Facilitators and barriers to community pharmacy PrEP delivery: a scoping review.

INTRODUCTION: Pre-exposure prophylaxis (PrEP) is an effective medication to reduce the risk of acquiring HIV. PrEP is available free of charge in the UK from sexual health clinics. Expanding PrEP delivery to community pharmacies holds promise and aligns with UK government goals to eliminate new cases of HIV by 2030. The aim of this scoping review was to describe the existing evidence about the barriers to and facilitators of community pharmacy oral PrEP delivery, for pharmacists and pharmacy clients, as aligned with the Capacity Opportunity, Motivation Behaviour (COM-B) Model. METHODS: Five bibliographic and five review databases were searched from inception to August 2023. Literature of any study design was included if it discussed barriers and facilitators of community pharmacy PrEP delivery. Trial registrations, protocols and news articles were excluded. RESULTS: A total of 649 records were identified, 73 full texts were reviewed and 56 met the inclusion criteria, predominantly from high-income/westernized settings. Most of the included literature was original research (55%), from the United States (77%) conducted during or after the year 2020 (63%). Barriers to PrEP delivery for pharmacists included lack of knowledge, training and skills (capability), not having the necessary facilities (opportunity), concern about the costs of PrEP and believing that PrEP use could lead to risk behaviours and sexually transmitted infections (motivation). Facilitators included staff training (capability), time, the right facilities (opportunity), believing PrEP could be a source of profit and could reduce new HIV acquisitions (motivation). For clients, barriers included a lack of PrEP awareness (capability), pharmacy facilities (opportunity) and not considering pharmacists as healthcare providers (motivation). Facilitators included awareness of PrEP and pharmacist's training to deliver it (capability), the accessibility of pharmacies (opportunity) and having an interest in PrEP (motivation). DISCUSSION: To effectively enhance oral PrEP delivery in UK community pharmacies, the identified barriers and facilitators should be explored for UK relevance, addressed and leveraged at the pharmacy team, client and care pathway level. CONCLUSIONS: By comprehensively considering all aspects of the COM-B framework, community pharmacies could become crucial providers in expanding PrEP accessibility, contributing significantly to HIV prevention efforts.

The association between nurse staffing and quality of care in emergency departments: A systematic review.

BACKGROUND: The relationship between nurse staffing, skill-mix and quality of care has been well-established in medical and surgical settings, however, there is relatively limited evidence of this relationship in emergency departments. Those that have been published identified that lower nurse staffing levels in emergency departments are generally associated with worse outcomes with the conclusion that the evidence in emergency settings was, at best, weak. METHODS: We searched thirteen electronic databases for potentially eligible papers published in English up to December 2023. Studies were included if they reported on patient outcomes associated with nurse staffing within emergency departments. Observational, cross-sectional, prospective, retrospective, interrupted time-series designs, difference-in-difference, randomised control trials or quasi-experimental studies and controlled before and after studies study designs were considered for inclusion. Team members independently screened titles and abstracts. Data was synthesised using a narrative approach. RESULTS: We identified 16 papers for inclusion; the majority of the studies (n = 10/16) were observational. The evidence reviewed identified that poorer staffing levels within emergency departments are associated with increased patient wait times, a higher proportion of patients who leave without being seen and an increased length of stay. Lower levels of nurse staffing are also associated with an increase in time to medications and therapeutic interventions, and increased risk of cardiac arrest within the emergency department. CONCLUSION: Overall, there remains limited high-quality empirical evidence addressing the association between emergency department nurse staffing and patient outcomes. However, it is evident that lower levels of nurse staffing are associated with adverse events that can result in delays to the provision of care and serious outcomes for patients. There is a need for longitudinal studies coupled with research that considers the relationship with skill-mix, other staffing grades and patient outcomes as well as a wider range of geographical settings. TWEETABLE ABSTRACT: Lower levels of nurse staffing in emergency departments are associated with delays in patients receiving treatments and poor quality care including an increase in leaving without being seen, delay in accessing treatments and medications and cardiac arrest.

Sensory trap leads to reliable communication without a shift in nonsexual responses to the model cue.

The sensory trap model of signal evolution suggests that males manipulate females into mating using traits that mimic cues used in a nonsexual context. Despite much empirical support for sensory traps, little is known about how females evolve in response to these deceptive signals. Female sea lamprey (Petromyzon marinus) evolved to discriminate a male sex pheromone from the larval odor it mimics and orient only toward males during mate search. Larvae and males release the attractant 3-keto petromyzonol sulfate (3kPZS), but spawning females avoid larval odor using the pheromone antagonist, petromyzonol sulfate (PZS), which larvae but not males, release at higher rates than 3kPZS. We tested the hypothesis that migratory females also discriminate between larval odor and the male pheromone and orient only to larval odor during anadromous migration, when they navigate within spawning streams using larval odor before they begin mate search. In-stream behavioral assays revealed that, unlike spawning females, migratory females do not discriminate between mixtures of 3kPZS and PZS applied at ratios typical of larval versus male odorants. Our results indicate females discriminate between the sexual and nonsexual sources of 3kPZS during but not outside of mating and show sensory traps can lead to reliable sexual communication without females shifting their responses in the original context.

Protocol for monitoring and analyzing pheromone-mediated behavioral response of sea lamprey in a natural system.

Olfactory-mediated behaviors in fish are often examined in artificial microcosms that enable well-controlled treatments but fail to replicate environmental and social contexts. However, observing these behaviors in nature poses challenges. Here, we describe a protocol for recording sea lamprey (Petromyzon marinus) behaviors in a natural system. We describe steps for administering and verifying accurate odorant concentrations, surveying sea lamprey abundance, and tracking sea lamprey movements. We also detail procedures to analyze treatment effects on pheromone-mediated spawning in a high-density population. For complete details on the use and execution of this protocol, please refer to Scott et al.1.

Synergistic behavioral antagonists of a sex pheromone reduce reproduction of invasive sea lamprey.

Sex pheromones impart maximal attraction when their components are present at optimal ratios that confer balanced olfactory inputs in potential mates. Altering ratios or adding pheromone analogs to optimal mixtures may disrupt balanced olfactory antagonism and result in reduced attraction, however, tests in natural populations are lacking. We tested this hypothesis in sea lamprey (Petromyzon marinus), a fish whose male sex pheromone attracts females when two critical components, 3-keto petromyzonol sulfate (3kPZS) and petromyzonol sulfate (PZS), are present at certain ratios. Here, we report a pheromone analog, petromyzonol tetrasulfate (3sPZS), reduced female attraction to 3kPZS but not to PZS. 3sPZS mixed with additional PZS synergistically disrupted female attraction to the male pheromone and reduced spawning by 97% in a high-density population. Our results provide evidence of balanced olfactory antagonism in a vertebrate and establish a tactic to disrupt spawning of sea lamprey, a destructive invader of the Laurentian Great Lakes.

The person-based development and realist evaluation of a summary report for GP consultations [version 1; peer review: 2 approved].

Background: Use of telephone, video and e-consultations is increasing. These can make consultations more transactional. This study aimed to develop a complex intervention to address patients' concerns more comprehensively in general practice and test the feasibility of this in a cluster-randomised framework.The complex intervention used two technologies: a patient-completed pre-consultation form used at consultation opening and a doctor-provided summary report provided at consultation closure. This paper reports on the development and realist evaluation of the summary report. Methods: A person-based approach was used to develop the summary report. An electronic protocol was designed to automatically generate the report after GPs complete a clinical template in the patient record. This was tested with 45 patients in 3 rounds each, with iterative adjustments made based on feedback after each round. Subsequently, an intervention incorporating the pre-consultation form with the summary report was then tested in a cluster-randomised framework with 30 patients per practice in six practices: four randomised to intervention, and two to control. An embedded realist evaluation was carried out. The main feasibility study results are reported elsewhere. Results: Intervention Development: 15 patients were recruited per practice. Eight patients and six GPs were interviewed and 18 changes made. The summary report improved substantially; GPs and patients in the final practice were more satisfied with the report than the first practice.Realist evaluation: The summary was most useful for consultations when safety-netting advice was important or with multiple complex follow-up steps in patients who have difficulty remembering or communicating. It generated greater clarity on the follow-up and greater patient empowerment and reassurance. Conclusions: The person-based approach was successful. The summary report creates clarity, empowerment and reassurance in certain consultations and patients. As it takes a few minutes per patient, GPs prefer to select patients who will benefit most.

Attenuation and recovery of an avoidance response to a chemical antipredator cue in an invasive fish: implications for use as a repellent in conservation.

The detection of predation risk without direct engagement with a predator is an important driver of prey movement strategies. Consequently, the application of alarm cues may prove an effective tool in guiding the movements of fishes targeted for control or conservation. However, failure to contemplate the sensory, physiological and cognitive outcomes of repeated or persistent exposure to the cue will likely lead to poor performance of management practices. Using a series of behavioural tests and physiological recordings from the olfactory organ, we examined the timing of onset and recovery of the alarm response in sea lamprey (Petromyzon marinus L.) when exposed continuously or sporadically to its alarm cue. In the laboratory, sea lamprey exhibited short-term, reversible attenuation of the alarm response over 2-4 h with continuous exposure. The alarm response spontaneously recovered after 30-60 min of removal from the cue. In long-duration free-swimming tests, where the animals were allowed to move into and out of the odour plume volitionally, repeated but sporadic encounter with the alarm cue over 5 h did not alter the alarm response. Electro-olfactogram recordings from the main olfactory epithelium indicated that olfactory sensory neurons quickly adapt to alarm cue and recovered within 15 min. Our findings strongly implicate habituation as the mechanism that induces reduction in the alarm response and provide insight into the design of effective management practices that seek to use fish alarm cues as repellents.

Objective Nebuliser Adherence Data as "Proof" of Adherence in the Management of Cystic Fibrosis: A Qualitative Interview Study.

Purpose: Low adherence to medication via nebulisers is linked to poor clinical outcomes for people with Cystic Fibrosis (PWCF). Advances in technology allow electronic monitoring of nebuliser usage and feedback of objective adherence data to PWCF and clinical teams caring for them. CFHealthHub is a new intervention that collects and displays objective adherence data in easy-to-read formats with the aim of improving nebuliser adherence and health. There is little understanding of how objective adherence data is perceived by PWCF and healthcare professionals (HCPs). Patients and Methods: A qualitative study using semi-structured interviews with 22 PWCF and 31 HCPs who had used the CFHealthHub intervention. Results: Objective adherence data was welcomed by the majority of PWCF in the sample, and HCP delivering the intervention, because the data allowed PWCF to reflect on patterns of adherence or non-adherence. Ease of use and characteristics of data display were important, particularly the use of a "traffic light" system to allow PWCF to easily see if they were meeting their adherence targets. For PWCF objective adherence data was used as "proof to self", offering reassurance to high adherers, and a wake-up call to those with lower levels of adherence. It could also provide 'proof to others' where PWCF had higher levels of adherence than HCP or family members believed. The data could sometimes change HCP perceptions of PWCF's identities as poor adherers. Where adherence was not high, data was used to facilitate honest discussions between PWCF and HCPs about how to increase adherence. HCPs perceived that it was important to use the data positively to motivate, rather than criticise, PWCF. Conclusion: Objective nebuliser adherence data in CFHealthHub can offer proof of adherence to PWCF and HCPs. It is important to use it constructively to facilitate discussions on how to improve adherence.

The person-based development and realist evaluation of a pre-consultation form for GP consultations.

Background: Use of telephone, video and e-consultations is increasing. These can make consultations more transactional, potentially missing patients' concerns. This study aimed to develop a complex intervention to address patients' concerns more comprehensively in general practice and test the feasibility of this in a cluster-randomised framework.The complex intervention used two technologies: a patient-completed pre-consultation form used at consultation opening and a doctor-provided summary report provided at consultation closure. This paper reports on the development and realist evaluation of the pre-consultation questionnaire. Methods: A person-based approach was used to develop the pre-consultation form. An online questionnaire system was designed to allow patient self-completion of a form which could be shared with GPs. This was tested with 45 patients in three rounds, with iterative adjustments made based on feedback after each round.Subsequently, an intervention incorporating the pre-consultation form with the summary report was then tested in a cluster-randomised framework with 30 patients per practice in six practices: four randomised to intervention, and two to control. An embedded realist evaluation was carried out. The main feasibility study results are reported elsewhere. Results: Intervention Development: 15 patients were recruited per practice. Twelve patients, six GPs and three administrators were interviewed and 32 changes were made iteratively in three rounds. Recruitment rates (proportion of patients responding to the text) increased from 15% in round one to 50% in round three.Realist evaluation: The pre-consultation form was most useful for people comfortable with technology and with hidden concerns or anxiety about the consultation. It resulted in more issues being discussed and support provided, more effective use of time and greater patient satisfaction. Conclusions: The person-based approach was successful. The pre-consultation form uncovers more depth and improves satisfaction in certain consultations and patients. Technological improvements are required before this could be rolled out more widely.

THE PROBLEM: For some patients, GP consultations are too short. Sometimes patients' problems are missed. We wanted to improve GP consultations. What we did: We developed a better way to start and end consultations using a new digital method. Before a GP consultation, patients fill in a form online that lets them describe their problems. This is shared with their GP. At the end of the consultation GPs can give patients a one-page summary of what was discussed. This paper reports on how we developed and tested the online pre-consultation form. How we tested it: We first piloted the online form in three GP practices in turn. We interviewed patients, GPs and an administrator in each practice and made changes based on their suggestions. Each new version was tested in a new practice. We then tested the final online form together with the one-page summary in four practices with 30 patients each. We interviewed patients and GPs to find who it was most useful for and when. What we found: GPs and patients agreed the final version of the online form was much better than the first version. The percentage of patients who filled in a form after getting a text message increased from 15% in practice 1 to 50% in practice 3. By testing the final form in four practices, we found it worked best for people who find technology easy to use and have hidden concerns or worries about the consultation. These patients found their GP was better prepared and problems were dealt with better. GPs thought consultations were more efficient. CONCLUSIONS: The approach we took was very successful in developing the online form and patients and GPs found it useful. The technology would need to be improved before it could be rolled out more widely.

Social, Psychological, and Behavioral Predictors of Salivary Bacteria, Yeast in Caries-Free Children.

INTRODUCTION: Early childhood caries (ECC) is a complex, multifactorial oral disease that is a major public health concern because it is prevalent, profoundly alters a child's quality of life, is difficult to treat effectively, and has a distressing tendency to recur following treatment. OBJECTIVES: The purpose of the study was to examine social, psychological, and behavioral predictors of salivary bacteria and yeast in young children at risk for ECC. METHODS: A sample of 189 initially caries-free preschool children was assessed for child stress physiology from salivary cortisol, child and family stress exposure, diet, oral health behaviors, and sociodemographic risks. Multiple logistic regression analysis was implemented to examine the associations between these risk factors and cariogenic microorganisms: mutans streptococci (MS), lactobacilli (LB), and Candida species. RESULTS: Higher baseline salivary cortisol (odds ratio [OR] = 6.26; 95% confidence level [CL], 1.69-23.16) and a blunted response to an acute laboratory stressor (OR = .56; 95% CL, .37-.83) were associated with an increased likelihood of elevated salivary MS (≥105 colony-forming units/mL) in caries-free children. Sociodemographic risk for cariogenic microorganisms was also found. Specifically, lower education attainment of the parent/primary caregiver was associated with children being more likely to carry salivary Candida species and elevated salivary MS; in addition, children from households with an unemployed parent/primary caregiver were more likely (OR = 3.13; 95% CL, 1.2-8.05) to carry salivary Candida species and more likely (OR = 3.03; 95% CL, 1.25-7.33) to carry elevated levels of MS and/or salivary Candida and/or LB. CONCLUSIONS: The impact of sociodemographic risk and stress physiology on cariogenic disease processes are evident prior to ECC onset. The findings provide novel data on the early onset of cariogenic processes in children and the importance of considering sociodemographic, psychosocial, and behavioral factors when judging ECC risk. KNOWLEDGE TRANSFER STATEMENT: The findings provide valuable and novel findings that, pre-ECC onset, the caries disease process is explicable from a detailed assessment of behavioral, sociodemographic, and psychosocial stress variables.

Convergent olfactory trace amine-associated receptors detect biogenic polyamines with distinct motifs via a conserved binding site.

Biogenic amines activate G-protein-coupled receptors (GPCRs) in the central nervous system in vertebrate animals. Several biogenic amines, when excreted, stimulate trace amine-associated receptors (TAARs), a group of GPCRs in the main olfactory epithelium, and elicit innate behaviors. How TAARs recognize amines with varying numbers of amino groups is largely unknown. We reasoned that a comparison between lamprey and mammalian olfactory TAARs, which are thought to have evolved independently but show convergent responses to polyamines, may reveal structural determinants of amine recognition. Here, we demonstrate that sea lamprey TAAR365 (sTAAR365) responds strongly to biogenic polyamines cadaverine, putrescine, and spermine, and shares a similar response profile as a mammalian TAAR (mTAAR9). Docking and site-directed mutagenesis analyses show that both sTAAR365 and mTAAR9 recognize the two amino groups of cadaverine with the conserved Asp3.32 and Tyr6.51 residues. sTAAR365, which has remarkable sensitivity for cadaverine (EC50 = 4 nM), uses an extra residue, Thr7.42, to stabilize ligand binding. These cadaverine recognition sites also interact with amines with four and three amino groups (spermine and spermidine, respectively). Glu7.36 of sTAAR365 cooperates with Asp3.32 and Thr7.42 to recognize spermine, whereas mTAAR9 recognizes spermidine through an additional aromatic residue, Tyr7.43. These results suggest a conserved mechanism whereby independently evolved TAAR receptors recognize amines with two, three, or four amino groups using the same recognition sites, at which sTAAR365 and mTAAR9 evolved distinct motifs. These motifs interact directly with the amino groups of the polyamines, a class of potent and ecologically important odorants, mediating olfactory signaling.

Maintaining face-to-face contact during the COVID-19 pandemic: a longitudinal qualitative investigation in UK primary care.

BACKGROUND: In March 2020, the COVID-19 pandemic required a rapid reconfiguration of UK general practice to minimise face-to-face contact with patients to reduce infection risk. However, some face-to-face contact remained necessary and practices needed to ensure such contact could continue safely. AIM: To examine how practices determined when face-to-face contact was necessary and how face-to-face consultations were reconfigured to reduce COVID-19 infection risk. DESIGN & SETTING: Qualitative interview study in general practices in Bristol, North Somerset, and South Gloucestershire. METHOD: Longitudinal semi-structured interviews with clinical and managerial practice staff were undertaken at four timepoints between May and July 2020. RESULTS: Practices worked flexibly within general national guidance to determine when face-to-face contact with patients was necessary, influenced by knowledge of the patient, experience, and practice resilience. For example, practices prioritised patients according to clinical need using face-to-face contact to resolve clinician uncertainty or provide adequate reassurance to patients. To make face-to-face contact as safe as possible and keep patients separated, practices introduced a heterogeneous range of measures that exploited features of their indoor and outdoor spaces, and altered their appointment processes. As national restrictions eased in June and July, the number and proportion of patients seen face to face generally increased. However, the reconfiguration of buildings and processes reduced the available capacity and put increased pressure on practices. CONCLUSION: Practices responded rapidly and creatively to the initial lockdown restrictions. The variety of ways practices organised face-to-face contact to minimise infection highlights the need for flexibility in guidance.

Using Crash Outcome Data Evaluation System (CODES) to examine injury in front vs. rear-seated infants and children involved in a motor vehicle crash in New York State.

BACKGROUND: In New York State (NYS), motor vehicle (MV) injury to child passengers is a leading cause of hospitalization and emergency department (ED) visits in children aged 0-12 years. NYS laws require appropriate child restraints for ages 0-7 years and safety belts for ages 8 and up while traveling in a private passenger vehicle, but do not specify a seating position. METHODS: Factors associated with injury in front-seated (n = 11,212) compared to rear-seated (n = 93,092) passengers aged 0-12 years were examined by age groups 0-3, 4-7 and 8-12 years using the 2012-2014 NYS Crash Outcome Data Evaluation System (CODES). CODES consists of Department of Motor Vehicle (DMV) crash reports linked to ED visits and hospitalizations. The front seat was row 1 and the rear rows 2-3. Vehicle towed from scene and air bag deployed were proxies for crash severity. Injury was dichotomized based on Maximum Abbreviated Injury Severity (MAIS) scores greater than zero. Multivariable logistic regression (odds ratios (OR) with 95% CI) was used to examine factors predictive of injury for the total population and for each age group. RESULTS: Front-seated children had more frequent injury than those rear-seated (8.46% vs. 4.92%, p < 0.0001). Children in child restraints experienced fewer medically-treated injuries compared to seat belted or unrestrained children (3.80, 6.50 and 13.62%, p < 0.0001 respectively). A higher proportion of children traveling with an unrestrained vs. restrained driver experienced injury (14.50% vs 5.26%, p < 0.0001). After controlling for crash severity, multivariable adjusted predictors of injury for children aged 0-12 years included riding in the front seat (1.20, 1.10-1.31), being unrestrained vs. child restraint (2.13, 1.73-2.62), being restrained in a seat belt vs. child restraint (1.20, 1.11-1.31), and traveling in a car vs. other vehicle type (1.21, 1.14-1.28). Similarly, protective factors included traveling with a restrained driver (0.61, 0.50-0.75), a driver aged < 25 years (0.91, 0.82-0.99), being an occupant of a later vehicle model year 2005-2008 (0.68, 0.53-0.89) or 2009-2015 (0.55, 0.42-0.71) compared to older model years (1970-1993). CONCLUSIONS: Compared to front-seated children, rear-seated children and children in age-appropriate restraints had lower adjusted odds of medically-treated injury.

Estimating the economic cost of nurse sensitive adverse events amongst patients in medical and surgical settings.

AIMS: To identify the costs associated with nurse sensitive adverse events and the impact of these events on patients' length of stay. DESIGN: Retrospective cohort study using administrative hospital data. METHODS: Data were sourced from patient discharge information (N = 5544) from six acute wards within three hospitals (July 2016-October 2017). A retrospective patient record review was undertaken by extracting data from the hospitals' administrative systems on inpatient discharges, length of stay and diagnoses; eleven adverse events sensitive to nurse staffing were identified within the administrative system. A negative binomial regression is employed to assess the impact of nurse sensitive adverse events on length of stay. RESULTS: Sixteen per cent of the sample (n = 897) had at least one nurse sensitive adverse event during their episode of care. The model revealed when age, gender, admission type and complexity are controlled for, each additional nurse sensitive adverse event experienced by a patient was associated with an increase in the length of stay beyond the national average by 0.48 days (p = .001). Applying this to the daily average cost of inpatient stay per patient (€1456), we estimate the average cost associated with each nurse sensitive adverse event to be €694. Extrapolating this nationally, the economic cost of nurse sensitive adverse events to the health service in Ireland is estimated to be €91.3 million annually. CONCLUSION: These potentially avoidable events are associated with a significant economic burden to health systems. The estimates provided here can be used to inform and prepare the way for future economic evaluations of nurse staffing initiatives that aim to improve care and safety. IMPACT: As many of these nurse sensitive adverse events are avoidable, in addition to patient benefits, there is a potential substantial financial return on investment from strategies such as improved nurse staffing that can reduce their occurrence.

Bile acid production is life-stage and sex-dependent and affected by primer pheromones in the sea lamprey.

Pheromonal bile salts are important for sea lampreys (Petromyzon marinus Linnaeus) to complete their life cycle. The synthesis and release of a releaser/primer pheromone 3-keto petromyzonol sulfate (3kPZS) by spermiating males have been well characterized. 3kPZS evokes sexual behaviors in ovulatory females, induces immediate 3kPZS release in spermiating males, and elicits neuroendocrine responses in prespawning adults. Another primer pheromone released by spermiating males, 3-keto allocholic acid (3kACA), antagonizes the neuroendocrine effects of 3kPZS in prespermiating males. However, the effects of 3kACA and 3kPZS on pheromone production in prespawning adults is unclear. To understand the foundation of pheromone production, we examined sea lamprey bile salt levels at different life stages. To investigate the priming effects of 3kACA and 3kPZS, we exposed prespawning adults with vehicle or synthetic 3kACA or 3kPZS. We hypothesized that endogenous bile salt levels were life-stage and sex-dependent, and differentially affected by 3kACA and 3kPZS in prespawning adults. Using ultra-performance liquid chromatography tandem mass spectrometry, we found that sea lampreys contained distinct mixtures of bile salts in the liver and plasma at different life stages. Males usually contained higher amounts of bile salts than females. Petromyzonamine disulfate was the most abundant C27 bile salt and petromyzonol sulfate was the most abundant C24 bile salt. Waterborne 3kACA and 3kPZS exerted differential effects on bile salt production in the liver and gill, their circulation and clearance in the plasma, and their release into water. We conclude that bile salt levels are life-stage and sex-dependent and differentially affected by primer pheromones.

Cardiac amyloidosis masquerading as acute coronary syndrome.

A 53-year-old man presented to a district general hospital with chest pain, ECG changes and a small high-sensitivity cardiac troponin I rise. There were no symptoms of heart failure. CT coronary angiography revealed moderate calcific disease and conventional angiography confirmed no flow limitation. Echocardiography showed left ventricular hypertrophy (LVH). His blood pressure remained normal throughout his admission. The tertiary centre labelled this as a 'plaque rupture' event but the LVH remained unexplained. Cardiac MRI displayed an unusual pattern of late gadolinium enhancement, which was not classical of amyloid. However, a raised serum free kappa light chain along with the deposition of amyloid on his bone marrow aspirate confirmed the diagnosis of primary AL amyloidosis with cardiac involvement. The patient went on to have chemotherapy and remained stable at 1-year follow-up.

Implementation of remote consulting in UK primary care following the COVID-19 pandemic: a mixed-methods longitudinal study.

BACKGROUND: To reduce contagion of COVID-19, in March 2020 UK general practices implemented predominantly remote consulting via telephone, video, or online consultation platforms. AIM: To investigate the rapid implementation of remote consulting and explore impact over the initial months of the COVID-19 pandemic. DESIGN AND SETTING: Mixed-methods study in 21 general practices in Bristol, North Somerset and South Gloucestershire. METHOD: Longitudinal observational quantitative analysis compared volume and type of consultation in April to July 2020 with April to July 2019. Negative binomial models were used to identify if changes differed among different groups of patients. Qualitative data from 87 longitudinal interviews with practice staff in four rounds investigated practices' experience of the move to remote consulting, challenges faced, and solutions. A thematic analysis utilised Normalisation Process Theory. RESULTS: There was universal consensus that remote consulting was necessary. This drove a rapid change to 90% remote GP consulting (46% for nurses) by April 2020. Consultation rates reduced in April to July 2020 compared to 2019; GPs and nurses maintained a focus on older patients, shielding patients, and patients with poor mental health. Telephone consulting was sufficient for many patient problems, video consulting was used more rarely, and was less essential as lockdown eased. SMS-messaging increased more than three-fold. GPs were concerned about increased clinical risk and some had difficulties setting thresholds for seeing patients face-to-face as lockdown eased. CONCLUSION: The shift to remote consulting was successful and a focus maintained on vulnerable patients. It was driven by the imperative to reduce contagion and may have risks; post-pandemic, the model will need adjustment.

Safe and competent nursing care: An argument for a minimum standard?

There is no agreed minimum standard with regard to what is considered safe, competent nursing care. Limited resources and organizational constraints make it challenging to develop a minimum standard. As part of their everyday practice, nurses have to ration nursing care and prioritize what care to postpone, leave out, and/or omit. In developed countries where public healthcare is tax-funded, a minimum level of healthcare is a patient right; however, what this entails in a given patient's actual situation is unclear. Thus, both patients and nurses would benefit from the development of a minimum standard of nursing care. Clarity on this matter is also of ethical and legal concern. In this article, we explore the case for developing a minimum standard to ensure safe and competent nursing care services. Any such standard must encompass knowledge of basic principles of clinical nursing and preservation of moral values, as well as managerial issues, such as manpower planning, skill-mix, and time to care. In order for such standards to aid in providing safe and competent nursing care, they should be in compliance with accepted evidence-based nursing knowledge, based on patients' needs and legal rights to healthcare and on nurses' codes of ethics. That is, a minimum standard must uphold a satisfactory level of quality in terms of both professionalism and ethics. Rather than being fixed, the minimum standard should be adjusted according to patients' needs in different settings and may thus be different in different contexts and countries.

A pheromone antagonist liberates female sea lamprey from a sensory trap to enable reliable communication.

The evolution of male signals and female preferences remains a central question in the study of animal communication. The sensory trap model suggests males evolve signals that mimic cues used in nonsexual contexts and thus manipulate female behavior to generate mating opportunities. Much evidence supports the sensory trap model, but how females glean reliable information from both mimetic signals and their model cues remains unknown. We discovered a mechanism whereby a manipulative male signal guides reliable communication in sea lamprey (Petromyzon marinus). Migratory sea lamprey follow a larval cue into spawning streams; once sexually mature, males release a pheromone that mimics the larval cue and attracts females. Females conceivably benefit from the mimetic pheromone during mate search but must discriminate against the model cue to avoid orienting toward larvae in nearby nursery habitats. We tested the hypothesis that spawning females respond to petromyzonol sulfate (PZS) as a behavioral antagonist to avoid attraction to the larval cue while tracking the male pheromone despite each containing attractive 3-keto petromyzonol sulfate (3kPZS). We found 1) PZS inhibited electrophysiological responses to 3kPZS and abated preferences for 3kPZS when mixed at the same or greater concentrations, 2) larvae released more PZS than 3kPZS whereas males released more 3kPZS than PZS, and 3) mixtures of 3kPZS and PZS applied at ratios measured in larval and male odorants resulted in the discrimination observed between the natural odors. Our study elucidates how communication systems that arise via deception can facilitate reliable communication.

Socioeconomic disparities in access to intensive insulin regimens for adults with type 1 diabetes: a qualitative study of patient and healthcare professional perspectives.

BACKGROUND: Type 1 diabetes is a complex chronic condition which requires lifelong treatment with insulin. Health outcomes are dependent on ability to self-manage the condition. Socioeconomic inequalities have been demonstrated in access to treatment and health outcomes for adults with type 1 diabetes; however, there is a paucity of research exploring how these disparities occur. This study explores the influence of socioeconomic factors in gaining access to intensive insulin regimens for adults with type 1 diabetes. METHODS: We undertook a qualitative descriptive study informed by a phenomenological perspective. In-depth face-to-face interviews were conducted with 28 patients and 6 healthcare professionals involved in their care. The interviews were analysed using a thematic approach. The Candidacy theory for access to healthcare for vulnerable groups framed the analysis. RESULTS: Access to intensive insulin regimens was through hospital-based specialist services in this sample. Patients from lower socioeconomic groups had difficulty accessing hospital-based services if they were in low paid work and because they lacked the ability to navigate the healthcare system. Once these patients were in the specialist system, access to intensive insulin regimens was limited by non-alignment with healthcare professional goals, poor health literacy, psychosocial problems and poor quality communication. These factors could also affect access to structured diabetes education which itself improved access to intensive insulin regimens. Contact with diabetes specialist nurses and attendance at structured diabetes education courses could ameliorate these barriers. CONCLUSIONS: Access to intensive insulin regimens was hindered for people in lower socioeconomic groups by a complex mix of factors relating to the permeability of specialist services, ability to navigate the healthcare system and patient interactions with healthcare providers. Improving access to diabetes specialist nurses and structured diabetes education for vulnerable patients could lessen socioeconomic disparities in both access to services and health outcomes.