Validation of an automated wireless system for sleep monitoring during daytime naps.

An automated wireless system (WS) for sleep monitoring was recently developed and validated for assessing nighttime sleep. Here, we aimed to evaluate the validity of the WS to correctly monitor daytime sleep during naps compared to polysomnography (PSG). We found that the WS underestimated wake, sleep onset latency, and wake after sleep onset. Meanwhile, it overestimated total sleep time, sleep efficiency, and duration of REM sleep. Sensitivity was moderate for wake (58.51%) and light sleep (66.92%) and strong for deep sleep (83.46%) and REM sleep (82.12%). These results demonstrated that the WS had a low ability to detect wake and systematically overscored REM sleep, implicating the WS as an inadequate substitute for PSG in diagnosing sleep disorders or for research in which sleep staging is essential.

The benefit of offline sleep and wake for novel object recognition.

How do we segment and recognize novel objects? When explicit cues from motion and color are available, object boundary detection is relatively easy. However, under conditions of deep camouflage, in which objects share the same image cues as their background, the visual system must reassign new functional roles to existing image statistics in order to group continuities for detection and segmentation of object boundaries. This bootstrapped learning process is stimulus dependent and requires extensive task-specific training. Using a between-subject design, we tested participants on their ability to segment and recognize novel objects after a consolidation period of sleep or wake. We found a specific role for rapid eye movement (REM, n = 43) sleep in context-invariant novel object learning, and that REM sleep as well as a period of active wake (AW, n = 35) increased segmentation of context-specific object learning compared to a period of quiet wake (QW, n = 38; p = .007 and p = .017, respectively). Performance in the non-REM nap group (n = 32) was not different from the other groups. The REM sleep enhancement effect was especially robust for the top performing quartile of subjects, or "super learners" (p = .037). Together, these results suggest that the construction and generalization of novel representations through bootstrapped learning may benefit from REM sleep, and more specific object learning may also benefit from AW. We discuss these results in the context of shared electrophysiological and neurochemical features of AW and REM sleep, which are distinct from QW and non-REM sleep.

Risk Factors for Natural Cause Mortality in Schizophrenia.

Importance: Schizophrenia is associated with premature mortality from mostly natural causes. Decreased cognitive functioning has been identified as a determinant of mortality in the general population. However, there have been few prospective studies of this issue in persons with schizophrenia. Objective: To examine whether lower cognitive functioning is a risk factor for natural cause mortality in schizophrenia. Design, Setting, and Participants: This prospective cohort study included persons with schizophrenia or schizoaffective disorder enrolled between February 1, 1999, and December 31, 2022, at a nonprofit psychiatric system in Baltimore, Maryland. Participants were evaluated using the Repeatable Battery for the Assessment of Neuropsychological Status (RBANS) and other clinical measures. Exposure: Natural cause mortality. Main Outcomes and Measures: Associations of cognitive function, obesity, tobacco smoking, and medical conditions with natural cause mortality were evaluated using Cox proportional hazards regression models. Results: Of the 844 participants enrolled (mean [SD] age, 39.6 [12.1] years; 533 male [63.2%]), 158 (18.7%) died of natural causes during a median follow-up of 14.4 years (range, 7.0 days to 23.9 years). The most significant factor associated with mortality was lower cognitive functioning as measured by the RBANS (Cox coefficient, -0.04; 95% CI, -0.05 to -0.03; z = -5.72; adjusted P < .001). Additional factors independently associated with mortality included the diagnosis of an autoimmune disorder (hazard ratio [HR], 2.86; 95% CI, 1.83-4.47; z = 4.62; adjusted P < .001), tobacco smoking (HR, 2.26; 95% CI, 1.55-3.30; z = 4.23; adjusted P < .001), diagnosis of chronic obstructive pulmonary disease (HR, 3.31; 95% CI, 1.69-6.49; z = 3.48; adjusted P = .006), body mass index as a continuous variable (HR, 1.06; 95% CI, 1.02-1.09; z = 3.30; adjusted P = .01), diagnosis of a cardiac rhythm disorder (HR, 2.56; 95% CI, 1.40-4.69; z = 3.06; adjusted P = .02), and being divorced or separated (HR, 1.80; 95% CI, 1.22-2.65; z = 2.97; adjusted P = .02). An RBANS score below the 50th percentile displayed a joint association with being a smoker, having an elevated body mass index, and having a diagnosis of an autoimmune or a cardiac rhythm disorder. Conclusions and Relevance: In this prospective cohort study, lower cognitive functioning was a risk factor for natural cause mortality in schizophrenia. Efforts should be directed at methods to improve cognitive functioning, particularly among individuals with additional risk factors.

Engaging the Great Circle: a qualitative study of the Confederated Tribes of Grand Ronde's mobile medication unit

BACKGROUND: The Confederated Tribes of the Grand Ronde Community of Oregon began a Mobile Medication Unit (MMU) as part of their Great Circle Recovery Opioid Treatment Program (OTP) to address elevated rates of opioid use disorder (OUD) among American Indians and Alaska Natives in Oregon. The MMU provides methadone or buprenorphine for individuals with OUD, enrolled in the OTP, who are living either on the reservation or in surrounding rural communities. An implementation study describes the service through document review and qualitatively assesses patient and staff experiences and the perceived barriers and facilitators to mobile services. METHODS: Semi-structured qualitative interviews with patients (n = 11), MMU staff (n = 5), and the state opioid treatment authority (n = 1) gathered details on the initiative's development and operations. Provider interviews probed implementation experiences. Patient interviews focused on their experiences with the MMU and staff, changes in quality of life and recommendations for enhancing treatment. Interviews were transcribed and analysed using a Thematic Analysis approach. RESULTS: Staff themes identified two driving forces (i.e. staff desire for an inclusive approach to wellness that is accessible to all community members; the catalysts for the MMU), two steps toward MMU development (i.e. Tribal approvals and support; the construction and maintenance of community relationships) and two perspectives on MMU implementation and impact (i.e. initial implementation barriers; facilitators and observations of how the MMU reduced stigma associated with agonist therapy). Patients' themes noted the MMU's professional and 'caring' environment, accessible rural locations and general suggestions including culturally responsive ancillary services. CONCLUSION: The Great Circle MMU enhanced access to opioid agonist therapy for people with OUD (i.e. American Indians/Alaska Natives, and non-natives) living in rural communities. The Confederated Tribes of Grand Ronde operates the first Tribally owned OTP MMU, grounded in cultural humility and committed to Tribal members and the great circle of the larger community.

Anti-spike antibody responses to SARS-CoV-2 mRNA vaccines in people with schizophrenia and schizoaffective disorder.

Importance: Individuals with schizophrenia are at higher risk for severe COVID-19 illness and severe breakthrough infection following vaccination. It is unclear whether immune response to vaccination differs in this population. Objective: To assess whether anti-SARS-CoV-2 spike antibody titers after vaccination differ in people with a diagnosis of schizophrenia or schizoaffective disorder (SZ) compared to controls without a psychiatric disorder. Design: This cohort study assessed antibody response following the first and second dose of mRNA vaccines at longitudinal timepoints, up to 7 weeks following the first dose of vaccine. Setting: A multi-center study including psychiatric healthcare settings in the United States and Europe. Participants: 205 adults with no history of COVID-19 infection, including 106 individuals with SZ and 99 controls without a psychiatric disorder, who received their first dose of SARS-CoV-2 mRNA vaccine between December 20, 2020 and May 27, 2021. Main outcomes and measures: Mean SARS-CoV-2 anti-Spike IgG antibody levels within 7 weeks after the first dose of vaccination. Results: A total of 205 individuals (mean [SD] age, 44.7 [12.0] years; 90 [43.9%] male) were included, of which 106 (51.7%) were diagnosed with SZ. SZ was associated with lower mean log antibody levels (-0.15; 95% CI, -0.27 to -0.03, P = 0.016) after adjusting for age, sex, body mass index, smoking, days since vaccination, and vaccine manufacturer. In secondary analyses of dose-specific responses, SZ was associated with a lower mean log antibody level after the second dose of vaccine (-0.23; 95% CI -0.39 to -0.06, P = 0.006), but not the first dose of vaccine (0.00; 95% CI -0.18- 0.19, P = 0.96). Conclusions and Relevance: In this cohort study of individuals with SZ and a control group without psychiatric disorders, SZ was associated with lower SARS-CoV-2 anti-spike antibody levels following 2 doses of SARS-CoV-2 mRNA vaccination. This highlights the need for further studies assessing vaccine immunogenicity in individuals with schizophrenia.

Cigarette smoking is associated with Herpesviruses in persons with and without serious mental illness.

INTRODUCTION: Herpesviruses are recognized as major causes of human diseases. Following initial infection, Herpesviruses can undergo cycles of reactivation controlled largely by the immune system. Cigarette smoking is an important modulator of the immune system particularly in individuals with serious mental illness where smoking is associated with increased rates of cardiopulmonary diseases and mortality. However, the effect of smoking on Herpesviruses has not been extensively studied. METHODS: In this nested cohort study, cigarette smoking was assessed in 1323 persons with serious mental illness or without a psychiatric disorder ascertained in a psychiatric health care system and the adjacent community. Participants provided a blood sample from which were measured IgG class antibodies to five human Herpesviruses: Cytomegalovirus (CMV), Epstein Barr Virus (EBV), Herpes Simplex Virus-Type 1 (HSV-1); Varicella Zoster Virus (VZV); and Human Herpes Virus-Type 6 (HHV-6). The associations between smoking variables and antibody levels to the Herpesviruses were analyzed among diagnostic groups in multiple regression models adjusted for age, sex, and race. RESULTS: Current smoking was significantly associated with higher levels of antibodies to CMV (coefficient .183, 95% CI .049, .317, p<.001, q<.007) and the three EBV proteins (EBV NA -(coefficient .088, 95% CI .032, .143, p = .002, q<.014; EBV Virion - coefficient .100, 95% CI .037, .163, p = .002, q<.014; and EBV VCA - coefficient .119, 95% CI .061, .177, p = .00004, q<.0016). The amount of cigarettes smoked was also correlated with higher levels of antibodies to the three EBV proteins. Interaction analyses indicated that the association between cigarette smoking and levels of antibodies to CMV and EBV was independent of diagnostic group. Cigarette smoking was not significantly associated with the level of antibodies to HSV-1, VZV, or HHV-6. CONCLUSIONS: Individuals who smoke cigarettes have increased levels of IgG antibodies to CMV and EBV. Cigarette smoking may be a contributory factor in the relationship between CMV, EBV and chronic somatic disorders associated with these viruses.

Clinical predictors of driving status in Huntington's disease.

The aim of this study was to identify the motor, cognitive, and behavioral determinants of driving status and risk factors for driving cessation in Huntington's disease (HD). Seventy-four patients with HD were evaluated for cognitive, motor, psychiatric, and functional status using a standardized battery (Unified Huntington's Disease Rating Scale [UHDRS] and supplemental neuropsychological testing) during a research clinic visit. Chart review was used to categorize patients into two driving status categories: (1) "currently driving" included those driving and driving but with clinician recommendation to restrict, and (2) "not driving" included those with clinician recommendation to cease driving and those not currently driving because of HD. Multi- and univariate logistic regression was used to identify significant clinical predictors of those driving versus not driving. Global cognitive performance and UHDRS Total Functional Capacity scores provided the best predictive model of driving cessation (Nagelkerke R(2) = 0.65; P < 0.0001). Measures of learning (P = 0.006) and psychomotor speed/attention (P = 0.003) accounted for the overall cognitive finding. In univariate analyses, numerous cognitive, motor, and daily functioning items were significantly associated with driving. Although driving status is associated with many aspects of the disease, results suggest that the strongest association is with cognitive performance. A detailed cognitive evaluation is an important component of multidisciplinary clinical assessment in patients with HD who are driving.

Anxious symptoms and cognitive function in non-demented older adults: an inverse relationship.

BACKGROUND: The goals of this study were to determine the relationship between anxious symptoms and cognitive functioning in a non-demented, community-dwelling older adults sample (n = 48), and to determine the effect of depressive symptoms upon this relationship. METHODS: Anxious and depressive symptoms were assessed using the Symptom Checklist 90--Revised. Cognitive functioning was assessed with the Repeatable Battery for the Assessment of Neuropsychological Status. RESULTS: Results indicated that although both cognitive functioning and anxious symptoms were within normal limits in this sample, anxious symptoms showed a significant, inverse relationship with global cognitive function [r(47) = -0.400, p = 0.005]. In addition, specific relationships were noted between severity of anxious symptoms and visuospatial/constructional ability as well as immediate and delayed memory. With regard to the secondary objective, both anxiety and depressive symptoms together accounted for the highest level of variance [R(2) = 0.175, F(2, 45) = 4.786, p = 0.013] compared with anxiety [R(2) (47) = 0.160, p = 0.005] and depression [R(2) (47) = 0.106, p = 0.024] alone. Nevertheless, neither anxious nor depressive symptoms emerged as a unique correlate with cognitive ability [r(47) = -0.278, p = 0.058; r(48) = -0.136, p = 0.363, respectively]. CONCLUSION: This study demonstrates that subthreshold anxiety symptoms and cognitive functioning are significantly related even among generally healthy older adults whose cognitive ability and severity of anxious symptoms are within broad normal limits. These findings have implications both for clinical care of older patients, as well as for cognitive research studies utilizing this population.

Patterns of serotonergic antidepressant usage in prodromal Huntington disease.

Antidepressant usage in prodromal Huntington Disease (HD) remains uncharacterized, despite its relevance in designing experiments, studying outcomes of HD, and evaluating the efficacy of therapeutic interventions. We searched baseline medication logs of 787 prodromal HD and 215 healthy comparison (HC) participants for antidepressant use. Descriptive and mixed-effects logistic regression modeling characterized usage across participants. At baseline, approximately one in five prodromal HD participants took antidepressants. Of those, the vast majority took serotonergic antidepressants (selective serotonin reuptake inhibitor (SSRI) or serotonin/norepinephrine reuptake inhibitor (SNRI)). Significantly more prodromal HD participants used serotonergic antidepressants than their HC counterparts. Because of the prevalence of these medications, further analyses focused on this group alone. Mixed-effects logistic regression modeling revealed significant relationships of both closer proximity to diagnosis and female sex with greater likelihood to be prescribed a serotonergic antidepressant. More prodromal HD participants took antidepressants in general and specifically the subclass of serotonergic antidepressants than their at-risk counterparts, particularly when they were closer to predicted time of conversion to manifest HD. These propensities must be considered in studies of prodromal HD participants.

The kappa opioid receptor antagonist JDTic attenuates alcohol seeking and withdrawal anxiety.

The role of kappa-opioid receptors (KOR) in the regulation of alcohol-related behaviors is not completely understood. For example, alcohol consumption has been reported to increase following treatment with KOR antagonists in rats, but was decreased in mice with genetic deletion of KOR. Recent studies have further suggested that KOR antagonists may selectively decrease alcohol self-administration in rats following a history of dependence. We assessed the effects of the KOR antagonist JDTic on alcohol self-administration, reinstatement of alcohol seeking induced by alcohol-associated cues or stress, and acute alcohol withdrawal-induced anxiety ('hangover anxiety'). JDTic dose-dependently reversed hangover anxiety when given 48 hours prior to testing, a time interval corresponding to the previously demonstrated anxiolytic efficacy of this drug. In contrast, JDTic decreased alcohol self-administration and cue-induced reinstatement of alcohol seeking when administered 2 hours prior to testing, but not at longer pre-treatment times. For comparison, we determined that the prototypical KOR antagonist nor-binaltorphimine can suppress self-administration of alcohol at 2 hours pre-treatment time, mimicking our observations with JDTic. The effects of JDTic were behaviorally specific, as it had no effect on stress-induced reinstatement of alcohol seeking, self-administration of sucrose, or locomotor activity. Further, we demonstrate that at a 2 hours pre-treatment time JDTic antagonized the antinociceptive effects of the KOR agonist U50,488H but had no effect on morphine-induced behaviors. Our results provide additional evidence for the involvement of KOR in regulation of alcohol-related behaviors and provide support for KOR antagonists, including JDTic, to be evaluated as medications for alcoholism.

Psychometric properties of the Patient Assessment Of Chronic Illness Care measure: acceptability, reliability and validity in United Kingdom patients with long-term conditions.

BACKGROUND: The Patient Assessment of Chronic Illness Care (PACIC) is a US measure of chronic illness quality of care, based on the influential Chronic Care Model (CCM). It measures a number of aspects of care, including patient activation; delivery system design and decision support; goal setting and tailoring; problem-solving and contextual counselling; follow-up and coordination. Although there is developing evidence of the utility of the scale, there is little evidence about its performance in the United Kingdom (UK). We present preliminary data on the psychometric performance of the PACIC in a large sample of UK patients with long-term conditions. METHOD: We collected PACIC, demographic, clinical and quality of care data from patients with long-term conditions across 38 general practices, as part of a wider longitudinal study. We assess rates of missing data, present descriptive and distributional data, assess internal consistency, and test validity through confirmatory factor analysis, and through associations between PACIC scores, patient characteristics and related measures. RESULTS: There was evidence that rates of missing data were high on PACIC (9.6% - 15.9%), and higher than on other scales used in the same survey. Most PACIC sub-scales showed reasonable levels of internal consistency (alpha = 0.68 - 0.94), responses did not demonstrate high skewness levels, and floor effects were more frequent (up to 30.4% on the follow up and co-ordination subscale) than ceiling effects (generally <5%). PACIC demonstrated preliminary evidence of validity in terms of measures of long-term condition care. Confirmatory factor analysis suggested that the five factor PACIC structure proposed by the scale developers did not fit the data: reporting separate factor scores may not always be appropriate. CONCLUSION: The importance of improving care for long-term conditions means that the development and validation of measures is a priority. The PACIC scale has demonstrated potential utility in this regard, but further assessment is required to assess low levels of completion of the scale, and to explore the performance of the scale in predicting outcomes and assessing the effects of interventions.

Experiences of Persons With Serious Mental Illness During the COVID-19 Pandemic.

OBJECTIVE: This study aimed to characterize the experiences of persons with serious mental illness during the COVID-19 pandemic. METHODS: Adults with schizophrenia, bipolar disorder, major depression, or no psychiatric disorder (N=195) were interviewed between July 2020 and January 2021. All were previously enrolled in a cohort study. The interviews focused on mental distress and suicidal thoughts, the impact of the pandemic and pandemic-related worries, tobacco and alcohol use, and access to care. Responses of persons with serious mental illness were compared with responses of those without a psychiatric disorder by using multivariate ordered logistic regression analyses. For a subset of participants, responses about suicidal ideation were compared with their responses prior to the pandemic. RESULTS: Compared with participants with no psychiatric disorder, individuals with schizophrenia were more likely to endorse that they felt overwhelmed or anxious, had difficulty concentrating, or were concerned about medical bills and having enough food; they also reported significantly increased tobacco smoking. Individuals with bipolar disorder also reported more COVID-19-related worries than did participants without a psychiatric disorder. Overall, those with a psychiatric disorder reported more frequent mental distress and more recent missed medical visits and medications than did those with no psychiatric disorder. However, participants with serious mental illness did not report a higher rate of suicidal thoughts compared with their prepandemic responses. CONCLUSIONS: The pandemic poses significant challenges to individuals with serious mental illness in terms of COVID-19-related distress. Psychiatric services should proactively address the emotional distress and worries associated with the pandemic.

Lost2PrEP: Understanding Reasons for Pre-Exposure Prophylaxis and Sexual Health Care Disengagement Among Men Who Have Sex with Men Attending a Sexual Health Clinic at a Large Urban Academic Medical Center in New York City.

Pre-exposure prophylaxis (PrEP) prevents HIV, but low rates of retention in care limit its effectiveness. We conducted a prospective survey-based study to investigate reasons for PrEP disengagement among men who have sex with men attending a sexual health clinic at a large urban academic medical center in New York City who were lost to follow up; surveys asked about current PrEP status, reasons for disengagement, attitudes toward PrEP, substance use, sexual practices, and behavioral/social determinants of health. Outreach attempts were made to 634 patients; majority of eligible participants were unable to be contacted (59%). Among those who agreed to participate (n = 175), 21% asked to re-establish care. Among those who completed the questionnaire (n = 86), 36% were taking PrEP. The most common reasons for PrEP discontinuation were cost/lack of insurance coverage (31%), decreased HIV risk perception (29%), and side effects (16%). Among those with decreased perception of risk, 62% were less sexually active, 38% were no longer engaging in anal sex, and 31% were using condoms for prevention. Participants reported that free medication (60%), having a sexual partner recommend PrEP (13%), and being able to receive PrEP from a primary care provider (13%) would encourage restarting PrEP. Findings were limited by low response rate (12% of eligible subjects completed the survey) and lack of Spanish-language questionnaires. Understanding reasons for loss-to-PrEP follow-up is essential for HIV prevention. Many people lost to follow up still desired PrEP, underscoring the importance of outreach, benefits navigators, and expansion of PrEP into primary care settings.

Why do patients fail to follow long term treatment?

To enhance their understanding of issues around adherence to treatment, eight health professionals adhered to a randomly selected six-week treatment regimen suitable for patients with type 1 diabetes. These regimens are designed to promote optimal diabetes control and promote patients' health and wellbeing. The participants were expected to undertake a number of invasive tasks, including blood-glucose monitoring and the administration of placebo injections. The extent to which members of the team felt able to manage their care was measured using self-reported questionnaires and their reflections were documented throughout the trial. The trial forced the team to question their expectations of children and young people with diabetes, and those of their parents. It also gave them an insight into factors that influence adherence to treatment.

Risk factors for natural cause mortality in a cohort of 1494 persons with serious mental illness.

Persons with serious mental illness die on average more than 10 years younger than those in the overall population, mostly due to natural causes. Previous studies have identified predictors of natural cause mortality in this population but few have been prospective studies using clinical variables from in-person evaluations. A cohort of 1494 individuals with schizophrenia, bipolar disorder, or major depressive disorder were assessed at baseline and mortality status was determined from the US National Death Index after up to 20 years of follow-up. Analyses included multivariate Cox proportional hazard models to determine independent predictors of natural cause mortality. A total of 125 (8.4%) individuals died of natural causes. In multivariate models, the strongest predictor of mortality after age was tobacco smoking at baseline with a dose-related effect. Having diabetes, a cardiovascular condition, particularly hypertension, and lower cognitive functioning were also significant risks, along with divorced/separated status. The receipt of gabapentin or fluoxetine also significantly increased mortality risk. Premature death can be reduced by smoking cessation and the improved management of conditions such as hypertension and diabetes.

Exposure to Epstein Barr virus and cognitive functioning in individuals with schizophrenia.

Cognitive deficits are a central feature of schizophrenia whose etiology is not fully understood. Epstein Barr Virus (EBV) is a potentially neurotropic infectious agent that can generate persistent infections with immunomodulatory effects. Previous studies have found an association between EBV antibodies and cognitive functioning in different populations, but there has been limited investigation in schizophrenia. In this study, 84 individuals with schizophrenia were administered a comprehensive neuropsychological battery, the MATRICS Consensus Cognitive Battery (MCCB). Participants also provided a blood sample, from which antibodies to the EBV whole virion and specific proteins were measured. Multivariate models were constructed to determine the association between these antibodies and cognitive performance on the MCCB overall and domain scores. Using these models, we found a significant association between the MCCB overall percent composite score and level of antibodies to the EBV Nuclear Antigen-1 (EBNA-1) protein, the Viral Capsid Antigen (VCA) protein, and the EBV whole virion. A significant association was also found for the MCCB social cognition domain with the level of antibodies to the EBV Nuclear Antigen-1 (EBNA-1) protein, the Viral Capsid Antigen (VCA) protein, and the EBV whole virion. In all cases, a higher level of antibodies was associated with a lower level cognitive performance. These findings suggest that exposure to EBV may contribute to cognitive deficits in schizophrenia, a finding which may have implications for new methods of prevention and treatment.

A graphic elicitation technique to represent patient rights.

BACKGROUND: A patient charter is an explicit declaration of the rights of patients within a particular health care setting. In early 2020 the Save the Children Emergency Health Unit deployed to Cox's Bazar Bangladesh to support the establishment of a severe acute respiratory infection isolation and treatment centre as part of the COVID-19 response. We developed a charter of patient rights and had it translated into Bangla and Burmese; however, the charter remained inaccessible to Rohingya and members of the host community with low literacy. METHODS: To both visualise and contextualise the patient charter we undertook a graphic elicitation method involving both the Rohingya and host communities. We carried out two focus group discussions during which we discussed the charter and agreed how best to illustrate the individual rights contained therein. RESULTS: Logistical constraints and infection prevention and control procedures limited our ability to follow up with the original focus group participants and to engage in back-translation as we had planned; however, we were able to elicit rich descriptions of each right. Reflecting on our method we were able to identify several key learnings relating to: 1) our technique for eliciting feedback on the charter verbatim versus a broader discussion of concepts referenced within each right, 2) our decision to include both men and women in the same focus group, 3) our decision to ask focus group participants to describe specific features of each illustration and how this benefited the inclusivity of our illustrations, and 4) the potential of the focus groups to act as a means to introduce the charter to communities. CONCLUSIONS: Though executing our method was operationally challenging we were able to create culturally appropriate illustrations to accompany our patient charter. In contexts of limited literacy it is possible to enable access to critical clinical governance and accountability tools.

Management of Severe Hemiballismus: Treatment Challenges in the Acute Inpatient Rehabilitation Setting: A Case Presentation.

We report a case of a patient with profound right-sided hemiballismus resulting from an acute unilateral left thalamic lesion. The hemiballismus was significant and persistent, resulting in profound functional disability. We discuss the use of low-dose haloperidol in conjunction with acute rehabilitation in the treatment of hemiballismus, resulting in decreased amplitude and frequency of adventitious movements and leading to substantial functional gains in our patient. To our knowledge, this is the first extensive report of successful rehabilitation of a patient with functionally disabling hemiballismus. LEVEL OF EVIDENCE: V.

Care plans and care planning in the management of long-term conditions in the UK: a controlled prospective cohort study.

BACKGROUND: In the UK, the use of care planning and written care plans has been proposed to improve the management of long-term conditions, yet there is limited evidence concerning their uptake and benefits. AIM: To explore the implementation of care plans and care planning in the UK and associations with the process and outcome of care. DESIGN AND SETTING: A controlled prospective cohort study among two groups of patients with long-term conditions who were similar in demographic and clinical characteristics, but who were registered with general practices varying in their implementation of care plans and care planning. METHOD: Implementation of care plans and care planning in general practice was assessed using the 2009-2010 GP Patient Survey, and relationships with patient outcomes (self-management and vitality) were examined using multilevel, mixed effects linear regression modelling. RESULTS: The study recruited 38 practices and 2439 patients. Practices in the two groups (high and low users of written documents) were similar in structural and population characteristics. Patients in the two groups of practices were similar in demographics and baseline health. Patients did demonstrate significant differences in reported experiences of care planning, although the differences were modest. Very few patients in the cohort reported a written plan that could be confirmed. Analysis of outcomes suggested that most patients show limited change over time in vitality and self-management. Variation in the use of care plans at the practice level was very limited and not related to patient outcomes over time. CONCLUSION: The use of written care plans in patients with long-term conditions is uncommon and unlikely to explain a substantive amount of variation in the process and outcome of care. More proactive efforts at implementation may be required to provide a rigorous test of the potential of care plans and care planning.

Multimorbidity and delivery of care for long-term conditions in the English National Health Service: baseline data from a cohort study.

OBJECTIVES: Many patients with long-term conditions have multiple conditions. Current delivery of care is not designed around their needs and they may face barriers to effective self-management. This study assessed the relationships between multimorbidity, the delivery of care, and self-management. METHODS: We surveyed 2439 patients with long-term conditions concerning their experience of the delivery of care and self-management in England in 2011. We assessed multimorbidity in terms of a count of long-term conditions and the presence of 'probable depression'. We explored the relationships between multimorbidity, patient experience of the delivery of care, and self-management RESULTS: Neither measure of multimorbidity was a significant predictor of patients' experience of the delivery of care. Patients with multimorbidity reported higher levels of self-management behaviour, while the presence of depression was associated with less positive attitudes towards self-management. CONCLUSIONS: The current data do not demonstrate a consistent impact of multimorbidity on patients' experience of care or on self-management. Further research is required to assess those types of multimorbidity that are associated with significant deficits, or to identify other aspects of care that might be problematic in the context of multiple conditions.