Effects of exercise mode and intensity on patient-reported outcomes in cancer survivors: a four-arm intervention trial.

PURPOSE: The aim of this study was to compare the effects of different exercise modes (aerobic, resistance) and intensity prescriptions (standard, polarized, undulating) on patient-reported outcomes (PROs) in cancer survivors. METHODS: 107 breast or prostate cancer survivors (52% females, age 58 ± 10 years, 6-52 weeks after primary therapy) performed one out of four training programs, two sessions/week, over 12 weeks: work rate-matched vigorous intensity aerobic training (ATStandard, n = 28) and polarized intensity aerobic training (ATPolarized, n = 26) as well as volume-matched moderate intensity resistance training (RTStandard, n = 26) and daily undulating intensity resistance training (RTUndulating, n = 27). Health-related quality of life (HRQoL, EORTC-QLQ-C30) and cancer-related fatigue (CRF, MFI-20) were assessed at baseline, at the end of intervention and after a 12-week follow-up without further prescribed exercise. RESULTS: Over the intervention period, HRQoL-function-scales of the EORTC-QLQ-C30 improved over time (p = .007), but no group*time interaction was observed (p = .185). Similarly, CRF values of the MFI-20 improved over time (p = .006), but no group*time interaction was observed (p = .663). When including the follow-up period and pooling the AT and the RT groups, HRQoL-function-scales developed differently between groups (p = .022) with further improvements in RT and a decline in AT. For CRF no significant interaction was found, but univariate analyses showed a non-significant trend of more sustainable effects in RT. CONCLUSIONS: AT and RT with different work rate-/volume-matched intensity prescriptions elicits positive effects on HRQoL and CRF, without one regimen being significantly superior to another over the intervention period. However, RT might result in more sustainable effects compared to AT over a follow-up period without any further exercise prescription. CLINICAL TRIAL REGISTRATION: The study was registered at clinicaltrials.gov (NCT02883699).

Diagnosis of Skin Disease in Moderately to Highly Pigmented Skin by Artificial Intelligence.

BACKGROUND: Triage of patients with skin diseases often includes an initial assessment by a nurse or general practitioner, followed by a dermatologist. Artificial intelligence (AI) systems have been reported to improve clinician ability to diagnose and triage skin conditions. Previous studies have also shown that diagnosis in patients with skin of color can be more challenging. PURPOSE: This study seeks to determine the performance of AI in the screening and triage of benign-neoplastic, malignant-neoplastic, and non-neoplastic skin conditions for Fitzpatrick skin types IV-VI. METHODS: A set of 163 non-standardized clinical photographs of skin disease manifestations from patients with Fitzpatrick skin types IV-VI were obtained through a publicly available dataset (Scale AI and MIT Research Lab, “Fitzpatrick 17 Dataset”). All photos were diagnosed by a specialist and categorized into three disease classes: benign-neoplastic, malignant-neoplastic, or non-neoplastic. There were 23, 14, and 122 cases of each disease class, respectively. RESULTS: Overall, the AI was able to classify the disease classes with a high degree of accuracy for the Top 1 diagnosis (86.50%). Based on its first prediction, the AI demonstrated the greatest accuracy when classifying non-neoplastic conditions (90.98%), high accuracy in detecting malignant-neoplastic conditions (77.78%), and moderate accuracy of classifying benign-neoplastic conditions (69.57%). CONCLUSION: The AI had an overall accuracy of 86.50% in diagnosing skin disease in Fitzpatrick skin types IV to VI. This is an improvement over reported clinician diagnostic accuracy of 44.3% in darker skin types. Incorporating AI into front-line screening of skin conditions could thereby assist in patient triage and shorten the time to accurate diagnosis. Schneider LG, Mamelak AJ, Tejani I, et al. Diagnosis of skin disease in moderately to highly pigmented skin by artificial intelligence. J Drugs Dermatol. 2023;22(7):647-652. doi:10.36849/JDD.7581.

The arts in dementia: instrumental and experiential perspectives.

The indirect experience of dementia mediated through the arts shapes our preconceptions, educating us to understand dementia, gaining a deeper appreciation of how it may affect an individual. By contrast dementia research has largely regarded the arts through an 'instrumental' lens. They are treated as complex psychosocial interventions. Evidence from research on the arts and dementia remains piecemeal because most studies are small and not all are well designed. For numerous reasons the arts warrant further evaluation and investigation in relation to their potential impact on people with dementia. That research needs to be better-designed and adequately funded if it is to advance knowledge in this field. This is fraught with difficulties: the arts are dynamic and interactive; the medium (intervention) can be affected unpredictably by those people who engage with it. Many creative activities are deliberately participatory; think of group singing or stand-up comedy. The influence of human variability in relation to arts interventions means that large studies are necessary to control for individual differences. Moreover, few studies of the arts in dementia have been designed adequately to account for the intra-group interaction that is characteristic of many arts activities. Then, there is a lack of clarity around the purpose of the arts in dementia. There is scope for the development and adoption of comprehensive theoretical frameworks to guide research into the arts and dementia. This editorial sets out to clarify some aspects of the arts in dementia in order to pave way for further work.

Dependence of Water-equivalent Diameter and Size-specific Dose Estimates on CT Tube Potential.

Background The size-specific dose estimate (SSDE) is a patient-focused CT dose metric. However, published size-dependent conversion factors (fsize) used to calculate SSDE were determined primarily by using phantoms; only eight to 15 patient data sets were used, all at 120 kV. Purpose To determine the effect of different tube potentials on the water-equivalent diameter (WED) and SSDE for patient CT scans of the head, chest, and abdomen. Materials and Methods This retrospective study used 250 noncontrast CT scans acquired between March 2013 and June 2017. Bony structures were segmented, and their CT numbers were modified to reflect bone attenuation at 70, 90, 110, 130, and 150 kV. Soft-tissue CT numbers were unchanged because of negligible energy dependence. fsize was measured in anthropomorphic phantoms for each tube potential and fit to an exponential function. WED and SSDE were determined for each patient at all tube potentials, regression analysis was performed relative to the WED and SSDE at 120 kV, and mean differences relative to 120 kV were calculated. Results In 250 patients (median age, 21.5 years; interquartile range, 44 years; 130 women), WED for all tube potentials was linearly related to the WED at 120 kV in all body regions (R2 = 0.995-1.000). The effect of tube potential on WED was negligible for torso examinations (Cohen d < 0.05). In the head, a medium effect size was observed at 70 kV; however, the mean absolute difference in WED was small (-0.49 cm ± 0.08 [standard deviation]; P < .001). For commonly used combinations of tube potential and patient size, the mean differences in SSDE at alternative tube potentials relative to SSDE at 120 kV were less than 5%. Conclusion At noncontrast CT, published size-dependent conversion factors accurately determined size-specific dose estimates on 250 patient scans at five tube potentials other than 120 kV. © RSNA, 2022 Online supplemental material is available for this article. See also the editorial by Boone in this issue.

Feasibility of High-Intensity Resistance Training Sessions in Cancer Survivors.

ABSTRACT: Schlüter, K, Schneider, J, Rosenberger, F, and Wiskemann, J. Feasibility of high-intensity resistance training sessions in cancer survivors. J Strength Cond Res 36(9): 2643-2652, 2022-Moderate-intensity resistance training (MIRT) is regarded as safe in cancer survivors (CS), but for high-intensity resistance training (HIRT), evidence is lacking. Hence, in the current exploratory analyses, single sessions of HIRT are compared with MIRT regarding safety and feasibility. Twenty-three of 24 included CS (14 breast and 10 prostate CS, 61.6 ± 9.5 years, body mass index 27.0 ± 4.3 kg·m -2 , 6-52 weeks after end of primary therapy) started a 12-week resistance training (RT) with a daily undulating periodization model including HIRT (90% of 1 repetition maximum [1RM]) and MIRT (67% 1RM) sessions. Parameters of safety (adverse events [AEs] and training-related pain), feasibility (physical and mental exhaustion, sensation of effort, enjoyment, and dropout rate), and adherence were assessed. An alpha level of 0.05 was applied for analyses. Nineteen of 23 training starters (83%) completed all sessions. Fourteen minor AEs occurred. A significantly higher increase for physical exhaustion appeared in HIRT ( p < 0.001). For 18% (HIRT) and 19% (MIRT) of the sessions, training-related pain was reported with no significant difference between intensities. In total, 34% of HIRT and 35% of MIRT sessions were perceived as overstraining or partly overstraining with no significant difference between intensities, but enjoyment (median and quartiles on a 1-7 scale) was high for both (HIRT = 5 [5;6] and MIRT = 5 [4,6]). Our analysis indicates that HIRT sessions do not differ from MIRT sessions concerning safety or feasibility, but training-related pain should be monitored. RT protocols incorporating high-intensity training loads can be applied safely in breast and prostate CS.

Music-based interventions for people living with dementia, targeting behavioral and psychological symptoms: A scoping review.

INTRODUCTION: Dementia care is a major public health issue worldwide. The management of behavioral and psychological symptoms (BPSD) is one of the hardest challenges in this context. Non-pharmacological strategies, like music-based interventions (Mbi), seem promising options, being considered low-risk, widely available and inclusive. This scoping review aimed at mapping all Mbi used in dementia care, targeting BPSD, and debriefing its components, structure and rationale. Music therapy and other therapeutic music activities were included. METHODS: The Arksey and O'Malley framework, Cochrane recommendations and PRISMA checklist were followed. Embase, PubMed, PsycINFO, ASSIA and Humanities Index were searched from first records until the 31st of March 2020. Snowballing process and screening of relevant journals were also undertaken. A panel of experts critically guided the evidence synthesis. RESULTS: Overall, 103 studies (34 RCT; 12 NRT; 40 Before/After studies and 17 Case Studies) met inclusion criteria. Basic elements of the Mbi, the rationale supporting its development and hypothesis tested were mostly underreported, thus hampering cross-study comparisons and generalizations. Despite this, available evidence indicates that: it is feasible to deliver Mbi to PwD at very different stages and in different settings - from community to the acute setting - even for non-music therapists; positive or neutral effects in BPSD are often reported but not without exception; individualization seems a critical factor mediating Mbi effects. CONCLUSIONS: Detailed intervention and research reporting are essential to interpretation, replication and translation into practice. Ten years after the publication of specific reporting guidelines, this goal is not yet fully achieved in music in dementia care.

Field-testing an iCST touch-screen application with people with dementia and carers: a mixed method study.

OBJECTIVES: To test the individual Cognitive Stimulation Therapy (iCST) application with people with dementia and carers in order to modify and refine the application, and improve its usability. In an iterative development process, two different prototypes were used to elicit the subjects' views and preferences. This application may address the current need for more innovative approaches to support people with dementia and their carers. METHODS: An opportunistic sample of 13 people with dementia and 13 carers participated in four focus groups and ten semi-structured interviews to obtain feedback in key areas, including the layout and content of the application, and the experience of its use as a dyad. Data were audio-recorded, transcribed and analysed thematically. An additional 18 people with dementia and 16 carers completed a short usability and acceptability questionnaire regarding a subsequent version of the iCST application prototype. RESULTS: Most participants expressed enthusiasm about the iCST application, its usability, design, and content. Participants highlighted the importance of adaptability to individual preferences, indicating a need for a wider range of activities and flexibility in the use of the application. Furthermore, participants reported perceived benefits, including mental stimulation, quality time spent together, and enjoyment. The application was rated slightly better by carers than people with dementia in terms of usability and acceptability. CONCLUSIONS: This study gives insights from people with dementia and carers concerning the usability, feasibility, and perceived benefits of the iCST application. The feedback will be incorporated in an updated version of the iCST application for commercial release.

Exercise intensity prescription in cancer survivors: ventilatory and lactate thresholds are useful submaximal alternatives to VO2peak.

PURPOSE: Most studies with cancer survivors use percentages of peak oxygen uptake (VO2peak) for intensity prescription. Lactate or ventilatory thresholds might be useful submaximal alternatives, but this has never been investigated. Therefore, we aimed at comparing three training sessions prescribed using %VO2peak (reference), lactate thresholds, and ventilatory thresholds in terms of meeting the vigorous-intensity zone, physiological, and psychological responses. METHODS: Twenty breast (58 ± 10 years) and 20 prostate cancer survivors (68 ± 6 years), 3.6 ± 2.4 months after primary therapy, completed a maximal cardiopulmonary exercise test and three vigorous training sessions in randomized order: 38 min of cycling at 70% VO2peak (M-VO2peak), 97% of individual anaerobic lactate threshold (M-IAT), and 67% between ventilatory thresholds 1 and 2 (M-VT). Heart rate (HR), blood lactate concentration (bLa), perceived exertion, and enjoyment were assessed. RESULTS: Cancer survivors exercised at 75 ± 23, 85 ± 18, and 79 ± 19 W during M-VO2peak, M-IAT, and M-VT (p > .05). Sessions could not be completed in 3, 8, and 6 cases. Session completers showed HR of 82 ± 7, 83 ± 9, and 84 ± 8 %HRpeak and bLa of 3.7 ± 1.9, 3.9 ± 0.9, and 3.9 ± 1.5 mmol·l-1, which was not different between sessions (p > .05). However, variance in bLa was lower in M-IAT compared to M-VO2peak (p = .001) and to M-VT (p = .022). CONCLUSION: All intensity prescription methods on average met the targeted intensity zone. Metabolic response was most homogeneous when using lactate thresholds. IMPLICATIONS FOR CANCER SURVIVORS: Submaximal thresholds are at least as useful as VO2peak for intensity prescription in cancer survivors. Overall, slightly lower percentages should be chosen to improve durability of the training sessions.

In-PREP: a new learning design framework and methodology applied to a relational care training intervention for healthcare assistants.

BACKGROUND: 'Older People's Shoes' is a training intervention designed for healthcare assistants (HCAs) to improve the relational care of older people in hospital. The intervention formed part of a broader evaluation, in this paper we describe its development from a learning design and methodological perspective. METHODS: Learning theory and an instructional design model were key components of the In-PREP (Input, Process, Review and Evaluation, Product) development methodology used in the design of the 'Older People's Shoes' training intervention to improve the delivery of relational care by front-line hospital staff. An expert panel, current evidence, and pedagogical theory were used to co-design a training programme tailored to a challenging work environment and taking account of trainees' diverse educational experience. Peer review and process evaluation were built into the development model. RESULTS: In-PREP provided a methodological scaffold for producing evidence-based, peer-reviewed, co-designed training. The product, 'Older People's Shoes', involved a one-day Train the Trainers event, followed by delivery of a two-day, face-to-face training programme by the trainers, with accompanying handbooks underpinned by a range of digital resources. Evaluation found the approach met learner needs, was applicable in practice and won approval from trainers. DISCUSSION: In-PREP enables high quality learning content, alignment with learner needs and a product that is relevant, practical and straightforward to implement.

Involvement of People With Dementia in the Development of Technology-Based Interventions: Narrative Synthesis Review and Best Practice Guidelines.

BACKGROUND: Technology can be helpful in supporting people with dementia in their daily lives. However, people with dementia are often not fully involved in the development process of new technology. This lack of involvement of people with dementia in developing technology-based interventions can lead to the implementation of faulty and less suitable technology. OBJECTIVE: This systematic review aims to evaluate current approaches and create best practice guidelines for involving people with dementia in developing technology-based interventions. METHODS: A systematic search was conducted in January 2019 in the following databases: EMBASE (Excerpta Medica database), PsycINFO, MEDLINE (Medical Literature Analysis and Retrieval System Online), CINAHL (Cumulated Index to Nursing and Allied Health Literature), and Web of Science. The search strategy included search terms in 3 categories: dementia, technology, and involvement in development. Narrative synthesis wove the evidence together in a structured approach. RESULTS: A total of 21 studies met the inclusion criteria. Most studies involved people with dementia in a single phase, such as development (n=10), feasibility and piloting (n=7), or evaluation (n=1). Only 3 studies described involvement in multiple phases. Frequently used methods for assessing involvement included focus groups, interviews, observations, and user tests. CONCLUSIONS: Most studies concluded that it was both necessary and feasible to involve people with dementia, which can be optimized by having the right prerequisites in place, ensuring that technology meets standards of reliability and stability, and providing a positive research experience for participants. Best practice guidelines for the involvement of people with dementia in developing technology-based interventions are described.

Are BRCA1 and BRCA2 gene mutation patients underscreened for pancreatic adenocarcinoma?

BACKGROUND: Breast cancer (BRCA) mutations account for the highest proportion of hereditary causes of pancreatic ductal adenocarcinoma (PDAC). Screening is currently recommended only for patients with one first-degree relative or two family members with PDAC. We hypothesized that screening all BRCA1/2 patients would identify a higher rate of pancreatic abnormalities. METHODS: All BRCA1/2 patients at a single academic center were retrospectively reviewed (2005-2015). Pancreatic abnormalities were defined on cross-sectional imaging as pancreatic neoplasm (cystic/solid) or main-duct dilation. RESULTS: Two hundred and four patients were identified with BRCA mutations. Forty-seven (40%) had abdominal imaging (20 computerized tomography and 27 magnetic resonance imaging). Twenty-one percent had pancreatic abnormalities (PDAC [n = 2] and intraductal papillary mucinous neoplasm [IPMN; n = 8]). The prevalence of pancreatic abnormalities and IPMN was higher in BRCA2 patients than in the general population (21% vs 8% and 17% vs 1%; P = 0.0007 and P < 0.0001, respectively), with no influence of family history. Similarly, BRCA1 patients had an increased prevalence of IPMN (8.3% vs 1%; P < 0.0001). CONCLUSIONS: In this series, 4% and 17% of BRCA2 patients developed PDAC and IPMN, respectively. Eight percent of BRCA1 patients developed IPMN. Under current recommended screening, 60% of BRCA1/2 patients had incompletely pancreatic assessment. With no influence of family history, this study suggests all BRCA1/2 patients should undergo a high-risk screening protocol that will identify a higher rate of precancerous pancreatic neoplasms amenable to curative resection.

Mental Health Recovery Narratives and Their Impact on Recipients: Systematic Review and Narrative Synthesis.

OBJECTIVE: Mental health recovery narratives are often shared in peer support work and antistigma campaigns. Internet technology provides access to an almost unlimited number of narratives, and yet little is known about how they affect recipients. The aim of this study was to develop a conceptual framework characterizing the impact of recovery narratives on recipients. METHOD: A systematic review of evidence about the impact of mental health recovery narratives was conducted. Searches used electronic databases (n = 9), reference tracking, hand-searching of selected journals (n = 2), grey literature searching, and expert consultation (n = 7). A conceptual framework was generated through a thematic analysis of included articles, augmented by consultation with a Lived Experience Advisory Panel. RESULTS: In total, 8137 articles were screened. Five articles were included. Forms of impact were connectedness, understanding of recovery, reduction in stigma, validation of personal experience, affective responses, and behavioural responses. Impact was moderated by characteristics of the recipient, context, and narrative. Increases in eating disorder behaviours were identified as a harmful response specific to recipients with eating disorders. CONCLUSIONS: Mental health recovery narratives can promote recovery. Recovery narratives might be useful for clients with limited access to peers and in online interventions targeted at reducing social isolation in rural or remote locations, but support is needed for the processing of the strong emotions that can arise. Caution is needed for use with specific clinical populations. Protocol registration: Prospero-CRD42018090923.

Agency in dementia care: systematic review and meta-ethnography.

ABSTRACTObjectives:Dementia often limits the agency of the person to such an extent that there is need for external support in making daily life decisions. This support is usually provided by family members who are sometimes legally empowered to engage in decision-making on behalf of the person for whom they care. However, such family carers receive little or no information on how to best provide support when there is a lack of capacity. This may have an impact on the agency of the person with dementia. This review explores the experience of agency in people living with dementia. DESIGN: A systematic search was conducted on IBSS, MedLine, PsychINFO, EMBASE, and CINAHL. Two independent researchers screened the studies and conducted the quality appraisal. We used meta-ethnography for data analysis. As part of the synthesis, we identified behavioral mechanisms underlying the process of decision-making and looked at how the support of carers comes into play in making deliberate choices. RESULTS: The meta-ethnography involved 20 studies. Three levels of third-order constructs were identified, each describing a decision-making pathway and reflecting the degree of autonomy of the person with dementia: autonomous decision-making, shared decision-making, and pseudo decision-making. Findings highlight those inter-relational processes that promote or negatively impact on the agency of people with dementia. CONCLUSIONS: Our review will provide health and social care personnel with an understanding of the role of the carer in the decision-making process, and therefore which mechanisms need to be promoted or discouraged through training.

Dyadic construction of dementia: meta-ethnography and behaviour-process synthesis.

OBJECTIVES: Good interaction with family caregivers helps maintain positive identity in people with dementia. However, research in this area is limited. We aimed to systematically review the dyadic experience of dementia caring. METHOD: We searched on five databases: MedLine, EMBASE, PsycInfo, ASSIA, and CINAHL. Eligible studies employed qualitative or mixed method design, reported the experience of dyads of dementia with no comorbid organic or psychiatric disorders. No restrictions were made on language, year of publication, sex or age of participants. Two independent researchers conducted the quality appraisal of studies. We synthesise data through meta-ethnography and developed a behavioural model to explain dyadic interaction. RESULTS: Seventeen studies were included in the review. The meta-ethnography generated two third-order constructs: Personal orientation and noises. When people with dementia and their carers have dyadic-oriented goals, their behavioural responses may promote positive interaction. When only one partner has dyadic goals, context-related stress may affect the interaction, because of no perceived shared understanding of the situation. CONCLUSION: Our findings suggest that unequal power distribution within dyads, can cause significant stress, when coping strategies are impaired. We discussed implications for family carers, people with dementia, and health professionals deriving from greater understanding of dyadic dynamics to care.

The subjective world of home care workers in dementia: an "order of worth" analysis.

The perspective of domiciliary workers is needed to recruit a high-quality workforce and meet growing demand. An English ethnographic study yielded extensive insights. To structure analysis of the study data, we apply a method developed by political theorists Boltanski and Thévenot that identifies key variables in different values systems. This "orders of worth" framework is used to map out the distinctive features of the subjective world of home carers. The results can be drawn on to formulate recruitment and retention policies, to design reward strategies or to ensure that training and education opportunities engage effectively with the workforce.

Optimal healthcare delivery to care homes in the UK: a realist evaluation of what supports effective working to improve healthcare outcomes.

INTRODUCTION: care home residents have high healthcare needs not fully met by prevailing healthcare models. This study explored how healthcare configuration influences resource use. METHODS: a realist evaluation using qualitative and quantitative data from case studies of three UK health and social care economies selected for differing patterns of healthcare delivery to care homes. Four homes per area (12 in total) were recruited. A total of 239 residents were followed for 12 months to record resource-use. Overall, 181 participants completed 116 interviews and 13 focus groups including residents, relatives, care home staff, community nurses, allied health professionals and General Practitioners. RESULTS: context-mechanism-outcome configurations were identified explaining what supported effective working between healthcare services and care home staff: (i) investment in care home-specific work that legitimises and values work with care homes; (ii) relational working which over time builds trust between practitioners; (iii) care which 'wraps around' care homes; and (iv) access to specialist care for older people with dementia. Resource use was similar between sites despite differing approaches to healthcare. There was greater utilisation of GP resource where this was specifically commissioned but no difference in costs between sites. CONCLUSION: activities generating opportunities and an interest in healthcare and care home staff working together are integral to optimal healthcare provision in care homes. Outcomes are likely to be better where: focus and activities legitimise ongoing contact between healthcare staff and care homes at an institutional level; link with a wider system of healthcare; and provide access to dementia-specific expertise.

Care staff and the creative arts: exploring the context of involving care personnel in arts interventions.

BACKGROUND: Arts-based interventions play an important role in the care of people with dementia. Yet, creative arts are seldom implemented as a tool to enhance the care and wellbeing of people with dementia. METHODS: We examined the involvement of care staff in creative arts activities in residential care. Aspects of involvement that appear to influence outcomes in people with dementia were identified and analyzed. A broad systematic literature search of MedLine, EMBASE, PsychInfo, CINAHL, ASSIA, SCOPUS, and Web of Science led to the identification of 14 papers. The studies identified through the search process were examined in terms of intervention, context, mechanism and outcome, and the relationships between these aspects. RESULTS: Training sessions were identified as an opportunity to educate care personnel on useful techniques that are relevant to daily care practice. Evidence from the literature suggests that creative arts programs play a significant role in the way staff and residents interact and as a result influence the care practice of staff. Under certain conditions creative arts programs, that involve and engage staff, facilitate enhanced interactions and improve care strategies, which leads to the recognition and validation of personhood in residents with dementia. CONCLUSIONS: These findings provide a basis for illustrating which elements of care staff involvement in creative arts programs could be implemented in residential care contexts in order to have the upmost benefit.

Power, empowerment, and person-centred care: using ethnography to examine the everyday practice of unregistered dementia care staff.

The social positioning and treatment of persons with dementia reflects dominant biomedical discourses of progressive and inevitable loss of insight, capacity, and personality. Proponents of person-centred care, by contrast, suggest that such loss can be mitigated within environments that preserve rather than undermine personhood. In formal organisational settings, person-centred approaches place particular responsibility on 'empowered' direct-care staff to translate these principles into practice. These staff provide the majority of hands-on care, but with limited training, recognition, or remuneration. Working within a Foucauldian understanding of power, this paper examines the complex ways that dementia care staff engage with their own 'dis/empowerment' in everyday practice. The findings, which are drawn from ethnographic studies of three National Health Service (NHS) wards and one private care home in England, are presented as a narrative exploration of carers' general experience of powerlessness, their inversion of this marginalised subject positioning, and the related possibilities for action. The paper concludes with a discussion of how Foucault's understanding of power may help define and enhance efforts to empower direct-care staff to provide person-centred care in formal dementia care settings.

Unregistered health care staff's perceptions of 12 hour shifts: an interview study.

AIM: The purpose of the study was to explore unregistered health care staff's perceptions of 12 hour shifts on work performance and patient care. BACKGROUND: Many unregistered health care staff work 12 hour shifts, but it is unclear whether these are compatible with good quality care or work performance. METHOD: Twenty five health care assistants from a range of care settings with experience of working 12 hour shifts took part in interviews or focus groups. RESULTS: A wide range of views emerged on the perceived impact of 12 hour shifts in different settings. Negative outcomes were perceived to occur when 12 hour shifts were combined with short-staffing, consecutive long shifts, high work demands, insufficient breaks and working with unfamiliar colleagues. Positive outcomes were perceived to be more likely in a context of control over shift patterns, sufficient staffing levels, and a supportive team climate. CONCLUSION: The perceived relationship between 12 hour shifts and patient care and work performance varies by patient context and wider workplace factors, but largely focuses on the ability to deliver relational aspects of care. IMPLICATIONS FOR NURSING MANAGEMENT: Nursing managers need to consider the role of other workplace factors, such as shift patterns and breaks, when implementing 12 hour shifts with unregistered health care staff.

Practitioner Review: Pathways to care for ADHD - a systematic review of barriers and facilitators.

BACKGROUND: Attention-Deficit/Hyperactivity Disorder (ADHD) is a common neurodevelopmental disorder starting in childhood that may persist into adulthood. It can be managed through carefully monitored medication and nonpharmacological interventions. Access to care for children at risk of ADHD varies both within and between countries. A systematic literature review was conducted to investigate the research evidence related to factors which influence children accessing services for ADHD. METHOD: Studies investigating access to care for children at risk of ADHD were identified through electronic searches of the international peer-reviewed and grey literature. Databases were searched from inception till 30th April 2012. This identified 23,156 articles which were subjected to three levels of screening (title, abstract and full text) by a minimum of two independent reviewers. Due to the heterogeneity in the study designs, a narrative approach was used to present the findings. RESULTS: Twenty-seven papers met the inclusion criteria; these were grouped into four main themes, with some papers being included in more than one. These were wider determinants (10 papers); identification of need (9 papers); entry and continuity of care (13 papers) and interventions to improve access (4 papers). Barriers and facilitators to access were found to operate at the individual, organisational and societal level. Limited evidence of effective interventions to improve access was identified. CONCLUSION: This review explored the multilayered obstacles in the pathway to care for children at risk of ADHD and the lack of evidence-based interventions designed to address these issues, thereby indicating areas for service development and further evaluative research.