tissue. Application of the technique to the measurement of complex temperature distributions within fluid flow is of great interest to the engineering community and could also have medical applications. This work presents an experimental approach to reliably measure three-dimensional (3D) temperature fields in fluid flow using proton resonance frequency thermometry. METHODS: A velocity-compensated three-dimensional gradient echo sequence was used. A flexible pumping system was attached to an MR compatible double pipe heat exchanger. The temperature of two separate flow circuits could be adjusted to produce various three-dimensional spatial temperature distributions within the fluid flow. Validation was performed using MR compatible temperature probes in a uniformly heated flow. A comparative study was conducted with thermocouples in the presence of a spatially varying temperature distribution. RESULTS: In uniformly heated flow, temperature changes were accurately measured to within 0.5 K using proton resonance frequency thermometry, while spatially varying temperature changes measured with MR showed good qualitative agreement with pointwise measurements using thermocouples. CONCLUSION: Proton resonance frequency thermometry can be used in a variety of complex flow situations to address medical as well as engineering questions. This work makes it possible to gain new insights into fundamental heat transfer phenomena. Magn Reson Med 76:145-155, 2016. © 2015 Wiley Periodicals, Inc.

Validation of high temporal resolution spiral phase velocity mapping of temporal patterns of left and right coronary artery blood flow against Doppler guidewire.

BACKGROUND: Temporal patterns of coronary blood flow velocity can provide important information on disease state and are currently assessed invasively using a Doppler guidewire. A non-invasive alternative would be beneficial as it would allow study of a wider patient population and serial scanning. METHODS: A retrospectively-gated breath-hold spiral phase velocity mapping sequence (TR 19 ms) was developed at 3 Tesla. Velocity maps were acquired in 8 proximal right and 15 proximal left coronary arteries of 18 subjects who had previously had a Doppler guidewire study at the time of coronary angiography. Cardiovascular magnetic resonance (CMR) velocity-time curves were processed semi-automatically and compared with corresponding invasive Doppler data. RESULTS: When corrected for differences in heart rate between the two studies, CMR mean velocity through the cardiac cycle, peak systolic velocity (PSV) and peak diastolic velocity (PDV) were approximately 40 % of the peak Doppler values with a moderate - good linear relationship between the two techniques (R(2): 0.57, 0.64 and 0.79 respectively). CMR values of PDV/PSV showed a strong linear relationship with Doppler values with a slope close to unity (0.89 and 0.90 for right and left arteries respectively). In individual vessels, plots of CMR velocities at all cardiac phases against corresponding Doppler velocities showed a consistent linear relationship between the two with high R(2) values (mean +/-SD: 0.79 +/-.13). CONCLUSIONS: High temporal resolution breath-hold spiral phase velocity mapping underestimates absolute values of coronary flow velocity but allows accurate assessment of the temporal patterns of blood flow.

The use of child actors to simulate paediatric patients in the MRCGP Clinical Skills Assessment (CSA): developing an effective model.

Role-player consistency between candidates is a crucial component of the reliability of the Objective Structured Clinical Examination (OSCE) format used for clinical skills assessment (CSA). It is particularly important in a high-stakes licensing assessment such as the Membership of the Royal College of General Practitioners' (MRCGP's) CSA. The current organisation of the CSA examination poses particular challenges for child actors. The stringent licensing process for child actors limits the working hours of children aged under 13 years considerably, making it impossible for them to perform in both the morning and afternoon circuits on examination days. Children aged nine years or younger are not able to complete even a single morning or afternoon circuit. Younger children also appear disproportionately to become fatigued and less consistent with time. All children require significant support from their adult role-player parent. Careful piloting has allowed us to develop a solution which requires the use of natural pairs of adult and child role players in two teams for the morning and afternoon circuits. A new process for training and calibrating the children the day before their performance in addition to calibration on the day appears to improve the consistency of their performance. The aim of this paper is to describe the action research-based cycle through which we developed our training procedures for child actors for the MRCGP CSA. We believe, given the challenges we have outlined, our experience will be of interest to all educators involved in the CSA process.

Inter-study reproducibility of interleaved spiral phase velocity mapping of renal artery haemodynamics.

BACKGROUND: Qualitative and quantitative assessment of renal blood flow is valuable in the evaluation of patients with renal and renovascular diseases as well as in patients with heart failure. The temporal pattern of renal flow velocity through the cardiac cycle provides important information about renal haemodynamics. High temporal resolution interleaved spiral phase velocity mapping could potentially be used to study temporal patterns of flow and measure resistive and pulsatility indices which are measures of downstream resistance. METHODS: A retrospectively gated breath-hold spiral phase velocity mapping sequence (TR 19 ms) was developed at 3 Tesla. Phase velocity maps were acquired in the proximal right and left arteries of 10 healthy subjects in each of two separate scanning sessions. Each acquisition was analysed by two independent observers who calculated the resistive index (RI), the pulsatility index (PI), the mean flow velocity and the renal artery blood flow (RABF). Inter-study and inter-observer reproducibility of each variable was determined as the mean +/- standard deviation of the differences between paired values. The effect of background phase errors on each parameter was investigated. RESULTS: RI, PI, mean velocity and RABF per kidney were 0.71+/- 0.06, 1.47 +/- 0.29, 253.5 +/- 65.2 mm/s and 413 +/- 122 ml/min respectively. The inter-study reproducibilities were: RI -0.00 +/- 0.04 , PI -0.03 +/- 0.17, mean velocity -6.7 +/- 31.1 mm/s and RABF per kidney 17.9 +/- 44.8 ml/min. The effect of background phase errors was negligible (<2% for each parameter). CONCLUSIONS: High temporal resolution breath-hold spiral phase velocity mapping allows reproducible assessment of renal pulsatility indices and RABF.

The General Practitioner and the military veteran.

OBJECTIVES: To assess the knowledge of members of the Royal College of General Practitioners (RCGP) on veteran's health issues, assess present support, and establish what support is required for GPs when treating veterans. METHODS: An electronic survey of RCGP members across selected faculties. RESULTS: Forty-seven per cent of respondents were 'unsure' or 'didn't know' how many veterans they were responsible for. However, many GPs replied that they had seen a veteran in the last month. Only 7.9% of respondents used the unique Read Code for veterans. Disappointingly, 75% of GPs indicated that they had not seen the RCGP leaflet on veterans' health, and less than 2% had used the RCGP On-Line e-learning resource. CONCLUSIONS: Surveyed GPs had little understanding of how many veterans were registered with their practice, and only a few had accessed learning resources available. GPs requested more information on how to assess veterans and where they could be referred. Further work is required to identify the true size of the problem, while continuing to provide proactive guidance and support to GPs on the health needs of veterans.

Performance in the MRCGP CSA by candidates' gender: differences according to curriculum area.

BACKGROUND AND AIMS: Differences in performance between male and female candidates in the CSA exam have been reported. This study aimed to consider this in more detail, looking at gender performance overall, and to check if there are particular task domains or curriculum topic areas where male and female doctors score differently. METHOD: Routinely collected data were analysed, enabling detailed comparison of gender performance across 92 989 consecutive encounters, which were examined for any overall impact of candidate gender, and sub-analysed by assessment domain, and by curriculum area. Significance of differences was calculated by analysis of variance. RESULTS: Female GP trainees outperform their male peers in the CSA overall, in each assessment domain and in every curriculum area. The difference in performance is most marked in the areas of women's health and sexual health and least marked in cardiovascular problems and rheumatology and musculoskeletal. CONCLUSIONS: These findings have implications for GP trainees and trainers when planning educational activities and opportunities. As well as prioritising the development of consultation skills, consideration needs to be given to the case mix presented to trainees, especially in light of the changing role of the doctor within practices and the composition of training programmes.

The presentation of depression in the British Army.

BACKGROUND: The British Army is predominately composed of young men, often from disadvantaged backgrounds, in which Depression is a common mental health disorder. OBJECTIVES: To construct a predictive model detailing the presentation of depression in the army that could be utilised as an educational and clinical guideline for Army clinical personnel. METHOD AND PARTICIPANTS: Utilising a Constructivist Grounded Theory, phase 1 consisted of 19 interviews with experienced Army mental health clinicians. Phase 2 was a validation exercise conducted with 3 general practitioners. RESULTS: Depression in the Army correlates poorly with civilian definitions, and has a unique interpretation. CONCLUSION: Young soldiers presented with symptoms not in the International Classification of Disorders and older soldiers who feared being medically downgraded, sought help outside the Army Medical Services. Women found it easier to seek support, but many were inappropriately labelled as depressed. Implications include a need to address the poor understanding of military stressors; their relationships to depressive symptoms and raise higher awareness of gender imbalances with regard to access and treatment. The results have international implications for other Armed forces, and those employed in Young Men's Mental Health. The results are presented as a simple predictive model and aide memoire that can be utilised as an educational and clinical guideline. There is scope to adapt this model to international civilian healthcare practice.

Spiral tissue phase velocity mapping in a breath-hold with non-cartesian SENSE.

PURPOSE: Tissue phase velocity mapping (TPVM) is capable of reproducibly measuring regional myocardial velocities. However acquisition durations of navigator gated techniques are long and unpredictable while current breath-hold techniques have low temporal resolution. This study presents a spiral TPVM technique which acquires high resolution data within a clinically acceptable breath-hold duration. METHODS: Ten healthy volunteers are scanned using a spiral sequence with temporal resolution of 24 ms and spatial resolution of 1.7 × 1.7 mm. Retrospective cardiac gating is used to acquire data over the entire cardiac cycle. The acquisition is accelerated by factors of 2 and 3 by use of non-Cartesian SENSE implemented on the Gadgetron GPU system resulting in breath-holds of 17 and 13 heartbeats, respectively. Systolic, early diastolic, and atrial systolic global and regional longitudinal, circumferential, and radial velocities are determined. RESULTS: Global and regional velocities agree well with those previously reported. The two acceleration factors show no significant differences for any quantitative parameter and the results also closely match previously acquired higher spatial resolution navigator-gated data in the same subjects. CONCLUSION: By using spiral trajectories and non-Cartesian SENSE high resolution, TPVM data can be acquired within a clinically acceptable breath-hold.

Medical management of Captured Persons.

In most conflicts there is the potential that there will be Captured Persons (CPERS) whose medical care is the responsibility of the capturing army. The standard of this care should be to the same standard as that afforded to one's own troops. However the medical practicalities of maintaining such standards can be difficult. This article reviews the practicalities of the medical care of CPERS as part of the UK deployment in Afghanistan on Operation HERRICK.

Efficient and reproducible high resolution spiral myocardial phase velocity mapping of the entire cardiac cycle.

BACKGROUND: Three-directional phase velocity mapping (PVM) is capable of measuring longitudinal, radial and circumferential regional myocardial velocities. Current techniques use Cartesian k-space coverage and navigator-gated high spatial and high temporal resolution acquisitions are long. In addition, prospective ECG-gating means that analysis of the full cardiac cycle is not possible. The aim of this study is to develop a high temporal and high spatial resolution PVM technique using efficient spiral k-space coverage and retrospective ECG-gating. Detailed analysis of regional motion over the entire cardiac cycle, including atrial systole for the first time using MR, is presented in 10 healthy volunteers together with a comprehensive assessment of reproducibility. METHODS: A navigator-gated high temporal (21 ms) and spatial (1.4 × 1.4 mm) resolution spiral PVM sequence was developed, acquiring three-directional velocities in 53 heartbeats (100% respiratory-gating efficiency). Basal, mid and apical short-axis slices were acquired in 10 healthy volunteers on two occasions. Regional and transmural early systolic, early diastolic and atrial systolic peak longitudinal, radial and circumferential velocities were measured, together with the times to those peaks (TTPs). Reproducibilities were determined as mean ± SD of the signed differences between measurements made from acquisitions performed on the two days. RESULTS: All slices were acquired in all volunteers on both occasions with good image quality. The high temporal resolution allowed consistent detection of fine features of motion, while the high spatial resolution allowed the detection of statistically significant regional and transmural differences in motion. Colour plots showing the regional variations in velocity over the entire cardiac cycle enable rapid interpretation of the regional motion within any given slice. The reproducibility of peak velocities was high with the reproducibility of early systolic, early diastolic and atrial systolic peak radial velocities in the mid slice (for example) being -0.01 ± 0.36, 0.20 ± 0.56 and 0.14 ± 0.42 cm/s respectively. Reproducibility of the corresponding TTP values, when normalised to a fixed systolic and diastolic length, was also high (-13.8 ± 27.4, 1.3 ± 21.3 and 3.0 ± 10.9 ms for early systolic, early diastolic and atrial systolic respectively). CONCLUSIONS: Retrospectively gated spiral PVM is an efficient and reproducible method of acquiring 3-directional, high resolution velocity data throughout the entire cardiac cycle, including atrial systole.