Adolescent perceptions of sleep and influences on sleep behaviour: A qualitative study.

INTRODUCTION: Adolescent sleep deprivation is a growing public health problem. This qualitative study explores adolescents' perceptions of sleep and sleep behaviour, enhancing the current limited body of qualitative research in this area. METHODS: Thirty three 13-14 year olds (17 boys and 16 girls) from two schools in England participated in focus group discussions. Qualitative thematic analysis was used to identify and examine patterns emerging from the data. RESULTS: Participants understood recommended sleep requirements for their age group and 'sleep hygiene' strategies, yet most reported getting insufficient sleep. Both boys and girls acknowledged the influence of peers on sleep behaviour. A common obstacle to sleep was distractions from electronic devices. Gender was identified as influencing behaviour, with boys more likely to report watching videos and gaming and girls reporting being distracted by communicating on their mobile phones. Anxious dependency on phones at night was reported by some girl participants. Parents were considered key 'sleep messengers' and rulesetters. A variability in parental involvement in sleep behaviour was identified and can be understood as at least partially related to new challenges posed by adolescent use of electronic devices. CONCLUSIONS: Findings highlight the importance of parental and peer involvement in supporting adolescents to secure healthy sleep. Endeavours to bring about sustained changes in adolescent sleep practices should be predicated on the role of parents/carers as sleep enforcers and the impact of peers, as well as responding to the gendered aspects of compromised sleep behaviour.

Synthesising conceptual frameworks for patient and public involvement in research - a critical appraisal of a meta-narrative review.

BACKGROUND: A number of conceptual frameworks for patient and public involvement (PPI) in research have been published in recent years. Although some are based on empirical research and/or existing theory, in many cases the basis of the conceptual frameworks is not evident. In 2015 a systematic review was published by a collaborative review group reporting a meta-narrative approach to synthesise a conceptual framework for PPI in research (hereafter 'the synthesis'). As the first such synthesis it is important to critically scrutinise this meta-narrative review. The 'RAMESES publication standards for meta-narrative reviews' provide a framework for critically appraising published meta-narrative reviews such as this synthesis, although we recognise that these were published concurrently. Thus the primary objective of this research was to appraise this synthesis of conceptual frameworks for PPI in research in order to inform future conceptualisation. METHODS: Four researchers critically appraised the synthesis using the RAMESES publication standards as a framework for assessment. Data were extracted independently using a data extraction form closely based on the RAMESES publication standards. Each item from the standards was assessed on a four point scale (0 = unmet, 1 = minimally met, 2 = partly met, 3 = fully met). The four critical appraisals were then compared and any differences resolved through discussion. RESULTS: A good degree of inter-rater reliability was found. A consensus assessment of the synthesis as a meta-narrative review of PPI conceptual frameworks was achieved with an average of '1' (minimally met) across all 20 items. Two key items ('evidence of adherence to guiding principles of meta-narrative review' and 'analysis and synthesis processes') were both wholly unmet. Therefore the paper did not meet our minimum requirements for a meta-narrative review. We found the RAMESES publication standards were a useful tool for carrying out a critical appraisal although some minor improvements are suggested. CONCLUSIONS: Although the aims of the authors' synthesis were commendable, and the conceptual framework presented was coherent and attractive, the paper did not demonstrate a transparent and replicable meta-narrative review approach. There is a continuing need for a more rigorous synthesis of conceptual frameworks for PPI.

Conflicting priorities: Observation of medicine administration.

AIMS AND OBJECTIVES: To identify sources of interruptions and distractions to medicine administration rounds in hospitals. BACKGROUND: Nurses are frequently interrupted during medicine administration. There is no systematic description of nurses' behaviours and interruptions during administration of medicines to patients. DESIGN: Exploratory nonparticipant observational study. METHODS: Three hundred and fifty-one episodes of medicine administration with 32 nurses from three hospitals in Norway were observed using paper-based observation grids between December 2013 and March 2014. RESULTS: Nurses were frequently interrupted and distracted, mainly by nurses and other healthcare professionals. One-third of the nurses interrupted their medicine administration: They prioritised helping patients with direct patient care. When the nurses were interrupted, they left the round and re-entered the procedure. Even so, they managed to refocus and continue to administer the medicines: Interruptions and disturbances made little difference to most behaviours and actions, possibly because nurses double-checked more frequently. Some differences were seen in behaviours potentially affecting the safety of the medicine administration, such as leaving medicines at the bedside and not helping patients take their medicines. Some interruptions were avoidable, such as those by other nurses and professionals. CONCLUSIONS: This study offers insights into nurses' behaviours and actions when they are interrupted and distracted during medicine administration. The findings highlight a conflict for nurses administering medicines. Nurses are forced to prioritise between two important activities: direct patient care and medicine administration. Management and education providers need to recognise that nurse interrupting each other is a potential threat to patient safety. RELEVANCE TO CLINICAL PRACTICE: Our data indicate that nurses and other healthcare professionals should be warned not to interrupt colleague administering medicines and managers should ensure other staff are available to respond to patients' immediate needs during medicine rounds.

Auditory-verbal therapy for promoting spoken language development in children with permanent hearing impairments.

BACKGROUND: Congenital or early-acquired hearing impairment poses a major barrier to the development of spoken language and communication. Early detection and effective (re)habilitative interventions are essential for parents and families who wish their children to achieve age-appropriate spoken language. Auditory-verbal therapy (AVT) is a (re)habilitative approach aimed at children with hearing impairments. AVT comprises intensive early intervention therapy sessions with a focus on audition, technological management and involvement of the child's caregivers in therapy sessions; it is typically the only therapy approach used to specifically promote avoidance or exclusion of non-auditory facial communication. The primary goal of AVT is to achieve age-appropriate spoken language and for this to be used as the primary or sole method of communication. AVT programmes are expanding throughout the world; however, little evidence can be found on the effectiveness of the intervention. OBJECTIVES: To assess the effectiveness of auditory-verbal therapy (AVT) in developing receptive and expressive spoken language in children who are hearing impaired. SEARCH METHODS: CENTRAL, MEDLINE, EMBASE, PsycINFO, CINAHL, speechBITE and eight other databases were searched in March 2013. We also searched two trials registers and three theses repositories, checked reference lists and contacted study authors to identify additional studies. SELECTION CRITERIA: The review considered prospective randomised controlled trials (RCTs) and quasi-randomised studies of children (birth to 18 years) with a significant (≥ 40 dBHL) permanent (congenital or early-acquired) hearing impairment, undergoing a programme of auditory-verbal therapy, administered by a certified auditory-verbal therapist for a period of at least six months. Comparison groups considered for inclusion were waiting list and treatment as usual controls. DATA COLLECTION AND ANALYSIS: Two review authors independently assessed titles and abstracts identified from the searches and obtained full-text versions of all potentially relevant articles. Articles were independently assessed by two review authors for design and risk of bias. In addition to outcome data, a range of variables related to participant groups and outcomes were documented. MAIN RESULTS: Of 2233 titles and abstracts searched, only 13 abstracts appeared to meet inclusion criteria. All 13 full-text articles were excluded following independent evaluation by two review authors (CGBJ and JW), as they did not meet the inclusion criteria related to the research design. Thus, no studies are included in this review. AUTHORS' CONCLUSIONS: This review confirms the lack of well-controlled studies addressing the use of AVT as an intervention for promoting spoken language development in children with permanent hearing impairments. Whilst lack of evidence does not necessarily imply lack of effect, it is at present not possible for conclusions to be drawn as to the effectiveness of this intervention in treating children with permanent hearing impairments.

'Using human behaviour change can aid more impactful interactions with clients'.

The team at Human Behaviour Change for Life believes that by using the science of human behaviour change the veterinary community has an opportunity to better engage with pet breeders regarding extreme conformation.

Perceptions of Cross-Cultural Challenges and Successful Approaches in Facilitating the Improvement of Equine Welfare.

Projects that aim to improve the welfare of equids worldwide usually involve people from different countries and cultures working together. Given that professionals involved with multi-stakeholder projects often work cross-culturally, this study examined their experiences regarding the challenges involved in, and their reflections on, how to work in a culturally sensitive way. Semi-structured interviews were conducted with 14 participants working in a total of 29 countries and analysed using thematic analysis. Key response themes emerged from the responses to questions covering the areas of perceptions of animal welfare, challenges working cross-culturally and embracing cultural sensitivity. The overriding theme regarding perceptions of animal welfare was that of barriers to animal welfare, under which emerged the subthemes of limited financial and material resources, limited understanding of the tenets of animal welfare, and attachment to traditional medicines and practices. Exploring the key challenges resulted in two themes: challenges regarding the local context and etiquette, and those regarding working with different stakeholders. Considering cultural sensitivity, again, two themes emerged: the importance of trust and respect, and of working with local partners. Previous works have highlighted the importance of shared linguistic knowledge, interpersonal skills and cultural knowledge, and these elements also emerged in this research. As well as providing insights into the challenges of working cross-culturally, the findings of this study have enabled the development of suggestions for how this work could be taken forward in a practical way to be of use to professionals in this sector.

Understanding how to create healthier places: A qualitative study exploring the complex system of urban development decision-making.

Tackling complex system challenges like creating healthy environments requires understanding priorities and structures affecting multiple actors. This qualitative study, involving 132 multi-sectoral stakeholders spanning the urban development decision-making system, explores how to influence healthier place-making. Using thematic analysis we develop themes around competing stakeholder priorities; structural 'rules' and influential relationships; and justifying a focus on health, requiring greater clarity and consensus around definitions of 'healthy' urban development. Building on the socio-ecological model we highlight how a multi-faceted approach is required for change at multiple levels in the complex system to target individual actor motivations, organisational priorities and structural 'rules'.

Improving Equine Welfare through Human Habit Formation.

This paper explores the potential for interventions to develop pro-animal welfare habitual behaviours (PAWHBs) in people to improve the lives of animals. Human behavioural research indicates that opportunities exist to deliver lasting change through developing positive habitual behaviours. The routine nature of many equine care and management practices lends itself to habit formation and maintenance. This proof-of-concept paper aims to evaluate a theory-based intervention of developing and maintaining a PAWHB in people caring for equines. Qualitative research methods were used. A 30 day PAWHB intervention (PAWHBInt) of providing enrichment to an equine by scratching them in a consistent context linked to an existing routine behaviour was undertaken. Participants (n = 9) then engaged in semi-structured interviews that were analysed using thematic analysis, where the participants self-reported the outcomes they observed during the intervention. The study findings suggest that the PAWHBInt had a positive impact on human behaviour and habit formation. The research helps to address the dearth of evidence regarding the application of habit theory to equine welfare interventions and emphasised linking a desired new behaviour to an existing routine behaviour when developing PAWHBs. The research also highlights the role of mutual benefit for human and equine, and emotion in providing feedback and potential reward, supporting the link to the cue-routine-reward principle of habit theory.

Response of UK Horse, Pony and Donkey Owners to the Early Stages of the COVID-19 Pandemic.

In the UK, March 2020 was a time of great uncertainty as COVID-19 became increasingly widespread. The government responded by making suggestions about how people could reduce the risk of spread on 16 March, moved swiftly into closing schools on the 18 March before announcing a mandatory lockdown on the 23rd March. This was a challenging time for UK equestrians who had to balance maintaining their equine's routine and daily care alongside the increasing biosecurity measures. A cross-sectional survey was distributed to UK equestrians via social media over two days (28 and 29 March 2020) to better understand the decisions made by UK horse, pony and donkey owners during this time. Data from 452 respondents were generated across all four countries comprising the UK, although there were no significant differences in owner response to the pandemic between locations. The changes respondents made differed between the 16th and the 18th of March 2020, with an early emphasis on improving yard biosecurity and opting to stop riding, as well as reducing the time spent at the yard. After the 18 March, respondents placed more emphasis on risk reduction by changing the activities they did with their horse, including riding, with common examples including avoiding "high risk" activities such as riding on busy roads, jumping, riding young or nervous horses. Few respondents reported having an emergency plan in place should they become ill or otherwise unable to care for their equine. The findings highlight areas that would significantly benefit from in-depth investigation in future research. Equestrian behaviour and mindset around risk-taking and risk perception have already been researched in relation to equestrian activities and sport but have received little attention in the context of wider health challenges. Understanding the uptake of emergency planning and preparation in the UK equestrian community also warrants consideration. Using this information effectively to promote forward planning is likely to be of great benefit in equestrian responses to future health or climate-related crises.

Youth and parent perceptions on participating in specialized multidisciplinary pain rehabilitation options: A qualitative timeline effect analysis.

Background: Little is known about how the specialized treatment journey is perceived by youth with pain-related disability and their parents. Aims: Describe and compare the treatment effects and outcomes as perceived by youth and their parents enrolled in intensive interdisciplinary pain treatment (IIPT) or multimodal treatment (MMT). Methods: Eleven IIPT youth and five parents and three MMT youth and five parents were recruited. All were asked to complete a treatment journey timeline, followed by separately conducted semistructured interviews. Transcribed interviews were analyzed using reflective thematic analysis. Results: The main themes spanned the treatment trajectory. All participants described similar initial struggles (Theme 1). Positive and negative treatment effects associated with acquisitions and disruptions (Theme 2), and outcomes post-discharge related to supports and realities (Theme 3) emerged. Knowledge, skills, and support acquisition during treatment and feeling empowered and confident to self-manage postdischarge were identified as IIPT benefits. However, the change effort and life disruptions required and the difficulty transitioning to real life postprogram were acknowledged as detrimental IIPT impacts. Continuing with life as usual and maintaining supports in daily contexts (e.g., school personnel, friends) were reported MMT benefits. However, the challenges of managing pain, treatment adherence within the competing demands of daily realities, and the lack of support to integrate strategies were emphasized as detrimental MMT impacts. Conclusions: Detailed impacts of two specialized multidisciplinary pain rehabilitation interventions on the lives of youth with pain-related disability and their parents are described. The treatments benefits and previously unexplored detrimental effects are unveiled.

Contexte: On en sait peu sur les parcours de traitement spécialisés tels que perçus par les jeunes ayant une incapacité liée à la douleur et par leurs parents.Objectifs: Décrire et comparer les effets et les résultats du traitement tels qu'ils sont perçus par les jeunes inscrits à un traitement interdisciplinaire intensif de la douleur ou à un traitement multimodal, ainsi que par leurs parents.Méthodes: Onze jeunes inscrits à un traitement interdisciplinaire intensif de la douleur et cinq parents, ainsi que trois jeunes inscrits à un traitement multimodal et cinq parents, ont été recrutés. Tous ont été invités à décrire le calendrier de leur parcours de traitement, puis à participer à des entrevues semi-structurées menées séparément. Les entrevues transcrites ont été analysées à l'aide d'une analyse thématique réflexive.Résultats: Les principaux thèmes couvraient la trajectoire du traitement. Tous les participants ont décrit des difficultés initiales similaires (Thème 1). L'association des effets positifs et négatifs du traitement avec les acquis et les perturbations (Thème 2), et les issues liées au soutien et aux réalités suite à leur congé (Thème 3) ont émergé. L'acquisition de connaissances et d'habiletés, l'accès à du soutien et le sentiment d'autonomisation et de confiance en sa capacité d'autoprise en charge après le congé ont été répertoriés comme des avantages du traitement interdisciplinaire intensif de la douleur. Toutefois, les efforts de changement requis et les perturbations de la vie nécessaires, ainsi que les difficultés de la vie réelle après le programme, ont été considérés comme des répercussions négatives du traitement interdisciplinaire intensif de la douleur. La possibilité de poursuivre la vie comme d'habitude et de conserver le soutien dans des contextes de la vie quotidienne (ex. : personnel scolaire, amis) ont été rapportés comme des avantages du traitement multimodal. Toutefois, les défis liés à la prise en charge de la douleur, l'adhésion au traitement dans le cadre des exigences concurrentes des réalités quotidiennes, ainsi que le manque de soutien pour intégrer les stratégies, ont été mis en relief comme des effets néfastes du traitement multimodal.Conclusions: Les effets détaillés de deux interventions multidisciplinaires spécialisées en matière de réadaptation pour la douleur dans la vie de jeunes atteints d'une incapacité liée à la douleur et de leurs parents ont été décrits. Les avantages des traitements et leurs effets néfastes qui n'avaient pas encore été étudiés ont été dévoilés.

A model of child protection supervision for school health practitioners.

In 2005, a steering group was set up within Westminster Primary Care Trust (PCT) to review child protection supervision for school health practitioners (SHPs). Its purpose was to examine existing models of supervision and then establish an alternative, more effective model for SHPs in Westminster PCT. A decision was made within the steering group to move toward group supervision based on an action learning sets model. In addition,'mini one-to-one' meetings are arranged for SHPs who have been in post for over a year. Results from the evaluation and comments made by SHPs indicate that this combination of group and one-to-one supervision is working well, with practitioners stating that they feel more confident in relation to child protection and clearer about their role.

Primary cutaneous follicular lymphoma: a clinicopathologic and molecular study of 16 cases in support of a distinct entity.

Primary cutaneous B-cell lymphomas displaying a prominent follicular growth pattern are rare and remain poorly defined, particularly in terms of the frequency of detection of t(14;18) and whether or not, as a group, they represent an entity distinct from follicular lymphoma arising in lymph nodes. The morphologic, immunophenotypic, and clinical features of 16 cases of primary cutaneous follicular lymphoma, identified during a review of all PCBCL in the Scotland and Newcastle Lymphoma Group database, were studied and the number of cases harboring t(14;18) assessed by polymerase chain reaction using primers to the major breakpoint cluster region. Comparisons were made with stage I follicular lymphoma arising in lymph nodes and follicular lymphoma secondarily involving the skin. All cases of primary cutaneous follicular lymphoma had undergone thorough staging, including physical examination and CT scans of chest and abdomen, with 15 of 16 cases also having bone marrow aspiration and/or trephine performed. The morphology and immunophenotype of the lesions were similar to that expected in lymph nodes. All cases displayed a follicular architecture complete with follicular dendritic cell networks and comprised an admixture of CD10 and/or bcl-6-positive neoplastic centrocytes and centroblasts with 13 of 16 cases also expressing bcl-2 protein. None harbored t(14;18), a significantly different finding compared with cases of stage I nodal follicular lymphoma (p <0.001) and secondary cutaneous follicular lymphoma (p <0.039). Relapses occurred in five of 15 patients with a median time to first relapse of 20 months (range 1-73 months; mean 27.2 months). These were multiple in two patients and involved extracutaneous sites in two patients. The propensity for relapse was similar to that in a comparative cohort of stage I nodal follicular lymphoma, but the group of primary cutaneous follicular lymphoma were significantly more likely to attain complete remission; all cases of primary cutaneous follicular lymphoma were in complete remission when last seen compared with 49 of 87 patients with stage I nodal follicular lymphoma (p <0.005). No lymphoma-related deaths were encountered in 15 cases with a mean follow-up >60 months (range 5-119 months). These results support the concept of a subtype of follicular lymphoma lacking t(14;18) involving the major breakpoint cluster region, and with a propensity to arise in the skin. Despite a high relapse rate patients with primary cutaneous follicular lymphoma are more likely to achieve complete remission and may ultimately have a more favorable long-term prognosis than those with equivalent nodal disease.

Primary cutaneous diffuse large B-cell lymphoma: prognostic significance of clinicopathological subtypes.

Classification and subdivision of primary cutaneous diffuse large B-cell lymphoma (PCDLBCL) are a matter of ongoing debate. In this study we assessed the morphologic, immunophenotypic, and clinical features of 30 cases of PCDLBCL identified during a review of all primary cutaneous B-cell lymphomas in the Scotland and Newcastle Lymphoma Group database. We also determined the number of cases harboring t(14;18) using a polymerase chain reaction and primers to the major breakpoint cluster region. The effect on prognosis of a variety of clinical and pathologic factors was assessed for the group of 30 PCDLBCL and the 5-year disease-specific survival (DSS) of this cohort compared with that of 195 cases of stage I diffuse large B-cell lymphoma arising primarily in lymph nodes, also identified from within the Scotland and Newcastle Lymphoma Group database. Location on the leg was the only independent prognostic factor for determining outcome in PCDLBCL (67% 5-year DSS compared with 100% for the upper body; P = 0.0047). The presence of multiple lesions, involvement of more than one body site, and expression or not of CD10, bcl-2, bcl-6, and CD10 and bcl-6, had no effect on survival. Compared with cases arising above the waist, those on the leg were more often female, were of an older age, and had a significantly higher incidence of bcl-2 expression (P = 0.002) as well as the aforementioned poorer prognosis. They also showed more frequent co-expression of CD10 and bcl-6, supporting a follicle center cell origin for some, but this difference was not statistically significant. Although there was no significant difference in the 5-year DSS between the group of PCDLBCL and the cases of stage I nodal diffuse large B-cell lymphoma (88% 5-year DSS vs. 78%; P = 0.06), the latter were generally treated with more aggressive therapy. Moreover, a significant difference in 5-year DSS was seen when the nodal DLBCLs were compared with PCDLBCLs arising above the waist (78% vs. 100% respectively; P = 0.0135). These results support the current EORTC approach of subdividing PCLBCL on the basis of site to produce prognostically relevant groupings.

Spontaneous, field tested and tethered flight in healthy and infected Magicicada septendecim L.

Flight capabilities of healthy and fungus infected Magicicada septendecim L. (Homoptera: Cicadidae) were compared using 3 complementary techniques: 1) observations of spontaneous flights, 2) field-tested flights, and 3) tethered flights in which endurance was measured. Spontaneous flight distances are much lower than those obtained on field tested fliers. While healthy individuals flew significantly greater distances than did individuals bearing conidia or resting spores of the fungus, Massospora cicadina Peck, the two groups-healthy versus conidia and resting spores pooled-did not differ in flight speed or flight endurance. The magnitude of each of the 3 flight indicators is much lower than those of most dispersing insects, suggesting that this periodical cicada species is a relatively poor disperser.Nevertheless, and contrary to the results of one published study, cicadas flew long distances in single flights, also they often took many flights. Our data help to explain how periodical cicadas can invade new, sometimes distant, habitat each generation. Since infected individuals have both the speed and the endurance of healthy individuals, we conclude that the conspicuous absence of the fungus from early successional, manmade, and second growth habitat is due either to the inability of resting spores of this fungus to survive in recently plowed or fertilized soils or to an intrinsic aversion to flight of infected individuals.

The social care component of multidisciplinary mental health teams: a review and national survey.

BACKGROUND: The study reviewed the disciplinary composition of community mental health teams (CMHTs) and conducted a national survey of mental health providers in England and Wales to explore the determinants of the social care component of CMHTs. METHODS: A comprehensive literature review and a national survey of NHS mental health Trusts in England and Wales. RESULTS: The literature review showed that team composition was rarely well justified with regard to effectiveness, despite some evidence that greater professional diversity (i.e. inclusion of social workers) was associated with higher effectiveness. Forty-two mental health Trusts responded (53.2%) to the survey. There were no staffing differences between responding and non-responding Trusts. Social workers accounted for 19.3% of the staffing total. Nurses formed a third of the workforce and social support workers made up a further 10%. We found that there continues to be a shortage (compared to policy targets and previous research) of psychiatrists, psychologists and occupational therapists, whereas the numbers of nurses employed far exceeds their target numbers. Total staffing numbers appeared to be slightly higher in Trusts citing 'financial resources' as a determining factor of team composition. Despite being statistically non-significant, the 'financial resource' effect was of medium magnitude. Similarly, there was a non-significant but approaching medium-sized effect of higher numbers of social care support staff when guidance was cited as a rationale for CMHT composition. There was a non-significant (P = 0.076) medium magnitude (η(2)(p) = 0.067) trend towards higher staff numbers in more integrated trusts that did not cite financial resources as a driver of team composition. CONCLUSIONS: If service recipients are to gain equal access to appropriately staffed services, further attention needs to be paid to supporting an adequately skilled multidisciplinary workforce. The workforce needs to be organised in a way that best provides for local needs rather than a service based largely on the existing supply of different professionals and disjointed workforce planning.

DAS28 and Rheumatoid Arthritis: The Need for Standardization.

Disease Activity Score in 28 Joints (DAS28) scoring in rheumatoid arthritis (RA) is now recommended as a basis for clinical decisions about treatment initiation and alteration. The British Society of Rheumatology suggests that most RA patients should have a DAS28 assessment at every clinic visit, to monitor disease activity and the impact of therapy. Establishing an accurate baseline assessment of DAS28, with regular re-evaluation, is considered crucial, so that progress towards a defined target of remission (or low disease activity) can be measured. The Treat-to-Target initiative, launched in March 2010, is now impacting on clinical practice throughout the UK and Europe. One of its key recommendations is that patients should be regularly monitored using validated composite measures of disease activity that include joint assessments. DAS28 is recommended as one of the most useful of these methods but, although it is becoming more widely adopted and training is ongoing, supported by materials produced by the European League Against Rheumatism (EULAR), the variability inherent in the four components of DAS28 means that standardization of practice methods is now an important issue. This short report details some of the pitfalls that can occur when applying DAS28 in clinical practice and suggests some workable solutions to enable departments to set up their own standard operating procedure.