Association of Aortic Stiffness and Pressure Pulsatility With Noninvasive Estimates of Hepatic Steatosis and Fibrosis: The Framingham Heart Study.

BACKGROUND: Arterial stiffening may contribute to the pathogenesis of metabolic dysfunction-associated steatotic liver disease. We aimed to assess relations of vascular hemodynamic measures with measures of hepatic steatosis and fibrosis in the community. METHODS: Our sample was drawn from the Framingham Offspring, New Offspring Spouse, Third Generation, Omni-1, and Omni-2 cohorts (N=3875; mean age, 56 years; 54% women). We used vibration-controlled transient elastography to assess controlled attenuation parameter and liver stiffness measurements as measures of liver steatosis and liver fibrosis, respectively. We assessed noninvasive vascular hemodynamics using arterial tonometry. We assessed cross-sectional relations of vascular hemodynamic measures with continuous and dichotomous measures of hepatic steatosis and fibrosis using multivariable linear and logistic regression. RESULTS: In multivariable models adjusting for cardiometabolic risk factors, higher carotid-femoral pulse wave velocity (estimated ß per SD, 0.05 [95% CI, 0.01-0.09]; P=0.003), but not forward pressure wave amplitude and central pulse pressure, was associated with more liver steatosis (higher controlled attenuation parameter). Additionally, higher carotid-femoral pulse wave velocity (ß=0.11 [95% CI, 0.07-0.15]; P<0.001), forward pressure wave amplitude (ß=0.05 [95% CI, 0.01-0.09]; P=0.01), and central pulse pressure (ß=0.05 [95% CI, 0.01-0.09]; P=0.01) were associated with more hepatic fibrosis (higher liver stiffness measurement). Associations were more prominent among men and among participants with obesity, diabetes, and metabolic syndrome (interaction P values, <0.001-0.04). Higher carotid-femoral pulse wave velocity, but not forward pressure wave amplitude and central pulse pressure, was associated with higher odds of hepatic steatosis (odds ratio, 1.16 [95% CI, 1.02-1.31]; P=0.02) and fibrosis (odds ratio, 1.40 [95% CI, 1.19-1.64]; P<0.001). CONCLUSIONS: Elevated aortic stiffness and pressure pulsatility may contribute to hepatic steatosis and fibrosis.

Arterial Stiffness and Diabetes Risk in Framingham Heart Study and UK Biobank.

BACKGROUND: Microvascular damage from large artery stiffness (LAS) in pancreatic, hepatic, and skeletal muscles may affect glucose homeostasis. Our goal was to evaluate the association between LAS and the risk of type 2 diabetes using prospectively collected, carefully phenotyped measurements of LAS as well as Mendelian randomization analyses. METHODS: Carotid-femoral pulse wave velocity (CF-PWV) and brachial and central pulse pressure were measured in 5676 participants of the FHS (Framingham Heart Study) without diabetes. We used Cox proportional hazards regression to evaluate the association of CF-PWV and pulse pressure with incident diabetes. We subsequently performed 2-sample Mendelian randomization analyses evaluating the associations of genetically predicted brachial pulse pressure with type 2 diabetes in the UKBB (United Kingdom Biobank). RESULTS: In FHS, individuals with higher CF-PWV were older, more often male, and had higher body mass index and mean arterial pressure compared to those with lower CF-PWV. After a median follow-up of 7 years, CF-PWV and central pulse pressure were associated with an increased risk of new-onset diabetes (per SD increase, multivariable-adjusted CF-PWV hazard ratio, 1.36 [95% CI, 1.03-1.76]; P=0.030; central pulse pressure multivariable-adjusted CF-PWV hazard ratio, 1.26 [95% CI, 1.08-1.48]; P=0.004). In United Kingdom Biobank, genetically predicted brachial pulse pressure was associated with type 2 diabetes, independent of mean arterial pressure (adjusted odds ratio, 1.16 [95% CI, 1.00-1.35]; P=0.049). CONCLUSIONS: Using prospective cohort data coupled with Mendelian randomization analyses, we found evidence supporting that greater LAS is associated with increased risk of developing diabetes. LAS may play an important role in glucose homeostasis and may serve as a useful marker of future diabetes risk.

Blood Pressure Responses During Exercise: Physiological Correlates and Clinical Implications.

BACKGROUND: Abnormal blood pressure (BP) responses to exercise can predict adverse cardiovascular outcomes, but their optimal measurement and definitions are poorly understood. We combined frequently sampled BP during cardiopulmonary exercise testing with vascular stiffness assessment to parse cardiac and vascular components of exercise BP. METHODS: Cardiopulmonary exercise testing with BP measured every two minutes and resting vascular tonometry were performed in 2858 Framingham Heart Study participants. Linear regression was used to analyze sex-specific exercise BP patterns as a function of arterial stiffness (carotid-femoral pulse wave velocity) and cardiac-peripheral performance (defined by peak O2 pulse). RESULTS: Our sample was balanced by sex (52% women) with mean age 54±9 years and 47% with hypertension. We observed variability in carotid-femoral pulse wave velocity and peak O2 pulse across individuals with clinically defined exercise hypertension (peak systolic BP [SBP] in men ≥210 mm Hg; in women ≥190 mm Hg). Despite similar resting SBP and cardiometabolic profiles, individuals with higher peak O2 pulse displayed higher peak SBP (P≤0.017) alongside higher fitness levels (P<0.001), suggesting that high peak exercise SBP in the context of high peak O2 pulse may in fact be favorable. Although both higher (favorable) O2 pulse and higher (adverse) arterial stiffness were associated with greater peak SBP (P<0.0001 for both), the magnitude of association of carotid-femoral pulse wave velocity with peak SBP was higher in women (sex-carotid-femoral pulse wave velocity interaction P<0.0001). In sex-specific models, exercise SBP measures accounting for workload (eg, SBP during unloaded exercise, SBP at 75 watts, and SBP/workload slope) were directly associated with the adverse features of greater arterial stiffness and lower peak O2 pulse. CONCLUSIONS: Higher peak exercise SBP reflects a complex trade-off between arterial stiffness and cardiac-peripheral performance that differs by sex. Studies of BP responses to exercise accounting for vascular and cardiac physiology may illuminate mechanisms of hypertension and clarify clinical interpretation of exercise BP.

Co-design and evaluation of a digital serious game to promote public awareness about pancreatic cancer.

BACKGROUND: Pancreatic cancer, ranking seventh in global cancer-related deaths, poses a significant public health challenge with increasing incidence and mortality. Most cases are diagnosed at an advanced stage, resulting in low survival rates. Early diagnosis significantly impacts prognosis, making symptom awareness crucial. Symptoms are often subtle, leading to delayed help-seeking behaviour. Patients and their carers prioritise increased public awareness, indicating a need for innovative approaches to promote awareness of the disease. METHODS: This study employed a quasi-experimental pre-test/post-test design to assess the relationship between a serious game and pancreatic cancer awareness. Members of the public (N = 727) were recruited internationally, via social media and with signposting by relevant organisations. Participants completed measures of symptom awareness and help-seeking intentions before and after playing the game. The serious game, co-designed with experts by lived experience, patient advocates and healthcare professionals, presented participants with a human anatomy diagram, with each section linked to a question about pancreatic cancer. RESULTS: The serious game demonstrated a statistically significant improvement on pancreatic cancer awareness based on matched paired t-tests. Due to missing data, paired comparisons were only possible for 489 cases. Symptom awareness scores exhibited a statistically significant increase from pre-test to post-test, with a large effect size (p < 0.001, d = 1.43). Help-seeking intentions also markedly improved, showing a significant increase from pre-test to post-test, with a large effect size (p < 0.001, d = 1.10). Independent-samples t-tests were also conducted to determine if there were any group differences on pre- to post-test changes based on age, gender, and previous knowledge and/or experience of pancreatic cancer. Participants overwhelmingly endorsed the game's usability and educational value, suggesting its potential as an effective tool for enhancing public awareness and proactive health-seeking behaviour. DISCUSSION: This study is the first to explore a serious game's utility in pancreatic cancer awareness. Results suggest that such interventions can effectively increase public awareness and influence help-seeking intentions. The co-design process ensured content relevance, and participant satisfaction was high. Findings highlight the game's potential as an accessible and convenient tool for diverse populations.

Evaluation of a dementia awareness game for health professions students in Northern Ireland: a pre-/post-test study.

BACKGROUND: Dementia is a prevalent global health issue, necessitating comprehensive education for healthcare practitioners and students. Nursing and pharmacy students, provide support across healthcare settings often working as frontline caregivers. Therefore, it is imperative to equip these students with a profound understanding of dementia. The aim of this study was to evaluate whether a serious dementia game co-designed with stakeholders, students, and people living with dementia improved the attitudes of nursing and pharmacy students. METHODS: A pretest-posttest design was used to assess the attitudes of health professions students (nursing and pharmacy) towards dementia. The Approaches to Dementia Questionnaire (ADQ) was administered before and after playing a serious Dementia Game. The ADQ measured the total score, Hope subscale, and Recognition of Personhood subscale. Matched pairs t-test was used for analysis conducted with IBM SPSS statistics 27. RESULTS: A diverse cohort of 505 participants from one university in Northern Ireland participated, with 461 matched pairs used for analysis. Both nursing and pharmacy students demonstrated a significant increase in overall dementia attitudes post-gameplay, with nursing students showing an increase from 79.69 to 83.59 and pharmacy students from 75.55 to 79.86. Subscales for Hope (Nursing = 28.77 to 31.22, Pharmacy = 26.65 to 29.20). and Recognition of Personhood also exhibited significant improvement (Nursing = 50.93 to 52.38, Pharmacy = 48.89 to 50.67). Demographic data revealed predominantly female participants, a lack of personal connections to dementia, and varied training experiences. DISCUSSION: The study highlights the efficacy of the serious Dementia Game in enhancing attitudes to dementia amongst health professions students, indicating its potential as an educational tool. The study contributes to the growing body of evidence supporting serious games and gamification in healthcare education.

Co-design and mixed methods evaluation of an interdisciplinary digital resource for undergraduate health profession students to improve the prevention, recognition, and management of delirium in Ireland: a study protocol.

BACKGROUND: Delirium is a common symptom of acute illness which is potentially avoidable with early recognition and intervention. Despite being a growing concern globally, delirium remains underdiagnosed and poorly reported, with limited understanding of effective delirium education for undergraduate health profession students. Digital resources could be an effective approach to improving professional knowledge of delirium, but studies utilising these with more than one profession are limited, and no evidence-based, interdisciplinary, digital delirium education resources are reported. This study aims to co-design and evaluate a digital resource for undergraduate health profession students across the island of Ireland to improve their ability to prevent, recognise, and manage delirium alongside interdisciplinary colleagues. METHODS: Utilising a logic model, three workstreams have been identified. Workstream 1 will comprise three phases: (1) a systematic review identifying the format, methods, and content of existing digital delirium education interventions for health profession students, and their effect on knowledge, self-efficacy, and behavioural change; (2) focus groups with health profession students to determine awareness and experiences of delirium care; and (3) a Delphi survey informed by findings from the systematic review, focus groups, and input from the research team and expert reference group to identify resource priorities. Workstream 2 will involve the co-design of the digital resource through workshops (n = 4) with key stakeholders, including health profession students, professionals, and individuals with lived experience of delirium. Lastly, Workstream 3 will involve a mixed methods evaluation of the digital resource. Outcomes include changes to delirium knowledge and self-efficacy towards delirium care, and health profession students experience of using the resource. DISCUSSION: Given the dearth of interdisciplinary educational resources on delirium for health profession students, a co-designed, interprofessional, digital education resource will be well-positioned to shape undergraduate delirium education. This research may enhance delirium education and the self-efficacy of future health professionals in providing delirium care, thereby improving practice and patients' experiences and outcomes. TRIAL REGISTRATION: Not applicable.

Employing a serious game intervention to promote adolescent school children's perceptions of nursing and midwifery professions.

AIM: To test a serious game intervention about nursing and midwifery perceptions among adolescent school children. BACKGROUND: Nursing and midwifery professions face challenges in recruitment, with persistent gender stereotypes and a lack of clarity regarding the roles contributing to this issue. This study addresses the need for innovative approaches to reshape perceptions and encourage career exploration in adolescent school children. DESIGN: Employing a pre/post-test design, this study involved 137 post-primary students aged sixteen or seventeen in the United Kingdom. METHODS: Data collection occurred between November 2022 to April 2023, involving three post-primary schools. Participants engaged with a digital serious game designed to address misconceptions and promote a more accurate understanding of nursing and midwifery. Participants completed pre- and post-intervention questionnaires, including an adapted version of the Nursing as a Career Choice Questionnaire. Statistical analyses included descriptive statistics, paired t-tests, and independent groups t-tests. RESULTS: The serious game intervention resulted in statistically significant improvements in students' perceptions across multiple domains. Overall, participants showed higher mean post-test scores (M = 139.57, SD = 15.10) compared to their mean pre-test score (M = 131.06, SD = 14.73) on the questionnaire. The domains of self-efficacy (p < .001), job prospects (p < .001) and social influences (p < .001) exhibited the most substantial positive changes. Female participants showed higher perceptions than males in pre- and post-tests and students from all-girls schools consistently scored higher than those from all-boys and mixed-gender schools. CONCLUSIONS: A serious game about the nursing and midwifery professions appears to be capable of changing perceptions of self-efficacy and job prospects related to nursing and midwifery professions. The study suggests that a serious game intervention may have the potential to change adolescent perceptions of nursing and midwifery professions which may lead to their considering of these when making future career choices.

Multiple Prior Live Births Are Associated With Cardiac Remodeling and Heart Failure Risk in Women.

OBJECTIVE: Greater parity has been associated with cardiovascular disease risk. We sought to find whether the effects on cardiac remodeling and heart failure risk are clear. METHODS: We examined the association of number of live births with echocardiographic measures of cardiac structure and function in participants of the Framingham Heart Study (FHS) using multivariable linear regression. We next examined the association of parity with incident heart failure with preserved (HFpEF) or reduced (HFrEF) ejection fraction using a Fine-Gray subdistribution hazards model in a pooled analysis of n = 12,635 participants in the FHS, the Cardiovascular Health Study, the Multi-Ethnic Study of Atherosclerosis, and Prevention of Renal and Vascular Endstage Disease. Secondary analyses included major cardiovascular disease, myocardia infarction and stroke. RESULTS: Among n = 3931 FHS participants (mean age 48 ± 13 years), higher numbers of live births were associated with worse left ventricular fractional shortening (multivariable ß -1.11 (0.31); P = 0.0005 in ≥ 5 live births vs nulliparous women) and worse cardiac mechanics, including global circumferential strain and longitudinal and radial dyssynchrony (P < 0.01 for all comparing ≥ 5 live births vs nulliparity). When examining HF subtypes, women with ≥ 5 live births were at higher risk of developing future HFrEF compared with nulliparous women (HR 1.93, 95% CI 1.19-3.12; P = 0.008); by contrast, a lower risk of HFpEF was observed (HR 0.58, 95% CI 0.37-0.91; P = 0.02). CONCLUSIONS: Greater numbers of live births are associated with worse cardiac structure and function. There was no association with overall HF, but a higher number of live births was associated with greater risk for incident HFrEF.

Arterial Stiffness and Cardiovascular Risk in Hypertension.

Arterial stiffness, a leading marker of risk in hypertension, can be measured at material or structural levels, with the latter combining effects of the geometry and composition of the wall, including intramural organization. Numerous studies have shown that structural stiffness predicts outcomes in models that adjust for conventional risk factors. Elastic arteries, nearer to the heart, are most sensitive to effects of blood pressure and age, major determinants of stiffness. Stiffness is usually considered as an index of vascular aging, wherein individuals excessively affected by risk factor exposure represent early vascular aging, whereas those resistant to risk factors represent supernormal vascular aging. Stiffness affects the function of the brain and kidneys by increasing pulsatile loads within their microvascular beds, and the heart by increasing left ventricular systolic load; excessive pressure pulsatility also decreases diastolic pressure, necessary for coronary perfusion. Stiffness promotes inward remodeling of small arteries, which increases resistance, blood pressure, and in turn, central artery stiffness, thus creating an insidious feedback loop. Chronic antihypertensive treatments can reduce stiffness beyond passive reductions due to decreased blood pressure. Preventive drugs, such as lipid-lowering drugs and antidiabetic drugs, have additional effects on stiffness, independent of pressure. Newer anti-inflammatory drugs also have blood pressure independent effects. Reduction of stiffness is expected to confer benefit beyond the lowering of pressure, although this hypothesis is not yet proven. We summarize different steps for making arterial stiffness measurement a keystone in hypertension management and cardiovascular prevention as a whole.

BCL11B Regulates Arterial Stiffness and Related Target Organ Damage.

[Figure: see text].

Matrix Gla Protein Levels Are Associated With Arterial Stiffness and Incident Heart Failure With Preserved Ejection Fraction.

OBJECTIVE: Arterial stiffness is a risk factor for cardiovascular disease, including heart failure with preserved ejection fraction (HFpEF). MGP (matrix Gla protein) is implicated in vascular calcification in animal models, and circulating levels of the uncarboxylated, inactive form of MGP (ucMGP) are associated with cardiovascular disease-related and all-cause mortality in human studies. However, the role of MGP in arterial stiffness is uncertain. Approach and Results: We examined the association of ucMGP levels with vascular calcification, arterial stiffness including carotid-femoral pulse wave velocity (PWV), and incident heart failure in community-dwelling adults from the Framingham Heart Study. To further investigate the link between MGP and arterial stiffness, we compared aortic PWV in age- and sex-matched young (4-month-old) and aged (10-month-old) wild-type and Mgp+/- mice. Among 7066 adults, we observed significant associations between higher levels of ucMGP and measures of arterial stiffness, including higher PWV and pulse pressure. Longitudinal analyses demonstrated an association between higher ucMGP levels and future increases in systolic blood pressure and incident HFpEF. Aortic PWV was increased in older, but not young, female Mgp+/- mice compared with wild-type mice, and this augmentation in PWV was associated with increased aortic elastin fiber fragmentation and collagen accumulation. CONCLUSIONS: This translational study demonstrates an association between ucMGP levels and arterial stiffness and future HFpEF in a large observational study, findings that are substantiated by experimental studies showing that mice with Mgp heterozygosity develop arterial stiffness. Taken together, these complementary study designs suggest a potential role of therapeutically targeting MGP in HFpEF.

Neighborhood characteristics and arterial stiffness among Black adults - Results from the Jackson Heart Study and Morehouse-Emory Cardiovascular Center for Health Equity.

INTRODUCTION: Poor quality neighborhood environments are independent risk factors for cardiovascular disease (CVD) but are understudied in Black adults, who face large CVD health disparities. Arterial stiffness, a marker of early vascular aging, precedes development of hypertension and adverse CVD events but the effect of neighborhood on arterial stiffness among Black adults remains unknown. OBJECTIVE: We compared the association between neighborhood environment and arterial stiffness among Black adults in Jackson, MS and Atlanta, GA. METHODS: We studied 1582 Black adults (mean age 53 ± 10, 35% male) living in Jackson, MS from the Jackson Heart Study (JHS) and 451 Black adults (mean age 53 ± 10, 39% male) living in Atlanta, GA from the Morehouse-Emory Cardiovascular Center for Health Equity (MECA) study, without known CVD. Neighborhood problems (includes measures of aesthetic quality, walking environment, food access), social cohesion (includes activity with neighbors), and violence/safety were assessed using validated questionnaires. Arterial stiffness was measured as pulse wave velocity (PWV) using magnetic resonance imaging in JHS and as PWV and augmentation index (AIx) using applanation tonometry (SphygmoCor, Inc.) in MECA. Multivariable linear regression models were used to examine the association between neighborhood characteristics and arterial stiffness, adjusting for potential confounders. RESULTS: Improved social characteristics, measured as social cohesion in JHS (ß = -0.32 [-0.63, -0.02], p = 0.04) and activity with neighbors (ß = -0.23 [-0.40, -0.05], p = 0.01) in MECA, were associated with lower PWV in both cohorts and lower AIx (ß = -1.74 [-2.92, - 0.56], p = 0.004) in MECA, after adjustment for CVD risk factors and income. Additionally, in MECA, better food access (ß = -1.18 [-2.35, - 0.01], p = 0.05) was associated with lower AIx and, in JHS, lower neighborhood problems (ß = -0.33 [-0.64, - 0.02], p = 0.04) and lower violence (ß = -0.30 [-0.61, 0.002], p = 0.05) were associated with lower PWV. CONCLUSION: Neighborhood social characteristics show an independent association with the vascular health of Black adults, findings that were reproducible in two distinct American cities.

Trends among platelet function, arterial calcium, and vascular function measures.

Arterial tonometry and vascular calcification measures are useful in cardiovascular disease (CVD) risk assessment. Prior studies found associations between tonometry measures, arterial calcium, and CVD risk. Activated platelets release angiopoietin-1 and other factors, which may connect vascular structure and platelet function. We analyzed arterial tonometry, platelet function, aortic, thoracic and coronary calcium, and thoracic and abdominal aorta diameters measured in the Framingham Heart Study Gen3/NOS/OMNI-2 cohorts (n = 3,429, 53.7% women, mean age 54.4 years ±9.3). Platelet reactivity in whole blood or platelet-rich plasma was assessed using 5 assays and 7 agonists. We analyzed linear mixed effects models with platelet reactivity phenotypes as outcomes, adjusting for CVD risk factors and family structure. Higher arterial calcium trended with higher platelet reactivity, whereas larger aortic diameters trended with lower platelet reactivity. Characteristic impedance (Zc) and central pulse pressure positively trended with various platelet traits, while pulse wave velocity and Zc negatively trended with collagen, ADP, and epinephrine traits. All results did not pass a stringent multiple test correction threshold (p < 2.22e-04). The diameter trends were consistent with lower shear environments invoking less platelet reactivity. The vessel calcium trends were consistent with subclinical atherosclerosis and platelet activation being inter-related.

What is the context? Prior research has reported that measures of vascular system-influencing proteins such as angiopoietin-2, arterial calcium plaque formation, and arterial stiffness assessed by tonometry are associated with CVD risk.Since activated platelets produce and release vascular proteins like angiopoietin when activated, and microparticles that interact with endothelium, release of the foregoing mediators could provide one way in which vascular structure and platelet function influence each other.To our knowledge, no prior studies have directly investigated associations between these measures in a large sample. This investigation relates platelet function to arterial tonometry, aortic and arterial diameter, and arterial calcium measures in the Framingham Heart Study (FHS) Gen3/NOS/OMNI-2 cohorts (n = 3,429).What's new? Generally, higher arterial calcium measures trended with higher platelet reactivity, whereas larger aortic diameters trended with lower platelet reactivity.Arterial tonometry measures had positive and negative trends with platelet functions, including platelet measures with opposite relations to negative-inverse carotid-femoral pulse wave velocity (niCFPWV) and characteristic impedance (Zc). All tonometry, calcium, and diameter results did not reach a more stringent multiple testing threshold (p < 2.22e-04).What's the impact? The aortic diameter trends are consistent with lower shear stress invoking less platelet reactivity.The vessel calcium trends are consistent with increased vascular calcium buildup that could provoke platelet activation, thereby contributing to increased blood clot risk. Conversely, increased platelet activation could contribute to increased inflammation and thrombosis, leading to calcification in the arterial wall.

A rapid review of evaluated interventions to inform the development of a resource to support the resilience of care home nurses.

BACKGOUND: Nurses working in care homes face significant challenges that are unique to that context. The importance of effective resilience building interventions as a strategy to enable recovery and growth in these times of uncertainty have been advocated. The aim of this rapid review was to inform the development of a resource to support the resilience of care home nurses. We explored existing empirical evidence as to the efficacy of resilience building interventions. undertaken with nurses. METHODS: We undertook a rapid review using quantitative studies published in peer reviewed journals that reported resilience scores using a valid and reliable scale before and after an intervention aimed at supporting nurse resilience. The databases; Cumulative Index to Nursing and Allied Health Literature, Medline and PsychInfo. and the Cochrane Library were searched. The searches were restricted to studies published between January 2011 and October 2021 in the English language. Only studies that reported using a validated tool to measure resilience before and after the interventions were included. RESULTS: Fifteen studies were included in this rapid review with over half of the studies taking place in the USA. No studies reported on an intervention to support resilience with care home nurses. The interventions focused primarily on hospital-based nurses in general and specialist contexts. The interventions varied in duration content and mode of delivery, with interventions incorporating mindfulness techniques, cognitive reframing and holistic approaches to building and sustaining resilience. Thirteen of the fifteen studies selected demonstrated an increase in resilience scores as measured by validated and reliable scales. Those studies incorporating 'on the job,' easily accessible practices that promote self-awareness and increase sense of control reported significant differences in pre and post intervention resilience scores. CONCLUSION: Nurses continue to face significant challenges, their capacity to face these challenges can be nurtured through interventions focused on strengthening individual resources. The content, duration, and mode of delivery of interventions to support resilience should be tailored through co-design processes to ensure they are both meaningful and responsive to differing contexts and populations.

Exploring the experiences of people living with dementia in Dementia Friendly Communities (DFCs) in Northern Ireland: a realist evaluation protocol.

BACKGROUND: The aim of this study is to 1) explore the experiences of people living with dementia interacting with DFCs and 2) identify factors that influence empower and support people living with dementia to live successfully in DFCs. The main elements of a DFC are related to people; communities; organisations and partnerships. There are over 200 organisations recognised as dementia-friendly in Northern Ireland (NI). This realist evaluation is to understand how DFCs work for people living with dementia, how positive outcomes are achieved, for whom and in what contexts do DFCs work best. METHODS: A realist evaluation using case study methodology. The process evaluation includes a realist review of the literature, non-participant observation of people living with dementia in their local communities, semi-structured interviews to explore the facilitators and barriers to living well in DFCs and focus groups comprised of people living with dementia, family caregivers and people working in DFCs to support Context- Mechanisms and Outcomes (CMOs). This four-stage realist assessment cycle is used, including iterative rounds of theory development, data gathering, and theory testing. In the end, analysis will reveal context mechanisms that influence how dementia-friendly communities operate and present an initial theory of how people think, which, if adopted, may be able to alter current contexts so that "key" mechanisms are activated to generate desired outcomes. DISCUSSION: To give confidence in moving from hypothetical constructions about how DFCs could function to explanations of possible or observable causal mechanisms, the realist evaluation of a complex intervention incorporates a variety of evidence and perspectives. Despite playing a significant role in a person with dementia's everyday life, it appears that little is known about how communities function to achieve intended results. Even though there has been a lot of work to pinpoint the fundamentals and crucial phases of building DFCs, it is still unclear how people living with dementia benefit the most from these communities. This study intends to advance our understanding of how outcomes are produced for people living with dementia by contributing to the underlying theory of DFCs as well as addressing the primary research objectives.

Translating 'dementia friends' programme to undergraduate medical and nursing practice: a qualitative exploration.

INTRODUCTION: Dementia awareness is a key priority of medical and nursing pre-registration education. The 'dementia friends' programme is an internationally recognised and accredited dementia awareness workshop that is led by a trained facilitator. While this programme has been associated with positive outcomes, few studies have examined how medical and nursing students apply their learning in practice after the workshop. The aim of his study was to explore how nursing and medical students apply the dementia friend's programme into practice when caring for people living with dementia. METHODS: Seven focus-group interviews were conducted with 36 nursing students and 14 medical students at one university in Northern Ireland (n = 50), following 'the dementia friends programme. Interview guides were co-designed alongside people living with dementia. Interviews were audio-recorded, transcribed verbatim and analysed using thematic analysis. Ethical approval was granted for this study. RESULTS: Four themes emerged: 'reframing dementia', which highlighted how the education had enabled students to actively empower and support people living with dementia in practice; 'dementia friendly design', which focused on how students had modified their clinical environments when providing care for people living with dementia, 'creative communication', which considered how students had used their education to adapt their verbal and non-verbal communication with people living with dementia and 'realities of advanced dementia' which contemplated how students believed their dementia education could be improved within their current curriculum. DISCUSSION: The Dementia Friends programme has actively supported nursing and medical students to improve the lives of people with dementia in their care through environmental adaptions and creative approaches to communication. This study provides an evidence base that supports the provision of 'a dementia friends programme to healthcare professional students. The study also highlights how this education can actively influence how nursing and medical students support people living with dementia in their practice in the months and years after education.

Methodological and ethical challenges in designing and conducting research at the end of life: A systematic review of qualitative and textual evidence.

AIM: This systematic review aims to identify methodological and ethical challenges in designing and conducting research at the end of life from the perspective of researchers and provide a set of recommendations. BACKGROUND: Conducting research with patients and family carers facing end-of-life issues is ethically and methodologically complex. DESIGN: A systematic review was conducted. DATA SOURCES: Four databases (MEDLINE, EMBASE, CINAHL, PsycInfo) were searched from inception until the end of 2021 in February 2022. REVIEW METHODS: The Preferred Reporting Items for Systematic Reviews was followed, and the JBI Approach to qualitative synthesis was used for analysis. RESULTS: Seventeen of 1983 studies met inclusion criteria. Data were distilled to six main themes. These included (1) the need for flexibility at all stages of the research process; (2) careful attention to timing; (3) sensitivity in approach; (4) the importance of stakeholder collaboration; (5) the need for unique researcher skills; and (6) the need to deal with the issue of missing data. CONCLUSION: The findings illuminate several considerations that can inform training programmes, ethical review processes and research designs when embarking on research in this field.

Evaluation of a dementia awareness game for undergraduate nursing students in Northern Ireland: a Pre-/Post-Test study.

INTRODUCTION: Although it is possible to live well with dementia and many individuals with dementia lead active lives with the help of family, friends, and communities, the general impression of dementia is frequently negative. Dementia is a global health issue. Despite this, little research has been done on the effects of innovative dementia education strategies among undergraduate nursing students. The aim of this study was therefore to assess if this serious digital game, originally intended for the public, could increase knowledge about dementia in first-year nursing students. METHODS: The intervention was a digital serious game called "The Dementia Game", which was available to students throughout February 2021, to a convenience sample of first-year undergraduate nursing students (n = 560) completing a BSc Honours Nursing Degree programme in one university in Northern Ireland. The game was evaluated using a pretest-posttest design. The questionnaire comprised of a 30- item true- false Alzheimer's Disease Knowledge Scale (ADKS), which covers risk factors, assessment and diagnosis, symptoms, course, life impact, caregiving and treatment and management. Data were analysed using paired t-tests and descriptive statistics. RESULTS: Overall dementia knowledge increased significantly after playing the game. Pre-test to post-test increases were observed across a range of seven categories of dementia knowledge (life impact, risk factors, symptoms, treatment, assessment, caregiving and trajectory), with particularly large increases in knowledge of trajectory and risk factors, as shown using paired t-tests. All pre-test to post-test comparisons were significant at the p < 0.001 level. CONCLUSIONS: A short serious digital game on dementia improved first-year student's knowledge about dementia. Undergraduate students also expressed that this approach to dementia education was effective in improving their knowledge about the disease.

'Whose role is it anyway?' Experiences of community nurses in the delivery and support of oral health care for older people living at home: a grounded theory study.

BACKGROUND: Older people who receive care at home are likely to require support with oral health care. Community nurses, who are also referred to as district or home care nurses, have an important role with this population. This is because they are the healthcare professionals who are most likely to encounter this population, who may also not be receiving regular dental care or oral health promotion. However, few studies have explored community nursing experiences in the delivery and support of oral healthcare for older people living at home. METHODS: A grounded theory approach was used to explore experiences of community nurses in the delivery and support of oral health care for older people living at home. Fifteen practising community nurses from the United Kingdom participated in one-to-one semi-structed interviews from May 2021 to December 2021. These interviews were audio-recorded, transcribed verbatim and analysed using constant comparative analysis. Ethical approval was obtained for this study prior to data collection. RESULTS: Four categories emerged from the data to support development of the core phenomena. These four categories were: (1) Education, in relation to what community nurses knew about oral health, (2) Practice, with regards to how community nurses delivered oral health care to older people in their own home, (3) Confidence, with consideration to the extent to which this supported or impeded community nurses in providing oral healthcare to older people and (4) Motivation, in terms of the extent to which community nurses thought they could or should influence future practice improvement in the area. The core category was (C) Uncertainty as it was both present and central across all four categories and related to community nursing understanding about their specific role, and the role of other professionals, with reference to oral health of their patients. CONCLUSIONS: This study reveals community nurses' uncertainty in providing oral healthcare to older adults at home. Emphasising comprehensive and continuous oral health education can boost nurses' confidence in patient support. Interprofessional collaboration and clear role definitions with oral health professionals are crucial for improving oral health outcomes in this vulnerable population.

Evaluation of a co-designed educational e-resource about oral health for community nurses: study protocol.

BACKGROUND: Oral health is a crucial aspect of health and wellbeing for older people. Poor oral health has been found to significantly increase the risk of chronic health conditions and poor quality of life for older people. Nurses practicing in the community are well-placed to provide oral health care to older people in their own homes, yet there has been little research in this field to develop accessible support for them to do so. Previous literature, reviewed in an earlier phase of this work, revealed that there has, historically, been a paucity of oral health care education for nurses and very few educational resources have been developed in this field. METHODS: This study will evaluate an educational e-resource which has been co-designed by service users, carers and clinicians. In the first phase of research, evidence of promise will be evaluated by analysing quantitative data on community nurses' oral health attitudes and self-efficacy for oral health assessments of older people. In the second phase of research, facilitators and barriers to community nurses' provision of oral health care to older people and the acceptability of the educational e-resource will be evaluated. DISCUSSION: This research will investigate the potential of an educational e-resource to improve community nurses' capabilities to deliver oral health care to older people in their own homes. This research will inform both future intervention design and understanding of community nurses' knowledge and attitudes about oral health care. Facilitators and barriers to provision of this care for older people will also be explored.