Monitoring to detect changes in water quality to meet policy objectives.

Detecting change in water quality is key to providing evidence of progress towards meeting water quality objectives. A key measure for detecting change is statistical power. Here we calculate statistical power for all regularly (monthly) monitored streams in New Zealand to test the effectiveness of monitoring for policy that aims to decrease contaminant (phosphorus and nitrogen species, E. coli and visual clarity) concentrations to threshold levels in 5 or 20 years. While > 95% of all monitored sites had sufficient power and samples to detect change in nutrients and clarity over 20 years, on average, sampling frequency would have to double to detect changes in E. coli. Furthermore, to detect changes in 5 years, sampling for clarity, dissolved reactive phosphorus and E. coli would have to increase up to fivefold. The cost of sampling was predicted to increase 5.3 and 4.1 times for 5 and 20 years, respectively. A national model of statistical power was used to demonstrate that a similar number of samples (and cost) would be required for any new monitoring sites. Our work suggests that demonstrating the outcomes of implementing policy for water quality improvement may not occur without a step change in investment into monitoring systems. Emerging sampling technologies have potential to reduce the cost, but existing monitoring networks may also have to be rationalised to provide evidence that water quality is meeting objectives. Our study has important implications for investment decisions involving balancing the need for intensively sampled sites where changes in water quality occur rapidly versus other sites which provide long-term time series.

Influence of key factors on ammonia and nitrous oxide emission factors for excreta deposited by livestock and land-applied manure.

Ammonia (NH3) and nitrous oxide (N2O) emissions from livestock manure management have a significant impact on air quality and climate change. There is an increasing urgency to improve our understanding of drivers influencing these emissions. We analysed the DATAMAN ("DATAbase for MANaging greenhouse gas and ammonia emissions factors") database to identify key factors influencing (i) NH3 emission factors (EFs) for cattle and swine manure applied to land and (ii) N2O EFs for cattle and swine manure applied to land, and (iii) cattle urine, dung and sheep urine deposited during grazing. Slurry dry matter (DM) content, total ammoniacal nitrogen (TAN) concentration and method of application were significant drivers of NH3 EFs from cattle and swine slurry. Mixed effect models explained 14-59 % of the variance in NH3 EFs. Apart from the method of application, the significant influence of manure DM, manure TAN concentration or pH on NH3 EFs suggests mitigation strategies should focus on these. Identifying key factors influencing N2O EFs from manures and livestock grazing was more challenging, likely because of the complexities associated with microbial processes and soil physical properties impacting N2O production and emissions. Generally, significant factors were soil-related e.g. soil water content, pH, clay content, suggesting mitigations may need to consider the conditions of the receiving environment for manure spreading and grazing deposition. Total variability explained by terms in mixed effect model was on average 66 %, with the random effect 'experiment identification number' explaining, on average, 41 % of the total variability in the models. We suspect this term captured the effect of non-measured manure, soil and climate factors and any biases in application and measurement technique effects associated with individual experiments. This analysis has helped to improve our understanding of key factors of NH3 and N2O EFs for inclusion within models. With more studies over time, insights into the underlying processes influencing emissions will be further improved.

A Global Database of Soil Plant Available Phosphorus.

Soil phosphorus drives food production that is needed to feed a growing global population. However, knowledge of plant available phosphorus stocks at a global scale is poor but needed to better match phosphorus fertiliser supply to crop demand. We collated, checked, converted, and filtered a database of c. 575,000 soil samples to c. 33,000 soil samples of soil Olsen phosphorus concentrations. These data represent the most up-to-date repository of freely available data for plant available phosphorus at a global scale. We used these data to derive a model (R2 = 0.54) of topsoil Olsen phosphorus concentrations that when combined with data on bulk density predicted the distribution and global stock of soil Olsen phosphorus. We expect that these data can be used to not only show where plant available P should be boosted, but also where it can be drawn down to make more efficient use of fertiliser phosphorus and to minimise likely phosphorus loss and degradation of water quality.

Development and evaluation of a new pelvic floor muscle training Patient reported Outcome Measures (PROM) (PFMT-P).

OBJECTIVE: There are several Patient reported Outcome Measures (PROM) of knowledge, source of knowledge and practice of pelvic floor muscle training (PFMT), in different combinations but few integrating all three in one instrument. The objective of this study was the initial psychometric testing of a new PFMT PROM (PFMT-P), which aims to describe the knowledge, source of knowledge, and practices of PFMT for use by general female population, in order to contribute to preliminary validity and reliability. STUDY DESIGN: This study offered psychometric testing (validity and reliability) of a new assessment tool concerning PFMT (PFMT-P). The sample included 323 non-pregnant women, aged 20-50, who were heath care professionals and ancillary staff in one medical center in northern Israel. The PFMT-P was developed in Hebrew and composed of 3 sections: knowledge (score range 0-3), source of knowledge (initially scored), and practice (score range 3-35). A demographic and general health questionnaire was included. RESULTS: The face and content validity of the PFMT-P were evaluated by five experts with a factor analysis done on the practice component. Test-retest scores for internal consistency were reported for a group of 20 women, to whom the tool was administered 2 weeks apart. The results of the questionnaire components were knowledge, r= 0.538, p=0.014, and practice r=0.878, p<0.001. The component, source of knowledge on practice, showed non-significant results (p=0.796). Cronbach's alpha for the PFMT-P was 0.921 for the practice component. CONCLUSION: The PFMT-P was employed for the first time in a descriptive, correlational study, where its validity and reliability was tested and shows promise. The questionnaire is brief and easy to use. Continued research using this new PROM needs to be done to establish it as an assessment tool for PFMT programs.

Meta-analysis of New Zealand's nitrous oxide emission factors for ruminant excreta supports disaggregation based on excreta form, livestock type and slope class.

Globally, animal excreta (dung and urine) deposition onto grazed pastures represents more than half of anthropogenic nitrous oxide (N2O) emissions. To account for these emissions, New Zealand currently employs urine and dung emission factor (EF3) values of 1.0% and 0.25%, respectively, for all livestock. These values are primarily based on field studies conducted on fertile, flatland pastures predominantly used for dairy cattle production but do not consider emissions from hill land pastures primarily used for sheep, deer and non-dairy cattle. The objective of this study was to determine the most suitable urine and dung EF3 values for dairy cattle, non-dairy cattle, and sheep grazing pastures on different slopes based on a meta-analysis of New Zealand EF3 studies. As none of the studies included deer excreta, deer EF3 values were estimated from cattle and sheep values. The analysis revealed that a single dung EF3 value should be maintained, although the value should be reduced from 0.25% to 0.12%. Furthermore, urine EF3 should be disaggregated by livestock type (cattle > sheep) and topography (flatland and low sloping hill country > medium and steep sloping hill country), with EF3 values ranging from 0.08% (sheep urine on medium and steep slopes) to 0.98% (dairy cattle on flatland and low slopes). While the mechanism(s) causing differences in urine EF3 values for sheep and cattle are unknown, the 'slope effect' on urine EF3 is partly due to differences in soil chemical and physical characteristics, which influence soil microbial processes on the different slope classes. The revised EF3 values were used in an updated New Zealand inventory approach, resulting in 30% lower national N2O emissions for 2017 compared to using the current EF3 values. We recommend using the revised EF3 values in New Zealand's national greenhouse gas inventory to more accurately capture N2O emissions from livestock grazing.

Global mapping of freshwater nutrient enrichment and periphyton growth potential.

Periphyton (viz. algal) growth in many freshwater systems is associated with severe eutrophication that can impair productive and recreational use of water by billions of people. However, there has been limited analysis of periphyton growth at a global level. To predict where nutrient over-enrichment and undesirable periphyton growth occurs, we combined several databases to model and map global dissolved and total nitrogen (N) and phosphorus (P) concentrations, climatic and catchment characteristics for up to 1406 larger rivers that were analysed between 1990 and 2016. We predict that 31% of the global landmass contained catchments may exhibit undesirable levels of periphyton growth. Almost three-quarters (76%) of undesirable periphyton growth was caused by P-enrichment and mapped to catchments dominated by agricultural land in North and South America and Europe containing 1.7B people. In contrast, undesirable periphyton growth due to N-enrichment was mapped to parts of North Africa and parts of the Middle East and India affecting 280 M people. The findings of this global modelling approach can be used by landowners and policy makers to better target investment and actions at finer spatial scales to remediate poor water quality owing to periphyton growth.

Outcomes of hydrocephalus secondary to congenital toxoplasmosis.

OBJECTIVE: Hydrocephalus occurs in children with congenital toxoplasmosis and can lead to severe disability. In these cases, the decision to intervene is often influenced by the expectation of neurological recovery. In this study, clinical responses to neurosurgical intervention in children with hydrocephalus secondary to congenital toxoplasmosis are characterized. METHODS: Sixty-five participants with hydrocephalus due to congenital Toxoplasma gondii infection were evaluated as part of the National Collaborative Chicago-based Congenital Toxoplasmosis Study, and their neuroradiographic findings were reviewed. Clinical outcomes were scored on the basis of cognition and motor skills through the use of IQ scores and Gross Motor Function Classification System (GMFCS) level. Outcomes were then analyzed in relation to approach to management, anatomy of hydrocephalus, and time from diagnosis of hydrocephalus to surgical intervention. RESULTS: There was considerable variation in the outcomes of patients whose hydrocephalus was treated in early life, ranging from normal cognitive and motor function to profound developmental delay and functional limitation. Of the 65 participants included in the study, IQ and GMFCS level were available for 46 (70.8%). IQ and motor score were highly correlated (r = -0.82, p < 0.001). There were people with differing patterns of hydrocephalus or thickness of cortical mantle on initial presentation who had favorable outcomes. Time to neurosurgical intervention data were available for 31 patients who underwent ventriculoperitoneal (VP) shunt placement. Delayed shunt placement beyond 25 days after diagnosis of hydrocephalus was associated with greater cognitive impairment (p = 0.02). Motor impairment also appeared to be associated with shunt placement beyond 25 days but the difference did not achieve statistical significance (p = 0.13). Among those with shunt placement within 25 days after diagnosis (n = 19), the mean GMFCS level was 1.9 ± 1.6 (range 1-5). Five (29.4%) of 17 of these patients were too disabled to participate in formal cognitive testing, after excluding 2 patients with visual difficulties or language barriers that precluded IQ testing. Of the patients who had VP shunt placement 25 or more days after diagnosis (n = 12), the mean GMFCS level was 2.7 ± 1.4 (range 1-4). Of these, 1 could not participate in IQ testing due to severe visual difficulties and 8 (72.7%) of the remaining 11 due to cognitive disability. CONCLUSIONS: VP shunt placement in patients with hydrocephalus caused by congenital toxoplasmosis can contribute to favorable clinical outcomes, even in cases with severe hydrocephalus on neuroimaging. Shunt placement within 25 days of diagnosis was statistically associated with more favorable cognitive outcomes. Motor function appeared to follow the same pattern although it did not achieve statistical significance.

Publisher Correction: Toxoplasma Modulates Signature Pathways of Human Epilepsy, Neurodegeneration & Cancer.

A correction to this article has been published and is linked from the HTML and PDF versions of this paper. The error has been fixed in the paper.

Toxoplasma Modulates Signature Pathways of Human Epilepsy, Neurodegeneration & Cancer.

One third of humans are infected lifelong with the brain-dwelling, protozoan parasite, Toxoplasma gondii. Approximately fifteen million of these have congenital toxoplasmosis. Although neurobehavioral disease is associated with seropositivity, causality is unproven. To better understand what this parasite does to human brains, we performed a comprehensive systems analysis of the infected brain: We identified susceptibility genes for congenital toxoplasmosis in our cohort of infected humans and found these genes are expressed in human brain. Transcriptomic and quantitative proteomic analyses of infected human, primary, neuronal stem and monocytic cells revealed effects on neurodevelopment and plasticity in neural, immune, and endocrine networks. These findings were supported by identification of protein and miRNA biomarkers in sera of ill children reflecting brain damage and T. gondii infection. These data were deconvoluted using three systems biology approaches: "Orbital-deconvolution" elucidated upstream, regulatory pathways interconnecting human susceptibility genes, biomarkers, proteomes, and transcriptomes. "Cluster-deconvolution" revealed visual protein-protein interaction clusters involved in processes affecting brain functions and circuitry, including lipid metabolism, leukocyte migration and olfaction. Finally, "disease-deconvolution" identified associations between the parasite-brain interactions and epilepsy, movement disorders, Alzheimer's disease, and cancer. This "reconstruction-deconvolution" logic provides templates of progenitor cells' potentiating effects, and components affecting human brain parasitism and diseases.

Dark Matter Search Results from the PICO-60 C_{3}F_{8} Bubble Chamber.

New results are reported from the operation of the PICO-60 dark matter detector, a bubble chamber filled with 52 kg of C_{3}F_{8} located in the SNOLAB underground laboratory. As in previous PICO bubble chambers, PICO-60 C_{3}F_{8} exhibits excellent electron recoil and alpha decay rejection, and the observed multiple-scattering neutron rate indicates a single-scatter neutron background of less than one event per month. A blind analysis of an efficiency-corrected 1167-kg day exposure at a 3.3-keV thermodynamic threshold reveals no single-scattering nuclear recoil candidates, consistent with the predicted background. These results set the most stringent direct-detection constraint to date on the weakly interacting massive particle (WIMP)-proton spin-dependent cross section at 3.4×10^{-41} cm^{2} for a 30-GeV c^{-2} WIMP, more than 1 order of magnitude improvement from previous PICO results.

Implementation fidelity of a self-management course for epilepsy: method and assessment.

BACKGROUND: Complex interventions such as self-management courses are difficult to evaluate due to the many interacting components. The way complex interventions are delivered can influence the effect they have for patients, and can impact the interpretation of outcomes of clinical trials. Implementation fidelity evaluates whether complex interventions are delivered according to protocol. Such assessments have been used for one-to-one psychological interventions; however, the science is still developing for group interventions. METHODS: We developed and tested an instrument to measure implementation fidelity of a two-day self-management course for people with epilepsy, SMILE(UK). Using audio recordings, we looked at adherence and competence of course facilitators. Adherence was assessed by checklists. Competence was measured by scoring group interaction, an overall impression score and facilitator "didacticism". To measure "didacticism", we developed a novel way to calculate facilitator speech using computer software. Using this new instrument, implementation fidelity of SMILE(UK) was assessed on three modules of the course, for 28% of all courses delivered. RESULTS: Using the instrument for adherence, scores from two independent raters showed substantial agreement with weighted Kappa of 0.67 and high percent agreement of 81.2%. For didacticism, the results from both raters were highly correlated with an intraclass coefficient of 0.97 (p < 0.0001). We found that the courses were delivered with a good level of adherence (> 50% of scored items received the maximum of 2 points) and high competence. Groups were interactive (mean score: 1.9-2.0 out of 2) and the overall impression was on average assessed as "good". Didacticism varied from 42% to 93% of total module time and was not associated with the other competence scores. CONCLUSION: The instrument devised to measure implementation fidelity was reproducible and easy to use. The courses for the SMILE(UK) study were delivered with a good level of adherence to protocol while not compromising facilitator competence. TRIAL REGISTRATION: ISRCTN57937389 .

Point-of-care testing for Toxoplasma gondii IgG/IgM using Toxoplasma ICT IgG-IgM test with sera from the United States and implications for developing countries.

BACKGROUND: Congenital toxoplasmosis is a serious but preventable and treatable disease. Gestational screening facilitates early detection and treatment of primary acquisition. Thus, fetal infection can be promptly diagnosed and treated and outcomes can be improved. METHODS: We tested 180 sera with the Toxoplasma ICT IgG-IgM point-of-care (POC) test. Sera were from 116 chronically infected persons (48 serotype II; 14 serotype I-III; 25 serotype I-IIIa; 28 serotype Atypical, haplogroup 12; 1 not typed). These represent strains of parasites infecting mothers of congenitally infected children in the U.S. 51 seronegative samples and 13 samples from recently infected persons known to be IgG/IgM positive within the prior 2.7 months also were tested. Interpretation was confirmed by two blinded observers. A comparison of costs for POC vs. commercial laboratory testing methods was performed. RESULTS: We found that this new Toxoplasma ICT IgG-IgM POC test was highly sensitive (100%) and specific (100%) for distinguishing IgG/IgM-positive from negative sera. Use of such reliable POC tests can be cost-saving and benefit patients. CONCLUSIONS: Our work demonstrates that the Toxoplasma ICT IgG-IgM test can function reliably as a point-of-care test to diagnose Toxoplasma gondii infection in the U.S. This provides an opportunity to improve maternal-fetal care by using approaches, diagnostic tools, and medicines already available. This infection has serious, lifelong consequences for infected persons and their families. From the present study, it appears a simple, low-cost POC test is now available to help prevent morbidity/disability, decrease cost, and make gestational screening feasible. It also offers new options for improved prenatal care in low- and middle-income countries.

A disease, disorder, illness or condition: How to label epilepsy?

The International League Against Epilepsy (ILAE) is an important source of guidance for health professionals when it comes to epilepsy. Their latest recommendation that epilepsy should no longer be called a "disorder," but a "disease" has though caused controversy. The ILAE contends the change will improve epilepsy's image. Some clinicians and other organizations fear the change may not though be accepted by patients as in common parlance "disease" can be associated with "contagiousness"/"infection." To allow practicing clinicians to make informed judgements about what language they use, we completed the first study to assess the preferences of those with epilepsy and significant others and explore if any of their characteristics were associated with preference. Via epilepsy interest groups and associations in England, Wales, Scotland and the Republic of Ireland, 971 patients and significant others were surveyed. Participants identified which of four labels for epilepsy ("disorder," "illness," "disease," "condition") they favoured and rated each using a Likert-scale. Patients' median age was 39; 69% had experienced seizures in the prior year. "Condition" was favoured by most patients (74.3%) and significant others (71.2%). Only 2.2% of patients and 1.2% of significant others chose "disease"; it received a median Likert-rating indicating "strongly dislike." Multinomial logistic regression found it was not possible to reliably distinguish between participants favouring the different terms on the basis of demographics. The ILAE's position is at odds with what most patients and carers want and we discuss the implications of this.

Increased impedance near cut-off in plasma-like media leading to emission of high-power, narrow-bandwidth radiation.

Ultra-intense, narrow-bandwidth, electromagnetic pulses have become important tools for exploring the characteristics of matter. Modern tuneable high-power light sources, such as free-electron lasers and vacuum tubes, rely on bunching of relativistic or near-relativistic electrons in vacuum. Here we present a fundamentally different method for producing narrow-bandwidth radiation from a broad spectral bandwidth current source, which takes advantage of the inflated radiation impedance close to cut-off in a medium with a plasma-like permittivity. We find that by embedding a current source in this cut-off region, more than an order of magnitude enhancement of the radiation intensity is obtained compared with emission directly into free space. The method suggests a simple and general way to flexibly use broadband current sources to produce broad or narrow bandwidth pulses. As an example, we demonstrate, using particle-in-cell simulations, enhanced monochromatic emission of terahertz radiation using a two-colour pumped current source enclosed by a tapered waveguide.

Towards Attosecond High-Energy Electron Bunches: Controlling Self-Injection in Laser-Wakefield Accelerators Through Plasma-Density Modulation.

Self-injection in a laser-plasma wakefield accelerator is usually achieved by increasing the laser intensity until the threshold for injection is exceeded. Alternatively, the velocity of the bubble accelerating structure can be controlled using plasma density ramps, reducing the electron velocity required for injection. We present a model describing self-injection in the short-bunch regime for arbitrary changes in the plasma density. We derive the threshold condition for injection due to a plasma density gradient, which is confirmed using particle-in-cell simulations that demonstrate injection of subfemtosecond bunches. It is shown that the bunch charge, bunch length, and separation of bunches in a bunch train can be controlled by tailoring the plasma density profile.

Are "Theory of Mind" Skills in People with Epilepsy Related to How Stigmatised They Feel? An Exploratory Study.

Feelings of stigma are one of the main burdens reported by people with epilepsy (PWE). Adults with temporal or frontal lobe epilepsy and children with idiopathic generalised epilepsy are at risk of Theory of Mind (ToM) deficits. ToM refers to social cognitive skills, including the ability to understand the thoughts, intentions, beliefs, and emotions of others. It has been proffered that ToM deficits may contribute to the feelings of stigma experienced by PWE. In this study we tested this for the first time. We also determined the association between clinical and demographic factors and ToM performance. Five hundred and three PWE were recruited via epilepsy organisations and completed measures online. Feelings of stigma were measured using Jacoby's Stigma Scale, whilst the Reading the Mind in the Eyes Test and the Faux Pas Test measured ToM. The median age of participants was 37 years, their median years living with epilepsy were 15, and 70% had experienced seizures in the prior 12 months. Feelings of stigma held a negligible, negative, and nonsignificant association with ToM performance (r s -0.02 and -0.05). Our results indicate that the ToM model for understanding epilepsy stigma has limited utility and alternative approaches to understanding and addressing epilepsy-related stigma are required.

Follicular helper T cells are responsible for IgE responses to Der p 1 following house dust mite sensitization in mice.

BACKGROUND: Th2 cells have long been considered responsible for the switching of B cells to production of IgE during cognate interaction, primarily due to their expression of CD40L and secretion of IL-4. This concept has been challenged by the more recent definition of follicular helper T cells (Tfh) as the key T cell subset in B cell isotype switching, due to their physical location at the boundary of T cell:B cell areas in lymphoid follicles and ability to express IL-4 and CD40L. OBJECTIVE: To determine whether Tfh cells are responsible for IgE responses to Der p 1 allergen after house dust mite (HDM)-induced allergic sensitization. METHODS: Mice deficient in Tfh cells were sensitized to HDM and Der p 1-specific IgE measured by ELISA. RESULTS: Mice with a mutation in T cell-expressed IL-6R were unable to expand Tfh populations after HDM sensitization, and their anti-Der p 1 IgE, IgG1 and total IgE responses were reduced by 80-90% compared with wild-type mice. These animals displayed unaltered lung Th2 and eosinophilic responses after intranasal HDM challenge and normal IL-4 production, but B cell infiltration of the airways was abrogated. CONCLUSIONS AND CLINICAL RELEVANCE: Our data indicate that Tfh cells are largely responsible for switching B cells to IgE synthesis, most likely via an IgG1(+) intermediate. However, Th2 cells are the major source of IL-4 during HDM sensitization and this might contribute to IgE synthesis at a stage distal to Tfh-mediated isotype switching. The IL-6/follicular helper T cell pathway is a potential therapeutic target in allergic disease.

Which outcomes should we measure in adult epilepsy trials? The views of people with epilepsy and informal carers.

OBJECTIVE: So that informed treatment decisions can be made, clinical trials need to evaluate treatments against domains that are important to people with epilepsy (PWE), their carers, and clinicians. Health professionals have identified domains of importance to them via the International League Against Epilepsy's Commission on Outcome Measurement (COME). However, patients and carers have not been systematically asked. METHODS: Via the membership of the British Epilepsy Association, we recruited and surveyed 352 PWE and 263 of their informal carers. They were presented with 10 outcome domains (including the 5 identified by COME) and asked to rate their importance using a 9-point Likert scale. They were also asked to identify any additional domains of importance. RESULTS: The patients' mean age was 49years, the median number of years since diagnosis was 20, and 65% had experienced seizures in the prior 12months. Most carers were the spouse or parent. Patients' and carers' mean ratings indicated that their outcome priorities were similar, as were those of patients who had and had not experienced recent seizures. There was consensus among patients that 6 domains were of critical importance. These included the 5 identified by COME (namely, and in order of importance, the effects of the treatment on "Seizure severity", "Seizure frequency", "Quality of life", "Cognitive function", and "Adverse events"), as well as one additional domain ("Independence/need for support"). There was consensus among carers that the 5 COME domains were also critically important. They, however, identified 3 further domains as critically important. These were the effects of the treatment on patient "Depression", "Anxiety", and "Independence/need for support". CONCLUSIONS: Our study found some overlap between the priorities of PWE, carers, and health professionals. They, however, highlight additional areas of importance to patients and carers. Our results could inform a core outcome set for epilepsy that represents the domains that should be reported as a minimum by all trials. This could promote trials which produce meaningful results and consistency in measurement and reporting.

A pilot study of cognitive behavioural therapy and relaxation for migraine headache: a randomised controlled trial.

Headache is being viewed more commonly in a biopsychosocial framework, which introduces the possible utilisation of psychological treatment options, such as cognitive behavioural therapy and relaxation. No such treatments have been trialled in the UK. We conducted a randomised controlled pilot trial, comparing a brief guided self-help CBT and relaxation treatment with standard medical care (SMC), in a UK NHS setting. Participants were recruited from specialist headache clinics across London. Participants were randomised to receive either treatment or standard medical care. Our objective was to provide design information necessary for a future definitive trial of the SHE treatment, including, recruitment/retention rates, acceptability of randomisation, treatment fidelity and estimations of mean and variances of outcome measures. From the initial 275 patients identified, 73 were randomised. There was no difference in drop-out rates between SMC and treatment groups. Of the 36 participants randomised to receive treatment, 72% attended all sessions. Findings show that a future definitive trial of the SHE treatment is feasible, with small modifications of protocol, within a UK NHS context.