Use of either transcranial or whole-body photobiomodulation treatments improves COVID-19 brain fog.

There is increasing recognition of post-COVID-19 sequelae involving chronic fatigue and brain fog, for which photobiomodulation (PBM) therapy has been utilized. This open-label, pilot, human clinical study examined the efficacy of two PBM devices, for example, a helmet (1070 nm) for transcranial (tPBM) and a light bed (660 and 850 nm) for whole body (wbPBM), over a 4-week period, with 12 treatments for two separate groups (n = 7 per group). Subjects were evaluated with a neuropsychological test battery, including the Montreal Cognitive Assessment (MoCA), the digit symbol substitution test (DSST), the trail-making tests A and B, the physical reaction time (PRT), and a quantitative electroencephalography system (WAVi), both pre- and post- the treatment series. Each device for PBM delivery was associated with significant improvements in cognitive tests (p < 0.05 and beyond). Changes in WAVi supported the findings. This study outlines the benefits of utilizing PBM therapy (transcranial or whole-body) to help treat long-COVID brain fog.

The environmental impacts of different mask options for healthcare settings in the UK.

During the COVID-19 pandemic, different strategies emerged to combat shortages of certified face masks used in the healthcare sector. These strategies included increasing production from the original manufacturing sites, commissioning new production facilities locally, exploring and allowing the reuse of single-use face masks via various decontamination methods, and developing reusable mask alternatives that meet the health and safety requirements set out in European Standards. In this article, we quantify and evaluate the life-cycle environmental impacts of selected mask options available for use by healthcare workers in the UK, with the objective of supporting decision- and policy-making. We investigate alternatives to traditional single-use face masks like surgical masks and respirators (or FFP3 masks), including cloth masks decontaminated in washing machines; FFP3 masks decontaminated via vapour hydrogen peroxide, and rigid half masks cleaned with antibacterial wipes. Our analysis demonstrates that: (1) the reuse options analysed are environmentally preferential to the traditional "use then dispose" of masks; (2) the environmental benefits increase with the number of reuses; and (3) the manufacturing location and the material composition of the masks have great influence over the life-cycle environmental impacts of each mask use option, in particular for single-use options.

Renewable energy diversification: Considerations for farm business resilience.

With a varied landscape, Wales is resource rich in terms of wind and water and a suitable location to develop many different forms of sustainable energy. Whilst farm businesses face increasing challenges in terms of economic stability and traditional production methods, this paper considers the role of renewable energy production as a form of diversification. The study adopts mixed methods as a means of undertaking an in-depth investigation into the role of renewable energy generation in supporting agribusinesses in Wales. Initially a questionnaire obtained 118 responses from farmers in Wales. Subsequently, 15 follow-up semi-structured interviews with farmers were conducted to further investigate the issues from the initial questionnaire. The theoretical contribution of this paper is a segmentation of farmer businesses which allows for distinctions to be made of different attitudes to off-farm income and the adoption of renewable energy sources. Five farm types were identified, varying in relation to farm characteristics, attitudes to diversification, access to renewable energy and resource allocation. These farm types highlight the need for specific policies towards facilitating the increase in renewable energy along with sustaining farming incomes. Furthermore the research provides valuable information to the farming industry on opportunities in renewable energy production, particularly for farmers and farm businesses who are considering diversification strategies.

Statistics of heart failure and mechanical circulatory support in 2020.

Heart failure is increasing in prevalence, with approximately 26 million patients affected worldwide. This represents a significant cause of morbidity and mortality. Statistics regarding heart failure patient age, hospitalization likelihood, and mortality differ significantly by country. Heart failure patients are typically classified by ejection fraction, with distinct phenotypes associated with reduced ejection fraction (rEF) or preserved ejection fraction (pEF). Heart failure has a significant financial impact related to hospitalization, medication, and procedural expenses. The costs of heart failure also extend to the reduced quality of life conferred by heart failure symptoms. Management of heart failure includes a variety of interventions, including mechanical circulatory support (MCS). MCS, including left ventricular assist devices (LVADs), right ventricular assist devices (RVADs) and extracorporeal membrane oxygenation (ECMO), has been a means of managing end stage heart failure. Given the relative scarcity of transplant organs, the utilization of MCS, particularly as a bridge to transplantation (BTT) has grown significantly. In this review, we discuss statistics related to heart failure and MCS. We evaluate how patients are classified and examine global trends and regional differences. We then address MCS therapies, the costs associated with heart failure, the impact of heart failure on patient quality of life, and data regarding morbidity and mortality.

Effects of varying doses of estrogen and caudal pressure on wheel running in orchidectomized male mice.

Physical inactivity is a leading cause of hypokinetic diseases - obesity, heart disease, diabetes, and certain types of cancers. Increased city walkability, better access to fitness facilities, and remediation of socioeconomic barriers prove successful for limited populations within the confines of stringently controlled environments; however, these strategies fail to reverse the ever-increasing physical inactivity epidemic on a global scale indicating the existence of other unidentified factors. These purported biological factors remain critical targets to understand the regulation of this complex phenotype. An estrogenic mechanism that incompletely or slowly adjusts physical activity levels following reintroduction of estrogenic compounds to surgically gonadectomized mice has been postulated to exist. Currently, this mechanism remains scrutinized due to concerns that elevated estrogen levels induce urinary bladder distension. The distension of the urinary bladder may mechanically disrupt physical activity, masking any physiological effects estrogen has on physical activity. The purpose of this study was to evaluate the effects of estrogen on physical activity levels while employing dose-related strategies to alleviate distension in mice. Wheel running data were collected under normal physiological conditions, following removal of endogenous sex steroids via orchidectomy, and during estrogen replacement at various doses (0%, 10%, 50% or 100% estrogen-containing implants) to induce varying degrees of urinary bladder distension. Wheel running distance (P = 0.005) and duration (P = 0.006) decreased after orchidectomy, but slowly increased following estrogen replacement. During the study, wheel running did not return to the levels observed in physiologically intact mice. Significant distension was not observed between estrogen treatment groups indicating that a slow-responding estrogen effect exists in male mice that prevents wheel running from returning to normal levels immediately following steroid reintroduction. The limited increase in wheel running during estrogen treatment following orchidectomy is not an artifact of induced urinary bladder distension.

Prolonged Effects of Elevated 17ß-Estradiol on Physical Activity after Orchidectomy.

The biological mechanisms regulating physical activity patterns appear to be linked to the sex hormones. Elucidation of these regulatory mechanisms may enhance individual physical activity patterns producing positive gains in health. PURPOSE: The purpose of this study was to evaluate the prolonged effects of estrogen on wheel running distance, duration, and speed in orchidectomized mice. METHODS: The physical activity patterns of 9-wk-old C57BL/6j male mice (n = 28) were observed. Wheel running distance, duration, and speed were assessed under physiological conditions for 7 d. Next, physical activity patterns were evaluated after bilateral orchidectomy (n = 14) or sham orchidectomy (n = 14) for an additional 7 d. Orchidectomized mice were provided estrogen containing capsules for three additional weeks; control mice were provided estrogen-free capsules. Wheel running distance, duration, and speed were analyzed by three two-way (treatment group-phase of study) analysis of variance tests. RESULTS: Wheel running speed was unaffected by sex hormone status. Distance (mean ± SD = 6.74 ± 2.13 km at baseline) decreased significantly after orchidectomy (2.27 ± 1.55 km) and remained low after initial estrogen treatment (3.04 ± 1.05 km). Prolonged estrogen exposure sustained a significant elevation of daily distance (4.47 ± 1.87 km). Prolonged estrogen exposure recovered and significantly sustained wheel running duration (baseline, 248 ± 60 min; postorchidectomy, 102 ± 53 min; prolonged exposure, 170 ± 63 min). CONCLUSIONS: Wheel running behavior was reduced significantly after orchidectomy and remained low after initial treatment with estrogens, but recovered to near control levels after 2 wk of exposure to estrogens. The estrogenic mechanism regulating wheel running behavior in male mice appears to induce an extensive but slow acting biological mechanism. Understanding the biological drive behind this mechanism may aid in developing useful therapeutic strategies to combat health issues related to physical inactivity.

An Updated Review of Ciguatera Fish Poisoning: Clinical, Epidemiological, Environmental, and Public Health Management.

Ciguatera Fish Poisoning (CFP) is the most frequently reported seafood-toxin illness in the world. It causes substantial human health, social, and economic impacts. The illness produces a complex array of gastrointestinal, neurological and neuropsychological, and cardiovascular symptoms, which may last days, weeks, or months. This paper is a general review of CFP including the human health effects of exposure to ciguatoxins (CTXs), diagnosis, human pathophysiology of CFP, treatment, detection of CTXs in fish, epidemiology of the illness, global dimensions, prevention, future directions, and recommendations for clinicians and patients. It updates and expands upon the previous review of CFP published by Friedman et al. (2008) and addresses new insights and relevant emerging global themes such as climate and environmental change, international market issues, and socioeconomic impacts of CFP. It also provides a proposed universal case definition for CFP designed to account for the variability in symptom presentation across different geographic regions. Information that is important but unchanged since the previous review has been reiterated. This article is intended for a broad audience, including resource and fishery managers, commercial and recreational fishers, public health officials, medical professionals, and other interested parties.

Stromal Vascular Fraction from Lipoaspirate Infranatant: Comparison Between Suction-Assisted Liposuction and Nutational Infrasonic Liposuction.

INTRODUCTION: Lipoaspirate has shown great promise as a source of progenitor cells for use in regenerative medicine. The stromal vascular fraction (SVF) can be isolated from lipoaspirate using enzyme digestion and centrifugation, but this approach may be limited by the labor-intensive nature of the technique as well as ambiguities in current governmental regulations. An alternative approach to obtain SVF from lipoaspirate was studied. METHOD: Paired (collected from contralateral regions) lipoaspirate specimens were acquired from 30 consenting patients (age 24-62; 22 females, 8 males) by suction-assisted liposuction (SAL) and nutational infrasonic liposuction (NIL). The infranatant from 50 ml of adipose tissue (LAF) was centrifuged at 400g × 5 min and the resultant pellet was collected with a pipette. Time = 15-20 min. The respective SVFs cell populations were counted using an optical fluorescent cell counter (Nexcelom A2000) and the fluorescent stains-acridine orange (AO) and propidium iodide (PI). RESULTS: The number of nucleated, live cells from SAL infranatant was 97,345 ± 23,435 per ml of adipose tissue and from NIL infranatant was 335,621 ± 81,274 per ml of adipose tissue. The p value is <0.00001, n = 30. CONCLUSION: Regenerative cells can be isolated from the lipoaspirate infranatant from either SAL or NIL, although in lower quantities than from enzyme digestion. NIL acquisition yielded 3.5× the number of cells over that acquired from SAL. The time, skill, and cost of producing SVF from infranatant is less than using enzyme digestion, which potentially make these regenerative therapies accessible to more physicians and patients. NO LEVEL ASSIGNED: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Stabilization of the wheel running phenotype in mice.

PURPOSE: Increased physical activity is well known to improve health and wellness by modifying the risks for many chronic diseases. Rodent wheel running behavior is a beneficial surrogate model to evaluate the biology of daily physical activity in humans. Upon initial exposure to a running wheel, individual mice differentially respond to the experience, which confounds the normal activity patterns exhibited in this otherwise repeatable phenotype. To promote phenotypic stability, a minimum seven-day (or greater) acclimation period is utilized. Although phenotypic stabilization is achieved during this 7-day period, data to support acclimation periods of this length are not currently available in the literature. The purpose of this project is to evaluate the wheel running response in C57BL/6j mice immediately following exposure to a running wheel. METHODS: Twenty-eight male and thirty female C57BL/6j mice (Jackson Laboratory, Bar Harbor, ME) were acquired at eight weeks of age and were housed individually with free access to running wheels. Wheel running distance (km), duration (min), and speed (m∙min(-1)) were measured daily for fourteen days following initial housing. One-way ANOVAs were used to evaluate day-to-day differences in each wheel running character. Limits of agreement and mean difference statistics were calculated between days 1-13 (acclimating) and day 14 (acclimated) to assess day-to-day agreement between each parameter. RESULTS: Wheel running distance (males: F=5.653, p=2.14 × 10(-9); females: F=8.217, p=1.20 × 10(-14)), duration (males: F=2.613, p=0.001; females: F=4.529, p=3.28 × 10(-7)), and speed (males: F=7.803, p=1.22 × 10(-13); females: F=13.140, p=2.00 × 10(-16)) exhibited day-to-day differences. Tukey's HSD post-hoc testing indicated differences between early (males: days 1-3; females: days 1-6) and later (males: days >3; females: days >6) wheel running periods in distance and speed. Duration only exhibited an anomalous difference between wheel running on day 13 and wheel running on days 1 through 4 in males. In females, duration exhibited anomalous differences due to abnormally depressed wheel running on day 6 and abnormally elevated wheel running on day 14. Limits of agreement and mean difference statistics indicated stable phenotypic variability with an up-trending daily mean for distance and speed that stabilized within the first three days in males and within eight days in females. Duration exhibited stable variability after nine days in males and after seven days in females. CONCLUSION: Although it is common practice to allow a prolonged (≥ seven day) acclimation period prior to recording wheel running data, the current study suggests that phenotypic stabilization of all three indices is achieved at different times with distance and speed exhibiting stability by day three in males and day eight in females. Duration exhibits stability by day nine in males and day seven in females.

Mobile early detection and connected intervention to coproduce better care in severe mental illness.

Current approaches to the management of severe mental illness have four major limitations: 1) symptom reporting is intermittent and subject to problems with reliability; 2) service users report feelings of disengagement from their care planning; 3) late detection of symptoms delay interventions and increase the risk of relapse; and 4) care systems are held back by the costs of unscheduled hospital admissions that could have been avoided with earlier detection and intervention. The ClinTouch system was developed to close the loop between service users and health professionals. ClinTouch is an end-to-end secure platform, providing a validated mobile assessment technology, a web interface to view symptom data and a clinical algorithm to detect risk of relapse. ClinTouch integrates high-resolution, continuous longitudinal symptom data into mental health care services and presents it in a form that is easy to use for targeting care where it is needed. The architecture and methodology can be easily extended to other clinical domains, where the paradigm of targeted clinical interventions, triggered by the early detection of decline, can improve health outcomes.

The sum is greater than its parts: clinical evaluations and grade inflation in the surgery clerkship.

BACKGROUND: This study examines grading component distributions to determine whether alterations in clinical grade determination reduce skew and improve predictive capability of the clinical evaluation. METHODS: Rotation evaluations, examination scores, and final grades were collected for third-year medical students over a 2-year period. Conditional logistic regression and ordinary least squares regression models were run using SAS 9.3. RESULTS: Conditional logistic regression demonstrated significant association between global clinical score and final grade and between average clinical evaluation score and final grade. Inclusion of shelf score into either model demonstrated increase in overall final grade. CONCLUSIONS: Regressions using global and average clinical evaluation score indicate that average score is a better fit for a norm-based grading system. Arguably, the Shelf measures clinical knowledge more objectively than clinical evaluation, but both were significant. Clinical evaluation is prone to inflation because of its subjective nature; conceivably, inflation leads to the decreased correlation with shelf score.

Effects of age on the physiological and mechanical characteristics of human femoropopliteal arteries.

Surgical and interventional therapies for peripheral artery disease (PAD) are notorious for high rates of failure. Interactions between the artery and repair materials play an important role, but comprehensive data describing the physiological and mechanical characteristics of human femoropopliteal arteries are not available. Fresh femoropopliteal arteries were obtained from 70 human subjects (13-79 years old), and in situ vs. excised arterial lengths were measured. Circumferential and longitudinal opening angles were determined for proximal superficial femoral, proximal popliteal and distal popliteal arteries. Mechanical properties were assessed by multi-ratio planar biaxial extension, and experimental data were used to calculate physiological stresses and stretches, in situ axial force and anisotropy. Verhoeff-Van Gieson-stained axial and transverse arterial sections were used for histological analysis. Most specimens demonstrated nonlinear deformations and were more compliant longitudinally than circumferentially. In situ axial pre-stretch decreased 0.088 per decade of life. In situ axial force and axial stress also decreased with age, but circumferential physiological stress remained constant. Physiological circumferential stretch decreased 55-75% after 45 years of age. Histology demonstrated a thickened external elastic lamina with longitudinally oriented elastin that was denser in smaller, younger arteries. Axial elastin likely regulates axial pre-stretch to help accommodate the complex deformations required of the artery wall during locomotion. Degradation and fragmentation of elastin as a consequence of age, cyclic mechanical stress and atherosclerotic arterial disease may contribute to decreased in situ axial pre-stretch, predisposing to more severe kinking of the artery during limb flexion and loss of energy-efficient arterial function.

Implementation of a self-management support approach (WISE) across a health system: a process evaluation explaining what did and did not work for organisations, clinicians and patients.

BACKGROUND: Implementation of long-term condition management interventions rests on the notion of whole systems re-design, where incorporating wider elements of health care systems are integral to embedding effective and integrated solutions. However, most self-management support (SMS) evaluations still focus on particular elements or outcomes of a sub-system. A randomised controlled trial of a SMS intervention (WISE-Whole System Informing Self-management Engagement) implemented in primary care showed no effect on patient-level outcomes. This paper reports on a parallel process evaluation to ascertain influences affecting WISE implementation at patient, clinical and organisational levels. Normalisation Process Theory (NPT) provided a sensitising background and analytical framework. METHODS: A multi-method approach using surveys and interviews with organisational stakeholders, practice staff and trial participants about impact of training and use of tools developed for WISE. Analysis was sensitised by NPT (coherence, cognitive participation, collective action and reflective monitoring). The aim was to identify what worked and what did not work for who and in what context. RESULTS: Interviews with organisation stakeholders emphasised top-down initiation of WISE by managers who supported innovation in self-management. Staff from 31 practices indicated engagement with training but patchy adoption of WISE tools; SMS was neither prioritised by practices nor fitted with a biomedically focussed ethos, so little effort was invested in WISE techniques. Interviews with 24 patients indicated no awareness of any changes following the training of practice staff; furthermore, they did not view primary care as an appropriate place for SMS. CONCLUSION: The results contribute to understanding why SMS is not routinely adopted and implemented in primary care. WISE was not embedded because of the perceived lack of relevance and fit to the ethos and existing work. Enacting SMS within primary care practice was not viewed as a legitimate activity or a professional priority. There was failure to, in principle, engage with and identify patients' support needs. Policy presumptions concerning SMS appear to be misplaced. Implementation of SMS within the health service does not currently account for patient circumstances. Primary care priorities and support for SMS could be enhanced if they link to patients' broader systems of implementation networks and resources.

Aligning everyday life priorities with people's self-management support networks: an exploration of the work and implementation of a needs-led telephone support system.

BACKGROUND: Recent initiatives to target the personal, social and clinical needs of people with long-term health conditions have had limited impact within primary care. Evidence of the importance of social networks to support people with long-term conditions points to the need for self-management approaches which align personal circumstances with valued activities. The Patient-Led Assessment for Network Support (PLANS) intervention is a needs-led assessment for patients to prioritise their health and social needs and provide access to local community services and activities. Exploring the work and practices of patients and telephone workers are important for understanding and evaluating the workability and implementation of new interventions. METHODS: Qualitative methods (interviews, focus group, observations) were used to explore the experience of PLANS from the perspectives of participants and the telephone support workers who delivered it (as part of an RCT) and the reasons why the intervention worked or not. Normalisation Process Theory (NPT) was used as a sensitising tool to evaluate: the relevance of PLANS to patients (coherence); the processes of engagement (cognitive participation); the work done for PLANS to happen (collective action); the perceived benefits and costs of PLANS (reflexive monitoring). 20 patients in the intervention arm of a clinical trial were interviewed and their telephone support calls were recorded and a focus group with 3 telephone support workers was conducted. RESULTS: Analysis of the interviews, support calls and focus group identified three themes in relation to the delivery and experience of PLANS. These are: formulation of 'health' in the context of everyday life; trajectories and tipping points: disrupting everyday routines; precarious trust in networks. The relevance of these themes are considered using NPT constructs in terms of the work that is entailed in engaging with PLANS, taking action, and who is implicated this process. CONCLUSIONS: PLANS gives scope to align long-term condition management to everyday life priorities and valued aspects of life. This approach can improve engagement with health-relevant practices by situating them within everyday contexts. This has potential to increase utilisation of local resources with potential cost-saving benefits for the NHS. TRIAL REGISTRATION: ISRCTN45433299.

Three-dimensional bending, torsion and axial compression of the femoropopliteal artery during limb flexion.

High failure rates of femoropopliteal artery reconstruction are commonly attributed to complex 3D arterial deformations that occur with limb movement. The purpose of this study was to develop a method for accurate assessment of these deformations. Custom-made stainless-steel markers were deployed into 5 in situ cadaveric femoropopliteal arteries using fluoroscopy. Thin-section CT images were acquired with each limb in the straight and acutely bent states. Image segmentation and 3D reconstruction allowed comparison of the relative locations of each intra-arterial marker position for determination of the artery's bending, torsion and axial compression. After imaging, each artery was excised for histological analysis using Verhoeff-Van Gieson staining. Femoropopliteal arteries deformed non-uniformly with highly localized deformations in the proximal superficial femoral artery, and between the adductor hiatus and distal popliteal artery. The largest bending (11±3-6±1 mm radius of curvature), twisting (28±9-77±27°/cm) and axial compression (19±10-30±8%) were registered at the adductor hiatus and the below knee popliteal artery. These deformations were 3.7, 19 and 2.5 fold more severe than values currently reported in the literature. Histology demonstrated a distinct sub-adventitial layer of longitudinally oriented elastin fibers with intimal thickening in the segments with the largest deformations. This endovascular intra-arterial marker technique can quantify the non-uniform 3D deformations of the femoropopliteal artery during knee flexion without disturbing surrounding structures. We demonstrate that 3D arterial bending, torsion and compression in the flexed lower limb are highly localized and are substantially more severe than previously reported.

Biaxial mechanical properties of the human thoracic and abdominal aorta, common carotid, subclavian, renal and common iliac arteries.

The biomechanics of large- and medium-sized arteries influence the pathophysiology of arterial disease and the response to therapeutic interventions. However, a comprehensive comparative analysis of human arterial biaxial mechanical properties has not yet been reported. Planar biaxial extension was used to establish the passive mechanical properties of human thoracic (TA, [Formula: see text]) and abdominal (AA, [Formula: see text]) aorta, common carotid (CCA, [Formula: see text]), subclavian (SA, [Formula: see text]), renal (RA, [Formula: see text]) and common iliac (CIA, [Formula: see text]) arteries from 11 deceased subjects ([Formula: see text] years old). Histological evaluation determined the structure of each specimen. Experimental data were used to determine constitutive parameters for a structurally motivated nonlinear anisotropic constitutive model. All arteries demonstrated appreciable anisotropy and large nonlinear deformations. Most CCA, SA, TA, AA and CIA specimens were stiffer longitudinally, while most RAs were stiffer circumferentially. A switch in anisotropy was occasionally demonstrated for all arteries. The CCA was the most compliant, least anisotropic and least frequently diseased of all arteries, while the CIA and AA were the stiffest and the most diseased. The severity of atherosclerosis correlated with age, but was not affected by laterality. Elastin fibers in the aorta, SA and CCA were uniformly and mostly circumferentially distributed throughout the media, while in the RA and CIA, elastin was primarily axially aligned and concentrated in the external elastic lamina. Constitutive modeling provided good fits to the experimental data for most arteries. Biomechanical and architectural features of major arteries differ depending on location and functional environment. A better understanding of localized arterial mechanical properties may support the development of site-specific treatment modalities for arterial disease.

Developing cartoons for long-term condition self-management information.

BACKGROUND: Advocating the need to adopt more self-management policies has brought with it an increasing demand for information about living with and making decisions about long-term conditions, with a significant potential for using cartoons. However, the purposeful use of cartoons is notably absent in many areas of health care as is evidence of their acceptability to patients and lay others. This paper outlines the process used to develop and evaluate cartoons and their acceptability for a series of self-management guidebooks for people with inflammatory bowel disease, irritable bowel syndrome, diabetes, chronic obstructive pulmonary disease and chronic kidney disease (CKD). METHODS: Principles for a process to develop information and cartoons were developed. Cartoon topics were created using qualitative research methods to obtain lay views and experiences. The CKD guidebook was used to provide a detailed exemplar of the process. Focus group and trial participants were recruited from primary care CKD registers. The book was part of a trial intervention; selected participants evaluated the cartoons during in-depth interviews which incorporated think-aloud methods. RESULTS: In general, the cartoons developed by this process depict patient experiences, common situations, daily management dilemmas, making decisions and choices and the uncertainties associated with conditions. CKD cartoons were developed following two focus groups around the themes of getting a diagnosis; understanding the problem; feeling that facts were being withheld; and setting priorities. Think-aloud interviews with 27 trial participants found the CKD cartoons invoked amusement, recognition and reflection but were sometimes difficult to interpret. CONCLUSION: Humour is frequently utilised by people with long-term conditions to help adjustment and coping. Cartoons can help provide clarity and understanding and could address concerns related to health literacy. Using cartoons to engage and motivate people is a consideration untapped by conventional theories with the potential to improve information to support self-management.

Implementing, embedding and integrating self-management support tools for people with long-term conditions in primary care nursing: a qualitative study.

BACKGROUND: An implementation gap exists between policy aspirations for provision and the delivery of self-management support in primary care. An evidence based training and support package using a whole systems approach implemented as part of a randomised controlled trial was delivered to general practice staff. The trial found no effect of the intervention on patient outcomes. This paper explores why self-management support failed to become part of normal practice. We focussed on implementation of tools which capture two key aspects of self-management support - education (guidebooks for patients) and forming collaborative partnerships (a shared decision-making tool). OBJECTIVES: To evaluate the implementation and embedding of self-management support in a United Kingdom primary care setting. DESIGN: Qualitative semi-structured interviews with primary care professionals. SETTINGS: 12 General Practices in the Northwest of England located within a deprived inner city area. PARTICIPANTS: Practices were approached 3-6 months after undergoing training in a self-management support approach. A pragmatic sample of 37 members of staff - General Practitioners, nurses, and practice support staff from 12 practices agreed to take part. The analysis is based on interviews with 11 practice nurses and one assistant practitioner; all were female with between 2 and 21 years' experience of working in general practice. METHODS: A qualitative design involving face-to-face, semi-structured interviews audio-recorded and transcribed. Normalisation Process Theory framework allowed a systematic evaluation of the factors influencing the work required to implement the tools. FINDINGS: The guidebooks were embedded in daily practice but the shared decision-making tools were not. Guidebooks were considered to enhance patient-centredness and were minimally disruptive. Practice nurses were reluctant to engage with behaviour change discussions. Self-management support was not formulated as a practice priority and there was minimal support for this activity within the practice: it was not auditable; was insufficiently differentiated from existing content and processes of work to value in its own right, and considered too disruptive and time-consuming. CONCLUSION: Supporting self-management through the encouragement of lifestyle change was problematic to realise with limited evidence of the development of the needed collaborative partnerships between patients and practitioners required by the ethos of self-management support.

Implementation of self management support for long term conditions in routine primary care settings: cluster randomised controlled trial.

OBJECTIVE: To determine the effectiveness of an intervention to enhance self management support for patients with chronic conditions in UK primary care. DESIGN: Pragmatic, two arm, cluster randomised controlled trial. SETTING: General practices, serving a population in northwest England with high levels of deprivation. PARTICIPANTS: 5599 patients with a diagnosis of diabetes (n=2546), chronic obstructive pulmonary disease (n=1634), and irritable bowel syndrome (n=1419) from 43 practices (19 intervention and 22 control practices). INTERVENTION: Practice level training in a whole systems approach to self management support. Practices were trained to use a range of resources: a tool to assess the support needs of patients, guidebooks on self management, and a web based directory of local self management resources. Training facilitators were employed by the health management organisation. MAIN OUTCOME MEASURES: Primary outcomes were shared decision making, self efficacy, and generic health related quality of life measured at 12 months. Secondary outcomes were general health, social or role limitations, energy and vitality, psychological wellbeing, self care activity, and enablement. RESULTS: We randomised 44 practices and recruited 5599 patients, representing 43% of the eligible population on the practice lists. 4533 patients (81.0%) completed the six month follow-up and 4076 (72.8%) the 12 month follow-up. No statistically significant differences were found between patients attending trained practices and those attending control practices on any of the primary or secondary outcomes. All effect size estimates were well below the prespecified threshold of clinically important difference. CONCLUSIONS: An intervention to enhance self management support in routine primary care did not add noticeable value to existing care for long term conditions. The active components required for effective self management support need to be better understood, both within primary care and in patients' everyday lives. TRIAL REGISTRATION: Current Controlled Trials ISRCTN90940049.