Complete HLA genotyping of type 1 diabetes patients and controls from Mali reveals both expected and novel disease associations.

HLA genotyping was performed on 99 type 1 diabetes (T1D) patients and 200 controls from Mali. Next-generation sequencing of the classical HLA-A, -B, -C, -DRB1, -DRB3, -DRB4, -DRB5, -DQA1, -DQB1, -DPA1, and -DPB1 loci revealed strong T1D association for all loci except HLA-C and -DPA1. Class II association is stronger than class I association, with most observed associations predisposing or protective as expected based on previous studies. For example, HLA-DRB1*03:01, HLA-DRB1*09:01, and HLA-DRB1*04:05 predispose for T1D, whereas HLA-DRB1*15:03 is protective. HLA-DPB1*04:02 (OR = 12.73, p = 2.92 × 10-05 ) and HLA-B*27:05 (OR = 21.36, p = 3.72 × 10-05 ) appear highly predisposing, although previous studies involving multiple populations have reported HLA-DPB1*04:02 as T1D-protective and HLA-B*27:05 as neutral. This result may reflect the linkage disequilibrium between alleles on the extended HLA-A*24:02~HLA-B*27:05~HLA-C*02:02~HLA-DRB1*04:05~HLA-DRB4*01:03~HLA-DQB1*02:02~HLA-DQA1*02:01~HLA-DPB1*04:02~HLA-DPA1*01:03 haplotype in this population rather than an effect of either allele itself. Individual amino acid (AA) analyses are consistent with most T1D association attributable to HLA class II rather than class I in this data set. AA-level analyses reveal previously undescribed differences of the HLA-C locus from the HLA-A and HLA-B loci, with more polymorphic positions, spanning a larger portion of the gene. This may reflect additional mechanisms for HLA-C to influence T1D risk, for example, through expression differences or through its role as the dominant ligand for killer cell immunoglobulin-like receptors (KIR). Comparison of these data to those from larger studies and on other populations may facilitate T1D prediction and help elucidate elusive mechanisms of how HLA contributes to T1D risk and autoimmunity.

Sexual Decision Making When Intoxicated: Women's Reasons for and Against Having Sex in a Laboratory-Based Scenario.

Young adult women report high condom use intentions, but inconsistent condom use. Cognitive appraisals during sexual encounters are important determinants of condom use decisions, but a nuanced understanding of what cognitions emerge during women's "hot states" (e.g., sexual arousal, alcohol intoxication) remains lacking. To address this gap, we examined women's heat of the moment cognitions in their own words using mixed methods. Young adult women (N = 503; Mage = 25.01, SDage = 2.66) were randomized to a beverage condition (alcohol or control), then read and responded to questions about an eroticized sexual scenario. The nature and strength of reasons for and against having sex were reported before and after learning no condom was available. Multilevel models revealed intoxicated participants were more likely to let the partner decide how far to go sexually than sober participants at both timepoints, but the strength of cognitive appraisals (reasons for, reasons against, and feeling conflicted) only differed between beverage conditions after knowledge of no condom. These results suggest alcohol myopia was evident in the presence of inhibition conflict. Content analysis of these reasons revealed multifaceted cognitions that changed upon learning there was no condom. Findings highlight cognitions to target through interventions and underscore the importance of both alcohol and situational context in decision making.

Barriers experienced by emerging adults in discussing their sexuality with parents and health care providers: A mixed-method study.

While most parents and health care providers understand the importance of educating young people about their emerging sexuality, many report never discussing sex with the young people in their care. Using data from a survey of 1,193 emerging adults, we applied concept mapping to a corpus of over 2,350 short qualitative responses to two questions: (a) What, if anything, makes it difficult to talk to your parents about sexuality or your sexual health? and (b) What, if anything, makes it difficult to talk to your doctors, therapists, or mental health professionals about sexuality or your sexual health? Qualitative analyses revealed that while embarrassment, shame, and awkwardness were commonly reported barriers to communicating with both parents and providers, participants reported different effects across settings: Parent-related embarrassment was associated with concerns about changing the intimacy of the parental relationship, while provider-related embarrassment was associated with fears of seeming incompetent or eliciting dismissal. These observations were supported by multidimensional scaling and hierarchical cluster analyses, which we used to derive conceptual maps based on quantitative spatial analysis of single-concept statements. These analyses revealed a best-fit solution of eight conceptual groups for barriers to discussing sexuality with health care providers, but only four groups of barriers in discussing with parents. Broadly, our findings reinforce the need to tailor sexual health communication to patient characteristics and settings. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Bias among managers: Its prevalence across a decade and comparison across occupations.

Employees from minoritized and subjugated groups have poorer work experiences and fewer opportunities for advancement than do their peers. Biases among decision makers likely contributes to these patterns. The purposes of this study were to (a) examine the explicit biases and implicit biases among people in management occupations (e.g., chief executives, operations managers, advertising and promotions managers, financial managers, and distributions managers, among others) and (b) compare their biases with people in 22 other occupations. The authors analyzed responses from visitors to the Project Implicit website, including assessments of their racial, gender, disability, and sexual orientation biases from 2012 to 2021. Results indicate that managers expressed moderate levels of explicit and implicit bias across all dimensions. Managers differed from people in other occupations in roughly one-third of the comparisons. The biggest differences came in their implicit biases, with managers expressing more bias than people in other occupations. The study's originality rests in the scope of the work (the authors analyzed data from over 5 million visitors representing 23 broad occupations); comparison of people in management occupations to those in other work settings; and empirically demonstrating the biases that managers have.

New Local Explorations of the Unitary Coupled Cluster Energy Landscape.

The recent quantum information boom has effected a resurgence of interest in the unitary coupled cluster (UCC) theory. Our group's interest in local energy landscapes of unitary ansätze prompted us to investigate the classical approach of truncating the Taylor series expansion (instead of a perturbative expansion) of the UCC with singles and doubles (UCCSD) energy at the second order. This amounts to an approach where the electron correlation energy is estimated by taking a single Newton-Raphson step from Hartree-Fock toward UCCSD. Such an approach has been explored previously, but the accuracy was not extensively studied. In this paper, we investigate the performance and observe similar pathologies to the linearized coupled cluster with singles and doubles. We introduce the use of derivatives of order three or greater to help partially recover the variational lower bound of true UCCSD, restricting these derivatives to those of the "unmixed" category in order to simplify the model. By testing the approach on several potential energy surfaces and reaction energies, we find this "diagonal" approximation to higher order terms to be effective at reducing sensitivity near singularities for strongly correlated regimes, while not significantly diminishing the accuracy of weakly correlated systems.

Symmetry Breaking Slows Convergence of the ADAPT Variational Quantum Eigensolver.

Because quantum simulation of molecular systems is expected to provide the strongest advantage over classical computing methods for systems exhibiting strong electron correlation, it is critical that the performance of VQEs be assessed for strongly correlated systems. For classical simulation, strong correlation often results in symmetry breaking of the Hartree-Fock reference, leading to Löwdin's well-known "symmetry dilemma", whereby accuracy in the energy can be increased by breaking spin or spatial symmetries. Here, we explore the impact of symmetry breaking on the performance of ADAPT-VQE using two strongly correlated systems: (i) the "fermionized" anisotropic Heisenberg model, where the anisotropy parameter controls the correlation in the system, and (ii) symmetrically stretched linear H4, where correlation increases with increasing H-H separation. In both of these cases, increasing the level of correlation of the system leads to spontaneous symmetry breaking (parity and S^2, respectively) of the mean-field solutions. We analyze the role that symmetry breaking in the reference states and orbital mappings of the fermionic Hamiltonians have in the compactness and performance of ADAPT-VQE. We observe that improving the energy of the reference states by breaking symmetry has a deleterious effect on ADAPT-VQE by increasing the length of the ansatz necessary for energy convergence and exacerbating the problem of "gradient troughs".

Relational and Trait Factors Mediate the Associations between Women's Intoxication-Related Unwanted Sexual Experiences, Pleasure, and Desire.

Despite documented negative sexual health sequelae of unwanted sexual contact (USC), it is unclear why individuals who have experienced USC within the context of intoxication (intoxication-related USC) are at particular risk for poor sexual functioning. Intoxication-related USC may impact relational factors like relationship satisfaction, as trauma symptoms interfere with emotional closeness during sex. Additionally, although individual traits - such as sexual excitation and sensation seeking - affect the relationship between trauma and sexual functioning, it is unknown whether these factors differentially impact those who have experienced intoxication-related USC. Finally, because presence of a partner may evoke trauma-related symptoms during partnered (dyadic) sexual activity, mediators may differ across solitary versus dyadic sexual pleasure and desire. We tested relational and individual trait mediators of the association between intoxication-related USC and solitary and dyadic sexual pleasure and desire in a sample of heterosexual and sexual minority women. Trait factors consistently mediated the association between intoxication-related USC and both dyadic and solitary desire and pleasure, while relational factors such as emotional closeness were inconsistently related to sexual wellbeing. If replicated, these findings would suggest that trait factors may be useful targets for clinical sexual wellness interventions among sexuality-diverse women who have experienced intoxication-related USC.

Effectiveness of Predominantly Group Schema Therapy and Combined Individual and Group Schema Therapy for Borderline Personality Disorder: A Randomized Clinical Trial.

IMPORTANCE: Schema therapy (ST), delivered either in an individual or group format, has been compared with other active treatments for borderline personality disorder (BPD). To our knowledge, the 2 formats have not been compared with treatment as usual (TAU) or with each other. Such comparisons help determine best treatment practices. OBJECTIVE: To evaluate whether ST is more effectively delivered in a predominantly group or combined individual and group format and whether ST is more effective than optimal TAU for BPD. DESIGN, SETTING, AND PARTICIPANTS: In this multicenter, 3-arm randomized clinical trial conducted at 15 sites in 5 countries (Australia, Germany, Greece, the Netherlands, and the UK), outpatients aged 18 to 65 years who had BPD were recruited between June 29, 2010, and May 18, 2016, to receive either predominantly group ST (PGST), combined individual and group ST (IGST), or optimal TAU. Data were analyzed from June 4, 2019, to December 29, 2021. INTERVENTIONS: At each site, cohorts of 16 to 18 participants were randomized 1:1 to PGST vs TAU or IGST vs TAU. Both ST formats were delivered over 2 years, with 2 sessions per week in year 1 and the frequency gradually decreasing during year 2. Assessments were collected by blinded assessors. MAIN OUTCOMES AND MEASURES: The primary outcome was the change in BPD severity over time, assessed with the Borderline Personality Disorder Severity Index (BPDSI) total score. Treatment retention was analyzed as a secondary outcome using generalized linear mixed model survival analysis. RESULTS: Of 495 participants (mean [SD] age, 33.6 [9.4] years; 426 [86.2%] female), 246 (49.7%) received TAU, 125 (25.2%) received PGST, and 124 (25.0%) received IGST (1 of whom later withdrew consent). PGST and IGST combined were superior to TAU with regard to reduced BPD severity (Cohen d, 0.73; 95% CI, 0.29-1.18; P < .001). For this outcome, IGST was superior to TAU (Cohen d, 1.14; 95% CI, 0.57-1.71; P < .001) and PGST (Cohen d, 0.84; 95% CI, 0.09-1.59; P = .03), whereas PGST did not differ significantly from TAU (Cohen d, 0.30; 95% CI, -0.29 to 0.89; P = .32). Treatment retention was greater in the IGST arm than in the PGST (1 year: 0.82 vs 0.72; 2 years: 0.74 vs. 0.62) and TAU (1 year: 0.82 vs 0.73; 2 years: 0.74 vs 0.64) arms, and there was no significant difference between the TAU and PGST arms (1 year: 0.73 vs 0.72; 2 years: 0.64 vs 0.62). CONCLUSIONS AND RELEVANCE: In this randomized clinical trial, IGST was more effective and had greater treatment retention compared with TAU and PGST. These findings suggest that IGST is the preferred ST format, with high retention and continuation of improvement in BPD severity after the completion of treatment. TRIAL REGISTRATION: trialregister.nl Identifier: NTR2392.

Early mechanisms of neutrophil activation and transmigration in acute lung injury.

Introduction:Neutrophil transmigration is multifactorial and primarily driven by selectins and ß2-integrins (CD11b/CD18), whose expression are dependent on the underlying stimulus. Ventilator-induced lung injury (VILI) results in a predominantly CD18-independent mechanism of neutrophil recruitment, while direct endotoxin-induced lung injury results from a CD18-dependent mechanism. We previously observed that lack of NADPH oxidases DUOX1 and DUOX2 resulted in reduced neutrophil influx in a VILI model of lung injury but had no influence on neutrophil influx after LPS exposure. Based on these observations, we hypothesized that DUOX1/DUOX2 are an important component of CD18-independent mechanisms of neutrophil recruitment in the lung. Methods:We exposed Duoxa -/- (KO) mice and Duoxa +/+ (WT) mice to either an intratracheal exposure of lipopolysaccharide (LPS/endotoxin)-or high tidal volume ventilation and compared expression of neutrophil markers between groups. WT mice (129S6/SvEvTac) were obtained from Taconic Biosciences (One Discovery Drive Suite 304; Rensselaer, NY 1244) and were allowed to acclimatize for one week prior to study enrollment. KO mice were generated as previously described [Grasberger 2012] and bred in-house on a 129S6 background. We provided positive-pressure ventilation at a tidal volume of 10 ml/kg with 2 cmH20 positive end-expiratory pressure (PEEP). Mice were assigned to groups consisting of KO (n = 5) and WT (n = 5) in each group and divided into non-ventilated, positive-pressure ventilation, or LPS IT exposure groups. Positive-pressure ventilation was instituted for 4-h using a FlexiVent (Flexiware 8.1, Scireq, Montreal, QC, Canada). Lipopolysaccharide (Salmonella enterica serotype tryphimurium L6143, Millipore Sigma) was administered via an intratracheal (IT) route at a dose of 0.1 mg/kg. Mice were humanely euthanized at 4-h post-injection consistent with the UC Davis IAUCAC-approved protocol. Results:As previously observed, neutrophilic influx into the airways was significantly impaired in the Duoxa -/- (KO) mice after VILI, but not after LPS exposure. LPS-induced lung injury resulted in upregulation of CD11b+ neutrophils and shedding of CD62L and CD162 regardless of DUOX expression, whereas VILI resulted in upregulation of CD49+ neutrophils in the Duoxa +/+ (WT) mice but not the Duoxa -/- (KO) mice. Conclusion:Our data suggest DUOX is required for CD18-independent mechanisms of neutrophil recruitment in the lung induced by acute lung injury, but not for canonical CD18depedent mechanisms after LPS exposure.

Higher sexual excitation is associated with an increase in sex-linked substance use in women with a history of unwanted sexual contact.

Survivors of unwanted sexual contact have an increased likelihood of using substances in sexual situations, which puts them at heightened risk for intoxication-related harms. Separately, research has indicated that women may intentionally use substances in sexual situations to either enhance pleasure (i.e., increase sexual excitation) and/or reduce sexual anxiety or shame (i.e., reduce sexual inhibition), a phenomenon termed sex-linked substance use (SLSU). A predominant assumption in the literature is that women with unwanted sex histories are more likely to disengage during sex, suggesting greater inhibition-related SLSU; however, there is little prior research directly examining if women who have unwanted sex histories primarily engage in SLSU to increase sexual excitation or decrease inhibitions. We conducted exploratory analyses of an online survey in a convenience sample of 516 undergraduate women including data on their history of unwanted sex, SLSU, and sexual excitation/inhibition. Sexual excitation mediated the association between a history of unwanted sexual contact and SLSU, suggesting that women with unwanted sexual histories reported higher levels of sexual excitation, which in turn was associated with a higher likelihood of using substances to increase pleasure during sexual activity. Specifically, arousability, partner characteristics, and power dynamics subfactors were significant mediators. Sexual inhibition did not mediate the relationship between a history of unwanted sexual contact and SLSU, suggesting that women with unwanted sex histories may have been less likely to use substances to reduce sexual inhibitions. If replicated, these findings suggest that sexual excitation may be a useful target of intervention surrounding SLSU, particularly in women with histories of unwanted sexual contact. Specifically, treatments targeting cognitive and affective tendencies associated with sexual excitation may help women who engage in SLSU to have safe, pleasurable sexual activity, without increasing the risk of intoxication-related harms.

Soil water repellency and the five spheres of influence: A review of mechanisms, measurement and ecological implications.

Soil water repellency (SWR) is a widespread phenomenon that influences patterns of soil wetting, runoff, evapotranspiration and availability of water for plants. In natural ecosystems there is emerging evidence that some plants can take advantage of non-uniform wetting patterns, leading to the emergence of co-evolutionary behaviour. In this review, SWR is considered in terms of five spheres of influence. Given the presence of hydrophobic organic material in the biosphere, the strength, severity and persistence of SWR is influenced by properties at the surface of the lithosphere and prevailing conditions in the atmosphere and hydrosphere. These in turn, can be modified by activities in the anthroposphere. This review thus examines the strength, severity and persistence of non-wetting behaviour with reference to these five spheres of influence and also the interactions between the spheres. It is focused on (i) how SWR is characterised to provide insight into how different measurement techniques have specific operational ranges, (ii) how SWR has developed as an indirect consequence of evolution in natural ecosystems and (iii) how feedbacks across the different spheres have emerged. It demonstrates that management and restoration of natural ecosystems with water repellent soils is very different from management of productive crops in monocultural agricultural systems, controlled in the anthroposphere.

Lead Contamination in Ground Venison from Shotgun-Harvested White-Tailed Deer (Odocoileus virginianus) in Illinois.

Ground venison packets from shotgun- and archery-harvested White-tailed Deer in Illinois in 2013 and 2014 were analyzed for metal contamination. Radiographs indicated that 48% of 27 ground venison packets from 10 shotgun-harvested deer contained metal fragments, while none of the 15 packets from three archery-harvested deer contained fragments. ICP-MS analysis verified that all metal fragments from seven of the venison samples from shotgun-harvested deer were composed of lead, with average concentrations from 1.04 to 8.42 µg g-1, dry weight. A single serving of ground venison containing one of these metal fragments embedded in it would be predicted to have a lead concentration ranging from 6.4 to 51.8 µg g-1. Sixty percent of 20 commercial meat processing plants surveyed by phone in 2018 and 2019 indicated that they mixed venison from multiple deer when preparing ground venison products. However, our results do not show any cross-contamination in archery-harvested ground venison processed prior to the firearm hunting seasons.

Oral Health Inequalities in 0-17-year-old Children Referred for Dental Extractions Under General Anaesthesia in Wolverhampton, 2013-2017.

OBJECTIVE: Describe the inequalities in oral health in children treated in a hospital located in a deprived urban area in the UK. RESEARCH DESIGN: Case-note review of 1911 0-17-year-olds who underwent dental extractions under a general anaesthetic (DGA). MAIN OUTCOME MEASURES: Associations between Age, Ethnicity, Year-of-Treatment and Index of Multiple Deprivation (IMD) with the number of teeth extracted. Analysis used multilevel modelling assuming a Poisson distribution. RESULTS: Mean number of teeth extracted was higher in the youngest children treated aged 0-5 years (relative risk coefficient, (RR=exp(ß)=1.39; 95% CI 1.24 to 1.56) compared to those aged 6-17 years and in 'Other Whites' (predominantly immigrants from Eastern Europe) (RR=exp(ß)=1.34; 95% CI 1.25 to 1.43), 'South Asians' (RR=exp(ß)=1.15; 95% CI 1.08 to 1.23) but fewer in the 'Black' ethnic group (RR=exp(ß)=0.85; 95% CI 0.76 to 0.95). DGA increased during the study with more teeth extracted in 2015, 2016 and 2017 (RR=exp(ß)=1.12, 95% CI 1.22, 1.25) and with a negative gradient in the rate of DGA's (per decile) in children from the most deprived to most affluent locations (RR=exp(ß)=0.98; 95% CI 0.97 to 0.99). CONCLUSIONS: Significant oral health inequalities exist in children from a deprived urban area in the UK. A preventive approach to children's oral health is needed to reduce such inequalities, including public health and healthcare agencies to informing parents of children whose first language is not English about dental caries.

Is the Trotterized UCCSD Ansatz Chemically Well-Defined?

The variational quantum eigensolver (VQE) has emerged as one of the most promising near-term quantum algorithms that can be used to simulate many-body systems such as molecular electronic structures. Serving as an attractive ansatz in the VQE algorithm, unitary coupled cluster (UCC) theory has seen a renewed interest in recent literature. However, unlike the original classical UCC theory, implementation on a quantum computer requires a finite-order Suzuki-Trotter decomposition to separate the exponentials of the large sum of Pauli operators. While previous literature has recognized the nonuniqueness of different orderings of the operators in the Trotterized form of UCC methods, the question of whether or not different orderings matter at the chemical scale has not been addressed. In this Letter, we explore the effect of operator ordering on the Trotterized UCCSD ansatz, as well as the much more compact k-UpCCGSD ansatz recently proposed by Lee et al. [ J. Chem. Theory Comput. , 2019 , 15 , 311 . arXiv, 2019 , quant-ph:1909.09114. https://arxiv.org/abs/1909.09114 ]. We observe a significant, system-dependent variation in the energies of Trotterizations with different operator orderings. The energy variations occur on a chemical scale, sometimes on the order of hundreds of kcal/mol. This Letter establishes the need to define not only the operators present in the ansatz but also the order in which they appear. This is necessary for adhering to the quantum chemical notion of a "model chemistry", in addition to the general importance of scientific reproducibility. As a final note, we suggest a useful strategy to select out of the combinatorial number of possibilities, a single well-defined and effective ordering of the operators.

An adaptive variational algorithm for exact molecular simulations on a quantum computer.

Quantum simulation of chemical systems is one of the most promising near-term applications of quantum computers. The variational quantum eigensolver, a leading algorithm for molecular simulations on quantum hardware, has a serious limitation in that it typically relies on a pre-selected wavefunction ansatz that results in approximate wavefunctions and energies. Here we present an arbitrarily accurate variational algorithm that, instead of fixing an ansatz upfront, grows it systematically one operator at a time in a way dictated by the molecule being simulated. This generates an ansatz with a small number of parameters, leading to shallow-depth circuits. We present numerical simulations, including for a prototypical strongly correlated molecule, which show that our algorithm performs much better than a unitary coupled cluster approach, in terms of both circuit depth and chemical accuracy. Our results highlight the potential of our adaptive algorithm for exact simulations with present-day and near-term quantum hardware.

Phase IIa study of dabigatran etexilate in children with venous thrombosis: pharmacokinetics, safety, and tolerability.

Essentials Dabigatran etexilate may provide a new treatment option for pediatric venous thromboembolism. Children aged 1 to < 12 years were given dabigatran etexilate in an open-label, single-arm study. The pharmacokinetic-pharmacodynamic relationship was similar to that seen in adult patients. There were no serious adverse events, bleeding events or recurrent venous thromboembolism. SUMMARY: Background The current standard-of-care treatments for pediatric venous thromboembolism (VTE) have limitations. Dabigatran etexilate (DE), a direct thrombin inhibitor, may offer an alternative therapeutic option. Objectives To assess the pharmacokinetics, pharmacodynamics, safety, and tolerability of a DE oral liquid formulation (OLF) in pediatric patients with VTE. Patients/Methods Patients who had completed planned treatment with low molecular weight heparin or oral anticoagulants for VTE were enrolled in two age groups (2 to < 12 years and 1 to < 2 years), and received a DE OLF based on an age-adjusted and weight-adjusted nomogram. Originally, patients were to receive a DE OLF twice daily for 3 days, but the protocol was amended to a single dose on day 1. The primary endpoints were pharmacokinetics/pharmacodynamics-related: plasma concentrations of DE and its metabolites; activated partial thromboplastin time (APTT), ecarin clotting time (ECT), and dilute thrombin time (dTT); and pharmacokinetic (PK)-pharmacodynamic (PD) correlation. Safety endpoints included incidence rates of bleeding events and all other adverse events (AEs). Results Eighteen patients entered the study and received the DE OLF (an exposure equivalent to a dose of 150 mg twice daily in adults). The projected steady-state dabigatran trough concentrations were largely comparable between pediatric patients and adults. The PK/PD relationship was linear for ECT and dTT, and non-linear for APTT. No serious or severe AEs, bleeding events, or recurrent VTEs were reported. Mild AEs were reported in three patients in the single-dose group (screening period) and in one patient in the multiple-dose group (on-treatment period). Conclusion The current study supports the further evaluation of DE OLFs in pediatric patients with VTE.

Effect of implementation of a preconception counselling resource for women with diabetes: A population based study.

AIM: To evaluate the effect of regional implementation of a preconception counselling resource into routine diabetes care on pregnancy planning indicators. METHODS: A preconception counselling DVD was distributed to women by diabetes care teams and general practices. Subsequently, in a prospective population-based study, pregnancy planning indicators were evaluated. The post-DVD cohort (n=135), including a viewed-DVD subgroup (n=58), were compared with an historical cohort (pre-DVD, n=114). Primary outcome was HbA1c at first diabetes-antenatal visit. Secondary outcomes included preconception folic acid consumption, planned pregnancy and HbA1c recorded in the 6 months preconception. RESULTS: Mean first visit HbA1c was lower post-DVD vs. pre-DVD: 7.5% vs. 7.8% [58.4 vs. 61.8mmol/mol]; p=0.12), although not statistically significant. 53% and 20% of women with type 1 and 2 diabetes, respectively, viewed the DVD. The viewed-DVD subgroup were significantly more likely to have lower first visit HbA1c: 6.9% vs. 7.8% [52.1 vs. 61.8mmol/mol], P<0.001; planned pregnancy (88% vs. 59%, P<0.001); taken folic acid preconception (81% vs. 43%, P=0.001); and had HbA1c recorded preconception (88% vs. 53%, P<0.001) than the pre-DVD cohort. CONCLUSIONS: Implementation of a preconception counselling resource was associated with improved pregnancy planning indicators. Women with type 2 diabetes are difficult to reach. Greater awareness within primary care of the importance of preconception counselling among this population is needed.

Multi-stakeholder perspectives of locally commissioned enhanced optometric services.

OBJECTIVES: To explore views of all stakeholders (patients, optometrists, general practitioners (GPs), commissioners and ophthalmologists) regarding the operation of community-based enhanced optometric services. DESIGN: Qualitative study using mixed methods (patient satisfaction surveys, semi-structured telephone interviews and optometrist focus groups). SETTING: A minor eye conditions scheme (MECS) and glaucoma referral refinement scheme (GRRS) provided by accredited community optometrists. PARTICIPANTS: 189 patients, 25 community optometrists, 4 glaucoma specialist hospital optometrists (GRRS), 5 ophthalmologists, 6 GPs (MECS), 4 commissioners. RESULTS: Overall, 99% (GRRS) and 100% (MECS) patients were satisfied with their optometrists' examination. The vast majority rated the following as 'very good'; examination duration, optometrists' listening skills, explanations of tests and management, patient involvement in decision-making, treating the patient with care and concern. 99% of MECS patients would recommend the service. Manchester optometrists were enthusiastic about GRRS, feeling fortunate to practise in a 'pro-optometry' area. No major negatives were reported, although both schemes were limited to patients resident within certain postcode areas, and some inappropriate GP referrals occurred (MECS). Communication with hospitals was praised in GRRS but was variable, depending on hospital (MECS). Training for both schemes was valuable and appropriate but should be ongoing. MECS GPs were very supportive, reporting the scheme would reduce secondary care referral numbers, although some MECS patients were referred back to GPs for medication. Ophthalmologists (MECS and GRRS) expressed very positive views and widely acknowledged that these new care pathways would reduce unnecessary referrals and shorten patient waiting times. Commissioners felt both schemes met or exceeded expectations in terms of quality of care, allowing patients to be seen quicker and more efficiently. CONCLUSIONS: Locally commissioned schemes can be a positive experience for all involved. With appropriate training, clear referral pathways and good communication, community optometrists can offer high-quality services that are highly acceptable to patients, health professionals and commissioners.

Evaluation of a minor eye conditions scheme delivered by community optometrists.

BACKGROUND: The establishment of minor eye conditions schemes (MECS) within community optometric practices provides a mechanism for the timely assessment of patients presenting with a range of acute eye conditions. This has the potential to reduce waiting times and avoid unnecessary referrals to hospital eye services (HES). OBJECTIVE: To evaluate the clinical effectiveness, impact on hospital attendances and patient satisfaction with a minor eye service provided by community optometrists. METHODS: Activity and outcome data were collected for 12 months in the Lambeth and Lewisham MECS. A patient satisfaction questionnaire was given to patients at the end of their MECS appointment. A retrospective difference-in-differences analysis of hospital activity compared changes in the volume of referrals by general practitioners (GPs) from a period before (April 2011-March 2013) to after (April 2013-March 2015) the introduction of the scheme in Lambeth and Lewisham relative to a neighbouring area (Southwark) where the scheme had not been commissioned. Appropriateness of case management was assessed by consensus using clinical members of the research team. RESULTS: A total of 2123 patients accessed the scheme. Approximately two-thirds of patients (67.5%) were referred by their GP. The commonest reasons for patients attending for a MECS assessment were 'red eye' (36.7% of patients), 'painful white eye' (11.1%) and 'flashes and floaters' (10.2%). A total of 64.1% of patients were managed in optometric practice and 18.9% were referred to the HES; of these, 89.2% had been appropriately referred. First attendances to HES referred by GPs reduced by 26.8% (95% CI -40.5% to -13.1%) in Lambeth and Lewisham compared to Southwark. CONCLUSIONS: The Lambeth and Lewisham MECS demonstrates clinical effectiveness, reduction in hospital attendances and high patient satisfaction and represents a successful collaboration between commissioners, local HES units and primary healthcare providers.