Can proactive support prevent unscheduled care? A controlled observational retrospective cohort study in cancer patients in Scotland.

INTRODUCTION: Preventative spend is a global health and social care strategy. Improving Cancer Journeys (ICJ) is a proactive, holistic, multidisciplinary project consistent with this agenda, currently being rolled out across Scotland and parts of UK. ICJ helps people with cancer access whatever support they need to mitigate their most pressing concerns. This study hypothesised that ICJ service users should subsequently use less unscheduled care than matched cohorts not using ICJ. METHODS: Retrospective observational cohort study using linked national datasets. N = 1,214 ICJ users in Glasgow were matched for age, sex, deprivation, cancer type, stage, and diagnosis year to two control groups: 1. Cancer patients from Glasgow before ICJ (pre-2014), 2. Cancer patients from rest of Scotland during study period (2014-2018). Cancer registrations were linked for 12-month baseline and study periods to: NHS24 calls, A&E admissions, inpatient hospital admissions, unscheduled care, number & cost of psychotropic prescriptions. Per-person mean service uses were compared between groups. RESULTS: There was a significant increase in NHS24 calls in the ICJ group (0.36 per person vs. -0.03 or 0.35), more and longer A&E attendances in ICJ (0.37 per person vs. 0.19 or 0.26; 2.19 h per person vs. 0.81-0.92 h), more and longer hospital admissions in ICJ (4.25 vs. 2.59 or 2.53; 12.05 days vs. 8.37 or 8.64), more care pathways involving more steps in ICJ (0.77 spells vs. 0.39 or 0.57; 1.88 steps vs. 1.56 or 1.21), more psychotropic drug prescriptions and higher costs in ICJ (1.88 prescription vs. 1.56 or 1.21; £9.51 vs. £9.57 or £6.95) in comparison to both control groups. DISCUSSION: ICJ users sourced significantly more unscheduled care than matched cohorts. These findings were consistent with much of the comparable literature examining the impact of non-health interventions on subsequent health spend. They also add to the growing evidence showing that ICJ reached its intended target, those with the greatest need. Together these findings raise the possibility that those choosing to use ICJ may also be self-identifying as a cohort of people more likely to use unscheduled care in future. This needs to be tested prospectively, because this understanding would be very helpful for health and social care planners in all countries where proactive holistic services exist.

Healers and midwives accused of witchcraft (1563-1736) - What secondary analysis of the Scottish survey of witchcraft can contribute to the teaching of nursing and midwifery history.

BACKGROUND: Nearly 4000 people were accused of witchcraft in Scotland between 1563 and 1736. Some of these were healers, midwives, and nurses. OBJECTIVE: To investigate Scotland's folk-healers and midwives accused of witchcraft and review their work from a nursing and midwifery perspective. DESIGN: Secondary analysis of the Survey of Scottish Witchcraft. METHODS: Those on the Survey with witchcraft accusations relating to folk-healing or midwifery were identified and their biographies were created from Survey data (2021). Individual biographical data were descriptively analysed. Healing/midwifery practice information was tabulated and thematically analysed. RESULTS: 142 individuals were identified (85 % women), 51 % were found guilty, 90 % were executed. Most (98 %) were folk-healers with 10 accused for midwifery reasons. Mainly their work was accused of causing harm. Three themes emerged: their use of rituals; unorthodox religious practices and treatments. Rituals included actions carried out a certain number of times. Religious practices frequently referenced Catholicism. Many of their treatments for ingestion, application or bathing used items still recognised for their health properties. Approximately, 10 % of the 142, mainly in the 1500s/early 1600s, utilised expensive items and complex treatments which had more in common with 'elite' knowledge rather than simple folklore. CONCLUSIONS: Across all 142 people, many aspects of their work are identifiable within more contemporary nursing and midwifery practice including their use of rituals, treatments, and holism. Mostly the accused were folk-practitioners, but a few (1500s/early 1600s) appear to have been healers working akin to physicians. Following the Protestant reformation (1560) their work, unlike that of physicians, was marginalised, considered unorthodox and harmful because they were women and/or their work reflected Catholicism. European hospital nursing originates in the monastic houses, but little is known about these early religious nurses. This study is novel in suggesting that whoever taught these accused witch/healers may have been connected to the monastic hospitals pre-Reformation.

Using the Doughnut Economics framework to structure whole-system thinking in socioecological wellbeing with multidisciplinary stakeholders: an applied case study in Glasgow, Scotland.

BACKGROUND: Human and environmental health are inseparable and interdependent. Doughnut Economics is a conceptual framework combining the Sustainable Development Goals with Planetary Boundaries, thereby simultaneously considering human and planetary wellbeing. The vision is to "meet the needs of all people within the means of the living planet, for the benefit of both current and future generations". Glasgow City Council has committed to becoming a Green Wellbeing Economy, with a socially just transition to Net Zero by 2030. Through our City-University partnership, we are exploring whether Doughnut Economics can drive transformative action towards a sustainable, healthy, and equitable future. METHODS: Glasgow is a pilot site for the C40 Cities' Thriving City Portrait methodology that downscales Doughnut Economics to cities. The Portrait process combined desk-based research and policy review (from January to April, 2022) with participatory workshops to enrich initial findings. The five participatory workshops took place between April, 2022, and February, 2023, and involved about 130 stakeholders. Participants included civil servants, politicians, scientists, community representatives, employees and representatives of private and third-sector organisations, and social enterprises, identified through an iterative stakeholder mapping process with City Council partners. Workshop aims were to create pluralistic definitions of what thriving means for each of the Doughnut's social and ecological dimensions. Ethics approval for the study was granted by The University of Glasgow, College of Medical Veterinary and Life Sciences. FINDINGS: The workshops produced a shared, holistic vision for Glasgow's future as a thriving city. The Doughnut demonstrated potential as a tool for both understanding the city's socioecological impacts, and as a compass by which the city might set its policy agenda. It allows the multiple goals and priorities of a city system to congregate around a cohesive goal. The Portrait process led to a widening of stakeholders' perspectives, applying systems thinking to policy priorities, cross-sector discussion and collaboration, and significant buy-in from a diverse range of changemakers. INTERPRETATION: The Doughnut framework offered a starting point for Public and Planetary Health researchers to understand connections, co-benefits and trade-offs across different parts of the policy and intervention system. Applying this framework in cities could generate support for whole-system interventions and sustainable solutions to the complex and interconnected climate and social challenges we face. One of the limitations is that we do not yet know whether stakeholders can translate support for this co-created framework into tangible whole-systems action. FUNDING: UKRI Natural Environment Research Council and University of Glasgow.

Test, evidence, transition projects in Scotland: developing the evidence needed for transition of effective interventions in cancer care from innovation into mainstream practice.

BACKGROUND: A robust evidence base is required to assist healthcare commissioners and providers in selecting effective and sustainable approaches to improve cancer diagnosis and treatment. Such evidence can be difficult to build, given the fast-paced and highly pressured nature of healthcare delivery, the absence of incentives, and the presence of barriers in conducting pragmatic yet robust research evaluations. Cancer Research UK (CRUK) has played an active part in building the evidence base through its funding of programmes to identify, evaluate and scale-up innovative approaches across the UK. The aim of this paper is to describe and explain the research design and intended approach and activities for two cancer services improvement projects in Scotland funded by CRUK. METHODS: A hybrid effectiveness-implementation study design will assess both the efficiency of the new pathways and their implementation strategies, with the aim of generating knowledge for scale-up. A range of implementation, service and clinical outcomes will be assessed as determined by the projects' Theories of Change (ToCs). A naturalistic case study approach will enable in-depth exploration of context and process, and the collection and synthesis of data from multiple sources including routine datasets, patient and staff surveys, in-depth interviews and observational and other data. The evaluations are informed throughout by a patient/public representatives' group, and by small group discussions with volunteer cancer patients. DISCUSSION: Our approach has been designed to provide a holistic understanding of how (well) the improvement projects work (in relation to their anticipated outcomes), and how they interact with their wider contexts. The evaluations will help identify barriers, facilitators, and unanticipated consequences that can impact scalability, sustainability and spread. By opting for a pragmatic, participatory evaluation research design, we hope to inform strategies for scaling up successful innovations while addressing challenges in a targeted manner.

How effective is public health policy in Scotland on vitamin D deficiency during pregnancy?

OBJECTIVE: To evaluate the uptake of universal vitamin D supplementation during pregnancy, its effectiveness in preventing vitamin D deficiency and the factors associated with these. DESIGN: The regional public health organisation in Ayrshire, Scotland has a policy of universal provision of vitamin D supplements (10 µg/d) to all pregnant women for the duration of their pregnancy. Pregnant women in this area were recruited at their 12-week antenatal appointment. Blood samples were collected at the 12-week and 34-week appointments. To account for the seasonal variation, women were recruited in two cohorts: summer and winter. Telephone interviews were conducted at 34 weeks to assess the uptake of vitamin D supplements during pregnancy. Other variables were obtained from medical records. SETTING: The study was conducted in the NHS Ayrshire and Arran Health Board in Scotland. PARTICIPANTS: 612 pregnant women (aged 15-44 years) living in Ayrshire (latitude 55°), Scotland. RESULTS: Sixty-six percentage took supplementation as recommended. Consumption of supplementation was significantly associated with a higher median serum 25-hydroxyvitamin D concentrations at 34 weeks. Despite this at 34 weeks, 33 % of the summer cohort had insufficient or deficient vitamin D status, while 15 % of the winter cohort had insufficient or deficient status. In multivariable analysis, only adherence and season were independent predictors of vitamin D status. CONCLUSIONS: While supplementation improved and maintained vitamin D status during pregnancy, it was not adequate to ensure all those insufficient at 12 weeks achieved sufficient status at the end of pregnancy.

Identifying and prioritising future interventions with stakeholders to improve paediatric urgent care pathways in Scotland, UK: a mixed-methods study.

OBJECTIVES: To identify and prioritise interventions, from the perspectives of parents and health professionals, which may be alternatives to current unscheduled paediatric urgent care pathways. DESIGN: FLAMINGO (FLow of AdMissions in chIldren and youNG peOple) is a sequential mixed-methods study, with public and patient involvement (PPI) throughout. Data linkage for urgent admissions and three referral sources: emergency department, out of hours service and general practice, was followed by qualitative interviews with parents and professionals. Findings were presented and discussed at a stakeholder intervention prioritisation event. SETTING: National Health Service in Scotland, UK. PARTICIPANTS: Quantitative data: children with urgent medical admission to hospital from 2015 to 2017. Qualitative interviews: parents and health professionals with experiences of urgent short stay hospital admissions of children. PPI engagement was conducted with nine parent-toddler groups and a university-based PPI advisory group. Stakeholder event: parents, health professionals and representatives from Scottish Government, academia, charities and PPI attended. RESULTS: Data for 171 039 admissions which included 92 229 short stay admissions were analysed and 48 health professionals and 21 parents were interviewed. The stakeholder event included 7 parents, 12 health professionals and 28 other stakeholders. Analysis and synthesis of all data identified seven interventions which were prioritised at the stakeholder event: (1) addressing gaps in acute paediatric skills of health professionals working in community settings; (2) assessment and observation of acutely unwell children in community settings; (3) creation of holistic children's 'hubs'; (4) adoption of 'hospital at home' models; and three specialised care pathways for subgroups of children; (5) convulsions; (6) being aged <2 years old; and (7) wheeze/bronchiolitis. Stakeholders prioritised interventions 1, 2 and 3; these could be combined into a whole population intervention. Barriers to progressing these include resources, staffing and rurality. CONCLUSIONS: Health professionals and families want future interventions that are patient-centred, community-based and aligned to outcomes that matter to them.

Defining optimal thresholds for digital Brix refractometry to determine IgG concentration in ewe colostrum and lamb serum in Scottish lowland sheep flocks.

This research aimed to define thresholds for ewe colostrum and lamb serum Brix refractometer measurements in lowland Scottish sheep. This would facilitate the use of this convenient, sheep-side test, enabling quick and accurate identification of poor quality colostrum and prevention of failure of transfer of passive immunity (FTPI) in lambs. Secondary aims were to identify risk factors for poor colostrum quality and FTPI in lambs. Serum samples (n = 233) were collected from lambs between 24 and 48hrs after birth, from four lowland Scottish meat sheep farms. Pre-suckle colostrum samples (n = 112) were also collected from ewes on two of these farms. Farmers provided information on litter size, ewe body condition score, ewe breed and dystocia. Duplicate digital Brix refractometer measurements were compared with immunoglobulin G (IgG) radial immunodiffusion (RID) testing for all colostrum and serum samples. Receiver operating characteristic (ROC) curves were used to redefine thresholds for Brix testing in colostrum and serum. Linear regression models were constructed with colostrum and serum IgG concentration as the outcomes of interest. Colostrum and serum IgG concentrations were highly variable. The prevalence of inadequate colostrum quality (using <50 g/L IgG on RID) was 4.5% (95% CI = 1.5 - 10.1) and the prevalence of FTPI (using <15 g/L IgG in serum on RID) was 7.73% (95% CI = 4.64-11.93). A ewe's colostrum IgG concentration was significantly and positively associated with the serum IgG concentration of her lamb(s) (p = 0.02). ROC analysis defined a Brix threshold for adequate colostrum quality of > 22.10% (sensitivity 80% (95%CI=28.4-99.5), specificity 90% (95%CI=82.3-94.8)). ROC analysis defined a Brix threshold for serum of > 8.65% for adequate passive transfer of immunity in Scottish lambs (sensitivity 94% (95%CI=72.7-99.8), specificity 82% (95%CI=76.6-87.2)). To optimise passive transfer of immunity in lambs, we suggest that ewe colostrum Brix measurements be defined as 'poor' (<22%); 'fair' (22-26%) and 'good' (>26%); and lamb serum as 'poor' (<8%); 'fair' (8-9%) and 'good' (>9%). It is recommended that these tests are used as for flock screening, using samples from multiple animals.

Developing a combined framework for priority setting in integrated health and social care systems.

BACKGROUND: There is an international move towards greater integration of health and social care to cope with the increasing demand on services.. In Scotland, legislation was passed in 2014 to integrate adult health and social care services resulting in the formation of 31 Health and Social Care Partnerships (HSCPs). Greater integration does not eliminate resource scarcity and the requirement to make (resource) allocation decisions to meet the needs of local populations. There are different perspectives on how to facilitate and improve priority setting in health and social care organisations with limited resources, but structured processes at the local level are still not widely implemented. This paper reports on work with new HSCPs in Scotland to develop a combined multi-disciplinary priority setting and resource allocation framework. METHODS: To develop the combined framework, a scoping review of the literature was conducted to determine the key principles and approaches to priority setting from economics, decision-analysis, ethics and law, and attempts to combine such approaches. Co-production of the combined framework involved a multi-disciplinary workshop including local, and national-level stakeholders and academics to discuss and gather their views. RESULTS: The key findings from the literature review and the stakeholder workshop were taken to produce a final combined framework for priority setting and resource allocation. This is underpinned by principles from economics (opportunity cost), decision science (good decisions), ethics (justice) and law (fair procedures). It outlines key stages in the priority setting process, including: framing the question, looking at current use of resources, defining options and criteria, evaluating options and criteria, and reviewing each stage. Each of these has further sub-stages and includes a focus on how the combined framework interacts with the consultation and involvement of patients, public and the wider staff. CONCLUSIONS: The integration agenda for health and social care is an opportunity to develop and implement a combined framework for setting priorities and allocating resources fairly to meet the needs of the population. A key aim of both integration and the combined framework is to facilitate the shifting of resources from acute services to the community.

Why neuroscience changes some things but not everything for the law.

Neuroenthusiasts and neuroskeptics both exaggerate the strength of their positions. Neuroscience is already having a significant impact in the courts in many jurisdictions and as knowledge from the cognitive sciences expands, that knowledge, wherever relevant, should continue to inform legal systems. However, neuroscience will only ever be one influence among many. In certain areas, for example, our understanding of fear responses or the reliability of memory evidence, the cognitive sciences may help challenge errors of folk psychology and assist the law to adopt better approaches. In other areas such as juvenile responsibility, developmental neuroscience may prove decisive in reinforcing messages from educational psychology and the behavioral sciences both in persuading legislators and judges but also importantly in altering public attitudes. Drawing on examples from a range of countries including Argentina, Australia, Canada, England, the Netherlands, Scotland, Slovenia, and the United States, we argue that legal systems must be open to and learn from science and must not be afraid to engage with science even where there is no clear scientific consensus.

'A Unique opportunity to test things out': a qualitative study of broad-based training in Scotland.

OBJECTIVES: A recent review recommended UK postgraduate medical education should produce doctors capable of providing general care in broad specialties across a range of different settings. Responding to this, broad-based training (BBT) was introduced in Scotland in 2018 to provide postgraduate trainees with a grounding in four specialties. Introduced as an option for trainees after initial postgraduate 'Foundation' training, it comprises 6 months in general medicine, general practice, paediatrics and psychiatry.This study addresses two key BBT outcomes. It examines how successful BBT is in developing trainees who perceive they are able to work beyond traditional specialty boundaries to care for patients with complex, multifactorial healthcare needs. Second, it explores how well BBT prepares trainees for their next stage in training. DESIGN: A longitudinal qualitative study using semistructured interviews to collect data from BBT trainees, trainers and 'programme architects'. Fifty-one interviews were conducted, 31 with trainees (with up to three interviews per trainee across BBT and immediately afterwards (post-BBT)) and 20 with trainers. Data were subject to thematic analysis. RESULTS: Two overarching themes were identified: (1) trainees able to work beyond specialty boundaries and (2) preparation for the next stage in training. BBT trainees were able to see the links and overlap between different specialties and understand the interface between primary and secondary care. They did not perceive that BBT (as compared with single-specialty early-stage training) disadvantaged them, other than in terms of specialty examination preparation. BBT was seen as a way to keep career options open in a system where it is difficult to switch training pathway. CONCLUSIONS: BBT has the capacity to create doctors who will carry on using their generalist skills to care for patients more holistically, even if they end up working in focused practice areas. BBT helps to keep options open for longer, which is beneficial in a highly structured training environment.

Open extent IV thoracoabdominal aneurysm repair: 22-year experience of the Scottish National Service.

BACKGROUND: Since 1999, the Scottish National Service for Thoracoabdominal Aneurysms has offered repair of thoracoabdominal aneurysms (TAAAs) to a population of 5.5 million people. The open operation most commonly performed by the service is the extent IV TAAA repair. METHODS: All extent IV open TAAA repairs performed at the Scottish National Service for TAAAs from June 1999 until April 2021 were evaluated for clinical features, technical details, and clinical outcomes. The primary outcome measure was 30-day mortality; secondary outcomes included short-term (90 days, 6 months, 1 and 2 years) and long-term (5 and 10 years) survival, perioperative complications, and reintervention. Survival was assessed using Kaplan-Meier analysis. RESULTS: Some 248 patients underwent extent IV TAAA repair, with elective surgery in 204 (82.3 per cent). A totally abdominal transperitoneal approach was used for all patients, with a median visceral ischaemia time of 40 (i.q.r. 35-48) min. Overall, 18 patients (7.3 per cent) died within 30 days. The proportion of patients surviving at 90 days, 6 months, 1, 2, 5, and 10 years was 0.91, 0.90, 0.89, 0.85, 0.72, and 0.41, respectively. Ten patients (4.0 per cent) required a reintervention while in hospital, four (1.6 per cent) experienced permanent spinal cord ischaemia, 19 (7.9 per cent) required temporary renal replacement therapy (RRT), and four (1.6 per cent) required permanent RRT. CONCLUSION: Open extent IV TAAA repair performed in a high-volume national centre is associated with favourable short- and long-term survival, and acceptable complication rates.

Ancient DNA at the edge of the world: Continental immigration and the persistence of Neolithic male lineages in Bronze Age Orkney.

Orkney was a major cultural center during the Neolithic, 3800 to 2500 BC. Farming flourished, permanent stone settlements and chambered tombs were constructed, and long-range contacts were sustained. From ∼3200 BC, the number, density, and extravagance of settlements increased, and new ceremonial monuments and ceramic styles, possibly originating in Orkney, spread across Britain and Ireland. By ∼2800 BC, this phenomenon was waning, although Neolithic traditions persisted to at least 2500 BC. Unlike elsewhere in Britain, there is little material evidence to suggest a Beaker presence, suggesting that Orkney may have developed along an insular trajectory during the second millennium BC. We tested this by comparing new genomic evidence from 22 Bronze Age and 3 Iron Age burials in northwest Orkney with Neolithic burials from across the archipelago. We identified signals of inward migration on a scale unsuspected from the archaeological record: As elsewhere in Bronze Age Britain, much of the population displayed significant genome-wide ancestry deriving ultimately from the Pontic-Caspian Steppe. However, uniquely in northern and central Europe, most of the male lineages were inherited from the local Neolithic. This suggests that some male descendants of Neolithic Orkney may have remained distinct well into the Bronze Age, although there are signs that this had dwindled by the Iron Age. Furthermore, although the majority of mitochondrial DNA lineages evidently arrived afresh with the Bronze Age, we also find evidence for continuity in the female line of descent from Mesolithic Britain into the Bronze Age and even to the present day.

Practitioners' perspectives on health in Strategic Environmental Assessment of spatial planning policies in Scotland.

OBJECTIVES: Local authorities in Scotland are required to produce a Local Development Plan (LDP), which allocates sites for development and sets policies to guide decisions on planning applications. As part of this, local authorities must undertake a Strategic Environmental Assessment (SEA). This is a structured assessment of likely environmental impacts, which includes human health. This study explores how SEA practitioners and SEA consultation authorities consider health. STUDY DESIGN: Qualitative study design using eight in-depth semi-structured interviews. METHODS: Individual interviews were carried out with SEA practitioners from six local authority areas in Scotland and two SEA consultation authorities. Interviews were recorded, transcribed and analysed thematically. RESULTS: Respondents articulated a broad perspective on health, but this was not reflected in SEA practice. Barriers to considering health more fully in SEA included low confidence in assessing health, limited partnership working with public health professionals and the lack of a consultation authority able to cover all aspects of health. Respondents valued partnership work between public health and planning professionals. CONCLUSION: This study suggests recent work in Scotland to increase understanding of the role of spatial planning to influence health has been successful. However, further work is required to expand this to include links between spatial planning and health inequalities. SEA in Scotland does not currently support holistic consideration of health and health inequalities. Strong partnership working between public health and other sectors can increase understanding of links with health and create healthy places.

High-Resolution Molecular-Level Characterization of a Blanket Bog Peat Profile.

To understand peatland carbon-cycling processes ultimately requires the ability to track changes occurring on the molecular-level. In this study, we profile a peat core taken from the world's largest blanket bog, Flow Country, Scotland, using physicochemical properties, ATR-FTIR, solid/liquid-state NMR, and solid/liquid-state FT-ICR-MS. Air-dried peat and labile and recalcitrant peat extracts, including pore water dissolved organic matter (PW-DOM), are analyzed and the merits of each technique are discussed. Solid-state NMR demonstrated changing distribution of compound classes with core depth and water table, the latter not picked up by IR. Liquid-state NMR and MS both demonstrated variations in molecular composition along the core depth in all phases and extracts. Contrary to previous reports, the composition of PW-DOM varied with depth. Major compounds, some previously unreported, identified by 1D/2D NMR occurred throughout the core, suggesting the existence of hot spots of microbial activity/compound accumulation. Offering complementary views, the techniques provided evidence of gradual molecular level changes with age, zonation due to the water table, and hot spots due to microbial activity. This study provides new insights into the molecular signatures of peat layers and establishes the foundation for examining peat function and health at the molecular-level.

Risk factors for poor colostrum quality and failure of passive transfer in Scottish dairy calves.

Failure of passive transfer (FPT) has health, welfare and economic implications for calves. Immunoglobulin G (IgG) concentration of 370 dairy calf serum samples from 38 Scottish dairy farms was measured via radial immunodiffusion (RID) to determine FPT prevalence. IgG concentration, total bacteria count (TBC) and total coliform count (TCC) of 252 colostrum samples were also measured. A questionnaire was completed at farm enrollment to investigate risk factors for FPT and poor colostrum quality at farm-level. Multivariable mixed effect logistic and linear regressions were carried out to determine significant risk factors for FPT and colostrum quality. Prevalence of FPT at calf level was determined to be 14.05%. Of 252 colostrum samples, 111 (44.05%) failed to meet Brix thresholds for colostrum quality. Of these 28 and 38 samples also exceeded TBC and TCC thresholds, respectively. Increased time between parturition and colostrum harvesting was numerically (non-significantly) associated with a colostrum Brix result <22%, and increased time spent in a bucket prior to feeding or storing was significantly associated with high TBC (≥100 000 cfu/ml and also ≥10 000 cfu/ml). High TBC values in colostrum were significantly associated with lower serum IgG concentrations. This study highlights associations between colostrum quality and FPT in dairy calves as well as potential risk factors for reduced colostrum quality; recommending some simple steps producers can take to maximise colostrum quality on farm.

Antenatal Exposure to UV-B Radiation and Preeclampsia: A Retrospective Cohort Study.

Background Risk of preeclampsia varies by month of delivery. We tested whether this seasonal patterning may be mediated through maternal vitamin D concentration using antenatal exposure to UV-B radiation as an instrumental variable. Methods and Results Scottish maternity records were linked to antenatal UV-B exposure derived from satellites between 2000 and 2010. Logistic regression analyses were used to explore the association between UV-B and preeclampsia, adjusting for the potential confounding effects of month of conception, child's sex, gestation, parity, and mean monthly temperature. Of the 522 896 eligible singleton deliveries, 8689 (1.66%) mothers developed preeclampsia. Total antenatal UV-B exposure ranged from 43.18 to 101.11 kJ/m2 and was associated with reduced risk of preeclampsia with evidence of a dose-response relationship (highest quintile of exposure: adjusted odds ratio, 0.57; 95% CI, 0.44-0.72; P<0.001). Associations were demonstrated for UV-B exposure in all 3 trimesters. Conclusions The seasonal patterning of preeclampsia may be mediated through low maternal vitamin D concentration in winter resulting from low UV-B radiation. Interventional studies are required to determine whether vitamin D supplements or UV-B-emitting light boxes can reduce the seasonal patterning of preeclampsia.

"I'm empowered to look after myself" - Mindfulness as a way to manage chronic pain: An interpretative phenomenological analysis of participant experiences in Scotland.

BACKGROUND AND PRIMARY AIM: Chronic pain is a common problem that can impact on psychological and social wellbeing and activity levels. Despite pharmacological treatments, there is often a lack of improvement in physical and emotional functioning and health-related quality of life. Mindfulness meditation has become an increasingly popular self-management technique. The aim of the study was to explore the experiences of patients with chronic pain who took part in a mindfulness programme. METHODS: A mixed-methods feasibility study was carried out. Participants were aged 18 years or over with non-malignant chronic pain recruited from general medical practices in Fort William, Scotland. In 2013 participants undertook an eight-week mindfulness programme based on Mindfulness-Based Stress Reduction (MBSR) and were interviewed immediately post-programme and at eight-months' post-programme. Analysis of qualitative data involved Interpretative Phenomenological Analysis (IPA). FINDINGS: Thirty-four patients consented to take part in the study; twenty-four took part in the programme (14 attended four or more sessions, 10 attended one to three). Twenty-three were interviewed. Participant experiences of the programme were themed under: factors affecting experience (influence of earlier life events; the process of taking part in, and of relating to, the programme); and effects of the programme (impact on emotions, mental health, adverse events and a process of change). The process of change, resulting after better understanding the relationship between mindfulness and pain, involved learning to 'listen to the body', gaining a sense of community, learning to accept pain, and approaching life with more self-care, awareness, appreciation and empowerment. CONCLUSION: Participants reported a variety of experiences. For some, these included undergoing a process of change which may have supported them in living with their painful condition. This contributes to our understanding of how mindfulness could benefit people with chronic pain.

Introduction of Transnasal Endoscopy to a Scottish District General Hospital.

Esophagogastroduodenoscopy can be uncomfortable and distressing with many patients opting for conscious sedation over topical local anesthetic spray. Transnasal endoscopy is an alternative and we sought to assess how easily it could be introduced to a district general hospital and how acceptable patients found it. Selected patients requiring diagnostic endoscopy were offered transnasal endoscopy with topical nasal anesthetic by clinicians new to transnasal endoscopy but competent at esophagogastroduodenoscopy. Postal feedback questionnaires were used to assess comfort, distress, recollection of periprocedural consultation, and overall experience (visual analog scale 1-10). A total of 213 transnasal endoscopy procedures were undertaken with 207 completed successfully (97.2%). Two patients (0.9%) had self-limiting epistaxis and no patient required admission. One hundred (47%) questionnaires were returned including 98 from those with completed transnasal endoscopy. Thirty-three (33%) had previous esophagogastroduodenoscopy and 28 (85%) reported a preference for transnasal endoscopy. Fifty-eight patients (59%) found transnasal endoscopy comfortable (visual analog scale >6) with 17 reporting discomfort (visual analog scale <5). Seventeen patients found the procedure distressing (visual analog scale >6) but 70 (73%) did not (visual analog scale <5). Eighty-four patients (85.7%) had clear recollection of their procedure (visual analog scale >6) and overall satisfaction was reported as good (visual analog scale >6) by 94.7%. Transnasal endoscopy can be adopted by clinicians competent with conventional esophagogastroduodenoscopy with expectation of high procedure completion rate and low complication rate. Our patients reported high levels of satisfaction with few reporting distress. Perhaps as a consequence, most patients had a clear recollection of their procedure.

Process lessons from evaluating a combined continuity of carer and home birth scheme.

INTRODUCTION: Continuity of midwifery carer improves outcomes, but there is significant variation in how such schemes are implemented and evaluated cross-culturally. The Angus home birth scheme in Scotland incorporates continuity of carer throughout pregnancy, labor, birth, and the postnatal period. METHODS: Manual maternity case note review to evaluate the 80% continuity of carer and 3% planned home birth rate targets. RESULTS: Of 1466 women booking for maternity care, 69 joined the scheme. Forty-four had a planned home birth (3% overall), of whom seven were originally deemed ineligible. Of the 44, eight (18%) also achieved 80% continuity of carer with the primary midwife; by including a home birth team colleague, the continuity rate rose to 73%. Women whose care achieved home birth and continuity targets had lower deprivation scores. Eligibility issues, women's changing circumstances, and data recording lapses were complicating issues. CONCLUSIONS: Targets must be both feasible and meaningful and should be complemented by assessing a broad range of outcomes while viewing the scheme holistically. By expanding eligibility criteria, the home birth rate target was met; including input from a home birth team colleague in the calculation meant the continuity target was nearly met. With dedicated and competent staff, adequate resource and political support, and when considered in the round, the scheme's viability within local services was confirmed. Other generalizable learning points included the need to standardize definitions and data recording methods. Comparability across schemes helps grow the evidence base so that the links between processes and outcomes can be identified.

Randomized controlled trial of triple versus dual inhaler therapy on small airways in smoking asthmatics.

BACKGROUND: Smoking worsens underlying asthma inflammation and also induces resistance to inhaled corticosteroids (ICS). Small airways dysfunction measured by impulse oscillometry (IOS) is associated with worse control. OBJECTIVES: We investigated the effects on small airways of adding long-acting beta-agonist (LABA) alone or with long-acting muscarinic antagonist (LAMA) to ICS in asthmatic smokers. METHODS: Sixteen current smokers were enrolled: mean age 44 year, FEV1 84%, FEF25-75 47%, R5 158%, ACQ 1.69, 20 pack year . Patients were converted to a reference ICS as HFA-BDP during initial run-in at median dose of 800 µg/day. Open label olodaterol 5 µg od (OLO) or olodaterol 5 µg/tiotropium 5 µg od (OLO/TIO) was added to HFA-BDP for median duration of 3 weeks in a randomized cross over design, including run-in and washout periods on HFA-BDP. IOS and spirometry were measured after each treatment (BDP/OLO/TIO or BDP/OLO) and at baseline after run-in and washout (BDP). RESULTS: After chronic dosing, IOS outcomes at trough except for R20 were all significantly improved with OLO/TIO compared to OLO. For the primary end-point of total airway resistance (as R5), the mean difference (95%CI) at trough was 0.06 (0.015-0.10) kPa/l/s, peripheral airways resistance (as R5-R20) 0.03 (0.003-0.06) kPa/l/s, peripheral lung reactance area (as AX) 0.38 (0.08-0.68) kPa/l and resonant frequency (as RF) 2.28 (0.45-4.12) Hz. FEF25-75 at trough was also better with OLO/TIO vs TIO: 0.93 (0.86 - 0.95) l/s while FEV1 was not different. CONCLUSIONS: ICS/LABA/LAMA was superior to ICS/LABA on trough small airway outcomes in asthma patients who smoke.