The association between restricted activity and patient outcomes in older adults: systematic literature review and meta-analysis.

BACKGROUND: Restricted activity is a potential early marker of declining health in older adults. Previous studies of this association with patient outcomes have been inconclusive. This review aimed to evaluate the extent to which restricted activity is associated with decline in health. METHODS: A search was conducted for studies including people over 65 years old which investigated the association between measures of restricted activity and hospitalisation, cognitive decline, and mortality. Following data extraction by two reviewers, eligible studies were summarised using Inverse Variance Heterogeneity meta-analysis. RESULTS: The search identified 8,434 unique publications, with 11 eligible studies. Three measures of restricted activity were identified: bed rest, restricted movement, and dependency for activities of daily living (ADL). Three studies looked at hospitalisations, with two finding a significant association with bed rest or restricted movement and one showing no evidence of an association. Restricted activity was associated with a significant increase in mortality across all three measures (bed rest odds ratio [OR] 6.34, 95%CI 2.51-16.02, I2 = 76%; restricted movement OR 5.38 95%CI 2.60-11.13, I2 = 69%; general ADL dependency OR 4.65 95%CI 2.25-9.26, I2 = 84%). The significant heterogeneity observed could not be explained by restricting the analysis by length of follow-up, or measure of restricted activity. No meta-analysis was conducted on the limited evidence for cognitive decline outcomes. CONCLUSIONS: Limited studies have considered the prognostic value of restricted activity in terms of predicting future declining health. Current evidence suggests restricted activity is associated with hospitalisation and mortality, and therefore could identify a group for whom early intervention might be possible.

Exploring early career researchers' perspectives of training and funding opportunities: Motivations and setbacks when applying for the UK's National Institute for Health and Care Research's fellowships and research funding.

Despite the availability of training and funding opportunities with the UK's National Institute for Health and Care Research (NIHR), early career researchers (ECRs) invariably experience concern in sustaining an academic career in health research given the uncertainties of success following rejection from peer-reviewed funding bodies. The objective of this study was to consider what motivates ECRs when applying for funding to NIHR programmes and how they overcome funding setbacks. Eleven ECRs took part in a one-to-one virtual in-depth interview; the sample included more women (n = 8) than men (n = 3) and participants included pre-doctoral researchers (n = 5), and both doctoral (n = 2) and post-doctoral (n = 4) ECRs. The interviews were analysed using the logic of a systems theory framework identifying factors impacting on ECRs occurring within an individual, within their social system and within their broader environment. The central themes that emerged from the data focussed on: (1) facilitators for ECRs to apply for NIHR funding; (2) exploring ECRs' setbacks and disappointments; (3) improving chances of funding; and (4) deciding to apply with a view to re-applying in future. The participants' responses provided an honest and frank reflection of the uncertainties and challenges as ECRs in the current climate. Further strategies to support ECRs could be facilitated through local NIHR infrastructure, mentorship, better access to local support networks and hard-wiring research into an organisation's strategic priorities.

Shifting stoichiometry: Long-term trends in stream-dissolved organic matter reveal altered C:N ratios due to history of atmospheric acid deposition.

Dissolved organic carbon (DOC) and nitrogen (DON) are important energy and nutrient sources for aquatic ecosystems. In many northern temperate, freshwater systems DOC has increased in the past 50 years. Less is known about how changes in DOC may vary across latitudes, and whether changes in DON track those of DOC. Here, we present long-term DOC and DON data from 74 streams distributed across seven sites in biomes ranging from the tropics to northern boreal forests with varying histories of atmospheric acid deposition. For each stream, we examined the temporal trends of DOC and DON concentrations and DOC:DON molar ratios. While some sites displayed consistent positive or negative trends in stream DOC and DON concentrations, changes in direction or magnitude were inconsistent at regional or local scales. DON trends did not always track those of DOC, though DOC:DON ratios increased over time for ~30% of streams. Our results indicate that the dissolved organic matter (DOM) pool is experiencing fundamental changes due to the recovery from atmospheric acid deposition. Changes in DOC:DON stoichiometry point to a shifting energy-nutrient balance in many aquatic ecosystems. Sustained changes in the character of DOM can have major implications for stream metabolism, biogeochemical processes, food webs, and drinking water quality (including disinfection by-products). Understanding regional and global variation in DOC and DON concentrations is important for developing realistic models and watershed management protocols to effectively target mitigation efforts aimed at bringing DOM flux and nutrient enrichment under control.

Endovascular Porcine Model of Iliocaval Venous Thrombosis.

OBJECTIVE: To develop a large animal model of iliocaval deep venous thrombosis (DVT), which enables development and evaluation of interventional management and existing imaging modalities. METHODS: The experimental protocol consisted of a total endovascular approach. Pigs were percutaneously accessed through the right internal jugular and bilateral femoral veins. Three balloon catheters were inflated to induce venous stasis in the infrarenal inferior vena cava (IVC) and bilateral common iliac veins (CIVs). Hypercoagulability was induced by injecting 10 000 IU of thrombin. After 2.5 hours, the balloon catheters were removed before animal recovery. After seven, 14, 21, 28, or 35 days, animals were euthanised; the IVC and CIV were harvested en bloc, cross sectioned and prepared for histological examination. Multimodal imaging was performed before and after thrombus creation, and before animal euthanasia. RESULTS: Thirteen female domestic pigs with a mean weight of 59.3 kilograms were used. The mean maximum IVC diameter and area were 16.4 mm and 1.2 cm2, respectively. The procedure was successful in 12 animals with occlusive venous thrombosis in the region of interest on immediate post-operative magnetic resonance venography and a mean thrombus volume of 19.8 cm3. Clinical pathology results showed platelet consumption, D dimer increase, and inflammatory response. Histological evaluation demonstrated a red cell, fibrin, and platelet rich thrombus on day 1, with progressive inflammatory cell infiltration from day 7. Collagen deposition appeared in week 2 and neovascularisation in week 3. CONCLUSION: Endovascular occlusion combined with thrombin infusion is a reliable minimally invasive approach to produce acute and subacute DVT in a large animal model.

Persistent Nitrate in Alpine Waters with Changing Atmospheric Deposition and Warming Trends.

Nitrate concentrations in high-elevation lakes of the Colorado Front Range remain elevated despite declining trends in atmospherically deposited nitrate since 2000. The current source of this elevated nitrate in surface waters remains elusive, given shifts in additional nitrogen sources via glacial inputs and atmospheric ammonium deposition. We present the complete isotopic composition of nitrate (δ15N, δ18O, and Δ17O) from a suite of nitrate-bearing source waters collected during the summers of 2017-2018 from two alpine ecosystems to constrain the provenance of elevated nitrate in surface waters during the summer open-water season. The results indicate a consistent contribution of uncycled atmospheric nitrate throughout the summer (13-23%) to alpine lakes, despite seasonal changes in source water inputs. The balance of nitrate (as high as 87% in late summer) is likely from nitrate production within the catchment via nitrification of reduced nitrogen sources (e.g., thawed soil organic matter and ammonium deposition) and released with rock glacier meltwater. The role of microbially produced nitrate has become increasingly important over time based on historical surface water samples from the mid-90s to present, a trend coincident with increasing ammonium deposition to alpine systems.

Can linguistic analysis be used to identify whether adolescents with a chronic illness are depressed?

Comorbid depression is common in adolescents with chronic illness. We aimed to design and test a linguistic coding scheme for identifying depression in adolescents with chronic fatigue syndrome/myalgic encephalomyelitis (CFS/ME), by exploring features of e-consultations within online cognitive behavioural therapy treatment. E-consultations of 16 adolescents (aged 11-17) receiving FITNET-NHS (Fatigue in teenagers on the interNET in the National Health Service) treatment in a national randomized controlled trial were examined. A theoretically driven linguistic coding scheme was developed and used to categorize comorbid depression in e-consultations using computerized content analysis. Linguistic coding scheme categorization was subsequently compared with classification of depression using the Revised Children's Anxiety and Depression Scale published cut-offs (t-scores ≥65, ≥70). Extra linguistic elements identified deductively and inductively were compared with self-reported depressive symptoms after unblinding. The linguistic coding scheme categorized three (19%) of our sample consistently with self-report assessment. Of all 12 identified linguistic features, differences in language use by categorization of self-report assessment were found for "past focus" words (mean rank frequencies: 1.50 for no depression, 5.50 for possible depression, and 10.70 for probable depression; p < .05) and "discrepancy" words (mean rank frequencies: 16.00 for no depression, 11.20 for possible depression, and 6.40 for probable depression; p < .05). The linguistic coding profile developed as a potential tool to support clinicians in identifying comorbid depression in e-consultations showed poor value in this sample of adolescents with CFS/ME. Some promising linguistic features were identified, warranting further research with larger samples.

Precision medicine: Driving the evolution of biobanking quality.

The promise of precision medicine will only be realized if the healthcare system adapts to meet some key infrastructure needs. Among these needs are adequate biobanking practices, capable of producing the biological samples and data that precision medicine relies upon in both the research and clinical phases. Within the research domain, there have been significant improvements to biobanking processes over the past two decades, driven by increased understanding of the impact of pre-analytical variability and the critical role of biospecimen and data quality. In the era of precision medicine, biobanking to support clinical needs has similar quality requirements. The extensive knowledge and resources that have been developed by the research biobanking community are available for adoption by clinical biobanking. The challenge and opportunity now presented to the healthcare system is to adopt or adapt these resources, for example, external biobanking standards and verification programs.

Unprocessed Atmospheric Nitrate in Waters of the Northern Forest Region in the U.S. and Canada.

Little is known about the regional extent and variability of nitrate from atmospheric deposition that is transported to streams without biological processing in forests. We measured water chemistry and isotopic tracers (δ18O and δ15N) of nitrate sources across the Northern Forest Region of the U.S. and Canada and reanalyzed data from other studies to determine when, where, and how unprocessed atmospheric nitrate was transported in catchments. These inputs were more widespread and numerous than commonly recognized, but with high spatial and temporal variability. Only 6 of 32 streams had high fractions (>20%) of unprocessed atmospheric nitrate during baseflow. Seventeen had high fractions during stormflow or snowmelt, which corresponded to large fractions in near-surface soil waters or groundwaters, but not deep groundwater. The remaining 10 streams occasionally had some (<20%) unprocessed atmospheric nitrate during stormflow or baseflow. Large, sporadic events may continue to be cryptic due to atmospheric deposition variation among storms and a near complete lack of monitoring for these events. A general lack of observance may bias perceptions of occurrence; sustained monitoring of chronic nitrogen pollution effects on forests with nitrate source apportionments may offer insights needed to advance the science as well as assess regulatory and management schemes.

Acceptability of the BATHE technique amongst GPs and frequently attending patients in primary care: a nested qualitative study.

BACKGROUND: BATHE is a brief psychosocial intervention designed for physician use in patient consultations. The technique has gained some international recognition, but there is currently limited research evidence to demonstrate its acceptability and benefits to patient care. We conducted a pilot cluster randomised controlled trial and feasibility study to explore the use of BATHE as a key component of a person-focused intervention to improve the care of frequent attending patients in UK primary care. METHODS: A nested qualitative interview study conducted within a pilot trial. The trial took place in six general practices in the South West of England. Eligible patients had been identified as being in the top 3% of attenders in the previous 12 months. General practitioners (GPs) were trained to use BATHE during a one-hour initial training session, and two top-up trainings which included feedback on implementation fidelity. GPs were asked to use BATHE with their study patients for a period of 12 months. 34 GPs were trained and documented using BATHE in a total of 577 consultations with eligible patients during the intervention period. At the end of the intervention period, GPs and study patients from the intervention practices were invited to take part in an interview. Interviews were semi-structured, audio-recorded and transcribed. Thematic analysis was used. RESULTS: Eleven GPs and 16 patients took part in post-intervention interviews. Benefits of using BATHE included making consultations more person-centred, challenging assumptions that the GP knew what was going on for the patient and their main concerns, and supporting self-management. Difficulties reported included changing existing consultation habits, identifying appropriate consultations in which to use BATHE, and organisational constraints. CONCLUSIONS: The study suggests that using BATHE is both acceptable and beneficial but also highlighted some of the difficulties GPs had incorporating BATHE into routine practice. Strategies to reduce these difficulties are needed before the extent of the potential benefits of BATHE can be fully assessed. TRIAL REGISTRATION: ISRCTN62939408 Prospectively registered on 24/06/2015.

Understanding the influence of parent-clinician communication on antibiotic prescribing for children with respiratory tract infections in primary care: a qualitative observational study using a conversation analysis approach.

BACKGROUND: Acute respiratory tract infections (RTI) in children are a common reason for antibiotic prescribing. Clinicians' prescribing decisions are influenced by perceived parental expectations for antibiotics, however there is evidence that parents actually prefer to avoid antibiotics. This study aimed to investigate the influence of parent-clinician communication on antibiotic prescribing for RTI in children in England. METHODS: A mixed methods analysis of videoed primary care consultations for children (under 12 years) with acute cough and RTI. Consultations were video-recorded in six general practices in southern England, selected for socio-economic diversity. 56 recordings were transcribed in detail and a subset of recordings and transcripts used to develop a comprehensive interaction-based coding scheme. The scheme was used to examine communication practices between parents and clinicians and how these related to antibiotic or non-antibiotic treatment strategies. RESULTS: Parents' communication rarely implied an expectation for antibiotics, some explicitly offering a possible viral diagnosis. Clinicians mostly gave, or implied, a viral diagnosis and mainly recommended non-antibiotic treatment strategies. In the minority of cases where parents' communication behaviours implied they may be seeking antibiotic treatment, antibiotics were not usually prescribed. Where clinicians did prescribe antibiotics, they voiced concern about symptoms or signs, including chest pain, discoloured phlegm, prolonged fever, abnormal chest sounds, or pink /bulging ear drums. CONCLUSIONS: We found little evidence of a relationship between parents' communication behaviours and antibiotic prescribing. Rather, where antibiotics were prescribed, this was associated with clinicians' expressed concerns regarding symptoms and signs.

General Practitioner's use of online resources during medical visits: managing the boundary between inside and outside the clinic.

In an increasingly connected world, information about health can be exchanged at any time, in any location or direction, and is no longer dominated by traditional authoritative sources. We consider the ways information and advice given in consultations by doctors transcends the boundary between the clinic and the home. We explore how information that is widely accessible outside the consultation is transformed by General Practitioners (GPs) into a medical offering. Data comprise 18 consultations identified from 144 consultations between unselected patients and five GPs. We use conversation analytic methods to explore four ways in which GPs used online resources; (i) to check information; (ii) as an explanatory tool; (iii) to provide information for patients for outside the consultation; (iv) to signpost further explanation and self-help. We demonstrate the interactional delicacy with which resources from the Internet are introduced and discussed, developing and extending Nettleton's (2004) idea of 'e-scaped medicine' to argue that Internet resources may be 'recaptured' by GPs, with information transformed and translated into a medical offering so as to maintain the asymmetry between patients and practitioners necessary for the successful functioning of medical practice.

Riverine Export of Aged Carbon Driven by Flow Path Depth and Residence Time.

The flux of terrestrial C to rivers has increased relative to preindustrial levels, a fraction of which is aged dissolved organic C (DOC). In rivers, C is stored in sediments, exported to the ocean, or (bio)chemically processed and released as CO2. Disturbance changes land cover and hydrology, shifting potential sources and processing of DOC. To investigate the likely sources of aged DOC, we analyzed radiocarbon ages, chemical, and spectral properties of DOC and major ions from 19 rivers draining the coterminous U.S. and Arctic. DOC optics indicated that the majority is exported as aromatic, high molecular weight, modern molecules while aged DOC tended to consist of smaller, microbial degradation products. Aged DOC exports, observed regularly in arid basins and during base flow in arctic rivers, are associated with higher proportion of mineral weathering products, suggesting deeper flows paths. These patterns also indicate potential for production of microbial byproducts as DOC ages in soil and water with longer periods of time between production and transport. Thus, changes in hydrology associated with landscape alteration (e.g., tilling or shifting climates) that can result in deeper flow paths or longer residence times will likely lead to a greater proportion of aged carbon in riverine exports.

Preliminaries to Treatment Recommendations in UK Primary Care: A Vehicle for Shared Decision Making?

This paper focuses on a recurrent practice observed in UK primary care data - how physicians use pre-recommendations: action sequences that when initiated post-diagnosis are recognisably preliminary to the drug treatment recommendations that they contingently project. Data are drawn from recorded primary care consultations collected in England. Pre-recommendations consist of physician requests for information about prior medicines such as, What've you tried taking? or Have you taken anything so far? Patient responses subsequently shape the first part of the base treatment recommendation pair. These preliminaries can help physicians manage potential obstacles to patient acceptance: by avoiding prescribing something a patient is already taking, or has tried and found to be ineffective, and by accommodating concerns such as side effects or practical barriers to acceptance. Pre-recommendations are a strategy for convincing/persuading whilst allowing physicians to avoid making an ill-fitted recommendation that might be resisted or rejected as unwanted or unnecessary.

Treatment Recommendation Actions, Contingencies, and Responses: An Introduction.

In the era of patient participation in health care decision making, we know surprisingly little about the ways in which treatment recommendations are made, the contexts that shape their formulation, and the consequences of these formulations. In this article, we introduce a systematic collective investigation of how recommendations for medications are responded to and made in primary versus secondary care, in the US versus the UK, and in contexts where the medication was over the counter versus by prescription. This article provides an overview of the coding system that was used in this project including describing what constitutes a recommendation, the primary action types clinicians use for recommendations, and the types of responses provided by patients to recommendations.

Treatment Recommendations as Actions.

From the earliest studies of doctor-patient interaction (Byrne & Long, 1976), it has been recognized that treatment recommendations may be expressed in more or less authoritative ways, based on their design and delivery. There are clear differences between I'm going to start you on X and We can give you X to try and Would you like me to give you X? Yet little is known about this variation, its contexts, or its consequences. In this paper, we develop a basic taxonomy of treatment recommendations in primary care as a first step toward a more comprehensive investigation. We take as our point of departure the observation that treatment recommendations such as those above represent not only different formulations but also different social actions. We distinguish five main treatment recommendation actions: pronouncements, suggestions, proposals, offers, and assertions. We ask: what are the main dimensions on which these recommendations vary and to what end? And what sorts of factors shape a clinician's use of one action type over another with respect to recommending a medication in the primary care context?

Closing the Deal: A Cross-Cultural Comparison of Treatment Resistance.

This study investigates patient resistance to doctors' treatment recommendations in a cross-national comparison of primary care. Through this lens, we explore English and American patients' enacted priorities, expectations, and assumptions about treating routine illnesses with prescription versus over-the-counter medications. We perform a detailed analysis of 304 (American) and 393 (English) naturally occurring treatment discussions and conclude that American and English patients tend to use treatment resistance in different prescribing contexts to pursue different ends. While American patients are most likely to resist recommendations for non-prescription treatment and display an expectation for prescription treatment in these interactions, English patients show a high level of resistance to recommendations for all types of treatment and display an expectation of cautious prescribing. These behavioral trends reflect broader structural forces unique to each national context and ultimately maintain distinct cultural norms of good-practice prescribing.

Senior Services that Support Housing First in Metro Vancouver.

Housing First is a model and philosophy for housing homeless people in immediate and permanent housing. In order to implement and deliver Housing First, research is essential to understand the system of support services as they currently exist. Guided by principles of community-based participatory research, this paper presents the findings from a senior-focused deliberative dialogue workshop in Metro Vancouver, Canada. Participants (16 service providers and 1 service recipient) identified services and resources available to support seniors in maintaining housing and barriers and facilitators for accessing services. Broadly, data were organized into seven themes: (1) Housing; (2) Home support; (3) Transportation; (4) Information availability, accessibility, and navigation; (5) Cultural diversity; (6) Discrimination; and (7) Funding and financial support. Results found that affordable housing that adapts to changing health conditions, income supports, health services, homecare, transportation, and culturally appropriate and nondiscriminatory informational resources are among the supports most needed for persons as young as 50 years old to succeed under the Housing First model in Metro Vancouver. Barriers to Housing First service provision, including rigid eligibility criteria for chronically and episodically homeless, should be revised to better support the growing number of older adults who are newly entering homelessness in Metro Vancouver.

How do healthcare professionals interview patients to assess suicide risk?

BACKGROUND: There is little evidence on how professionals communicate to assess suicide risk. This study analysed how professionals interview patients about suicidal ideation in clinical practice. METHODS: Three hundred nineteen video-recorded outpatient visits in U.K. secondary mental health care were screened. 83 exchanges about suicidal ideation were identified in 77 visits. A convenience sample of 6 cases in 46 primary care visits was also analysed. Depressive symptoms were assessed. Questions and responses were qualitatively analysed using conversation analysis. χ 2 tested whether questions were influenced by severity of depression or influenced patients' responses. RESULTS: A gateway closed question was always asked inviting a yes/no response. 75% of questions were negatively phrased, communicating an expectation of no suicidal ideation, e.g., "No thoughts of harming yourself?". 25% were positively phrased, communicating an expectation of suicidal ideation, e.g., "Do you feel life is not worth living?". Comparing these two question types, patients were significantly more likely to say they were not suicidal when the question was negatively phrased but were not more likely to say they were suicidal when positively phrased (χ 2 = 7.2, df = 1, p = 0.016). 25% patients responded with a narrative rather than a yes/no, conveying ambivalence. Here, psychiatrists tended to pursue a yes/no response. When the patient responded no to the gateway question, the psychiatrist moved on to the next topic. A similar pattern was identified in primary care. CONCLUSIONS: Psychiatrists tend to ask patients to confirm they are not suicidal using negative questions. Negatively phrased questions bias patients' responses towards reporting no suicidal ideation.

Managing clients' expectations at the outset of online Cognitive Behavioural Therapy (CBT) for depression.

BACKGROUND: Engaging clients in psychotherapy by managing their expectations is important for therapeutic success. Initial moments in first sessions of therapy are thought to afford an opportunity to establish a shared understanding of how therapy will proceed. However, there is little evidence from analysis of actual sessions of therapy to support this. OBJECTIVE: This study utilised recorded session logs to examine how therapists manage clients' expectations during the first two sessions of online Cognitive Behavioural Therapy (CBT). METHODS: Expectation management was investigated through conversation analysis of sessions from 176 client-therapist dyads involved in online CBT. The primary focus of analysis was expectation management during the initial moments of first sessions, with a secondary focus on expectations at subsequent points. ANALYSIS: Clients' expectations for therapy were most commonly managed during the initial moments of first sessions of therapy. At this point, most therapists either produced a description outlining the tasks of the first and subsequent sessions (n = 36) or the first session only (n = 108). On other occasions (n = 32), no attempt was made to manage clients' expectations by outlining what would happen in therapy. Observations of the interactional consequences of such an absence suggest clients may struggle to engage with the therapeutic process in the absence of appropriate expectation management by therapists. CONCLUSION: Clients may more readily engage from the outset of therapy when provided with an explanation that manages their expectation of what is involved. Therapists can accomplish this by projecting how therapy will proceed, particularly beyond the initial session.