Effectiveness of a symptom-clinic intervention delivered by general practitioners with an extended role for people with multiple and persistent physical symptoms in England: the Multiple Symptoms Study 3 pragmatic, multicentre, parallel-group, individually randomised controlled trial.

BACKGROUND: People with multiple and persistent physical symptoms have impaired quality of life and poor experiences of health care. We aimed to evaluate the effectiveness of a community-based symptom-clinic intervention in people with multiple and persistent physical symptoms, hypothesising that this symptoms clinic plus usual care would be superior to usual care only. METHODS: The Multiple Symptoms Study 3 was a pragmatic, multicentre, parallel-group, individually randomised controlled trial conducted in 108 general practices in the UK National Health Service in four regions of England between Dec 6, 2018, and June 30, 2023. Participants were individually randomised (1:1) to the symptom-clinic intervention plus usual care or to usual care only via a computer-generated, pseudo-random list stratified by trial centre. Allocation was done by the trial statistician and concealed with a centralised, web-based randomisation system; masking participants was not possible due to the nature of the intervention. The symptom-clinic intervention was a sequence of up to four medical consultations that aimed to elicit a detailed clinical history, fully hear and validate the participant, offer rational explanations for symptoms, and assist the participant to develop ways of managing their symptoms; it was delivered by general practitioners with an extended role. The primary outcome was Patient Health Questionnaire-15 (PHQ-15) score 52 weeks after randomisation, analysed by intention to treat. The trial is registered on the ISRCTN registry (ISRCTN57050216). FINDINGS: 354 participants were randomly assigned; 178 (50%) were assigned to receive the community-based symptoms clinic plus usual care and 176 (50%) were assigned to receive usual care only. At the primary-outcome point of 52 weeks, PHQ-15 scores were 14·1 (SD 3·7) in the group receiving usual care and 12·2 (4·5) in the group receiving the intervention. The adjusted between-group difference of -1·82 (95% CI -2·67 to -0·97) was statistically significantly in favour of the intervention group (p<0·0001). There were 39 adverse events in the group receiving usual care and 36 adverse events in the group receiving the intervention. There were no statistically significant between-group differences in the proportion of participants who had non-serious adverse events (-0·03, 95% CI -0·11 to 0·05) or serious adverse events (0·02, -0·02 to 0·07). No serious adverse event was deemed to be related to the trial intervention. INTERPRETATION: Our symptom-clinic intervention, which focused on explaining persistent symptoms to participants in order to support self-management, led to sustained improvement in multiple and persistent physical symptoms. FUNDING: UK National Institute for Health and Care Research.

Liver disease as new work in the context of protocolised primary care - do GPs have a role? A qualitative interview study.

BACKGROUND: Liver disease is common, but not part of routine chronic disease management in primary care. AIM: The aim of this study was to explore the challenges of implementing pathways of care for liver disease within existing highly protocolised structures in primary care. METHOD: Semi-structured interviews with 20 health professionals working in primary care. Interviews were informed by normalisation process theory (NPT) and boundary theory. Data were subject to thematic analysis. RESULTS: Three themes were identified relating to chronic disease work; definitions; need and worth, and roles. Participants identified that understanding and value of roles within chronic disease management were pre-defined by targets imposed on them as part of national incentives schemes. Structural boundaries constrained professional autonomy and the potential to influence this area of primary care management, including taking on new work. CONCLUSION: The inability to influence care decisions blurs occupational boundaries and goes to the core of what it means to be a professional. Unless liver disease sits within this target-based system, it is unlikely to become part of routine work in primary care.

Explanation for symptoms and biographical repair in a clinic for persistent physical symptoms.

Introduction: Biographical disruption describes the process by which illness impacts not just on a person's body and their participation in activities, but also on their sense of self. Biographical disruption is often followed by a process of biographical repair in which identity is reconstructed and a new normality is restored. People with persistent physical symptoms (sometimes referred to as medically unexplained symptoms) experience biographical disruption. This can be complicated by lack of explanation and the implication that if the problem is not medical, then it might be the person/psychological. We aimed to examine this tension in people attending a novel "Symptoms Clinic" for people with persistent physical symptoms. Methods: This study reports an embedded qualitative study in a UK based randomised controlled trial. Data were collected by audio recordings of consultations and semi-structured interviews with patients. We used theoretically informed thematic analysis with regular coding and discussion meetings of the analysis team. This analysis explores the role of intervention components in facilitating biographical repair. Results: The lack of acceptable explanation for persistent symptoms acted as a block to biographical repair. In the clinic, multi-layered explanations were offered and negotiated that viewed persistent symptoms as understandable entities rather than as indicators of something still hidden. These explanations allowed study participants to make sense of their symptoms and in turn opened new opportunities for self-management. The result was that participants were able to reframe their symptoms in a way that enabled them to see themselves differently. Even if symptoms had not yet improved, there was a sense of being better. This can be understood as a process of biographical repair. Conclusion: Explaining persistent physical symptoms enables biographical repair.

How can asset-based approaches reduce inequalities? Exploring processes of change in England and Spain.

Initiatives to promote health and reduce inequalities in place-based communities have increasingly adopted asset-based approaches (ABAs). However, the processes through which such initiatives might reduce inequalities are not well understood, and evidence of their impact on health is still limited. This study aimed to understand how ABAs can impact practices, relationships and the redistribution of resources to reduce health inequalities in and between less advantaged neighbourhoods. Qualitative research was conducted in two settings (England and Spain) where similar asset-based initiatives, aimed at training community members to become health promoters, were being implemented. Data were collected using theory of change workshops, 120 hours of observations and semi-structured interviews with 44 stakeholders (trained community members, voluntary and community sector organizations' workers and health professionals). A thematic analysis informed by systems thinking was carried out. Three main processes of change were identified: first, 'enabling asset-based thinking' defined as supporting people to adopt a view that values their own resources and people's skills and expertise. Second, 'developing asset-based capacities', described as developing personal skills, knowledge, self-confidence and relationships underpinned by asset-based thinking. Finally, 'changing decision-making and wider health determinants through ABAs' referred to achieving changes in neighbourhoods through mobilizing the asset-based capacities developed. These processes were associated with changes at an individual level, with potential to contribute to reducing inequalities through supporting individual empowerment and social capital. However, contextual factors were found key to enable or hinder changes in the neighbourhoods and acted as barriers to processes of collective empowerment, thus limiting ABAs' impact on health inequalities.

Recognition, explanation, action, learning: Teaching and delivery of a consultation model for persistent physical symptoms.

OBJECTIVE: To describe the teaching and delivery of an extended consultation model designed for clinicians to use with patients with persistent physical symptoms and functional disorders. The model is underpinned by current scientific knowledge about persistent physical symptoms and the communication problems that arise in dealing with them. METHODS: Process evaluation of training and delivery of the Recognition, Explanation, Action, Learning (REAL) model within the Multiple Symptoms Study 3: a randomised controlled trial of an extended-role GP "Symptoms Clinic". Evaluation used clinician and patient interviews and consultation transcripts. RESULTS: 7 GPs were trained in the intervention and 6 of them went on to deliver the REAL model in Symptoms Clinics either face-to-face or online. The Symptoms Clinic provided a set of 4 extended consultations to approximately 170 patients. Evaluation of training indicated that there was a considerable load in terms of new knowledge and skills. Evaluation of delivery found clinicians could adapt the model to individual patients while maintaining a high level of fidelity to its core components. CONCLUSION: REAL is a teachable consultation model addressing specific clinical communication issues for people with persistent physical symptoms. PRACTICE IMPLICATIONS: REAL enables clinicians to explain persistent physical symptoms in a beneficial way.

Implementation of radio-frequency identification technology to optimize medication inventory management in the intraoperative setting.

PURPOSE: Manual restocking and tracking of noncontrolled medications in anesthesia workstations (AWSs) is complicated and time intensive, provides several opportunities for error, and lacks perpetual inventory transparency regarding expiration and lot number. This pre-post study assessed the impact of radio-frequency identification (RFID) technology on restocking of noncontrolled medications in AWSs in relation to workflow, improved patient safety due to reduced restocking errors, and restocking accuracy and efficiency, as well as the estimated costs of on-site medication RFID tagging versus purchase of pretagged products. SUMMARY: Pre- and postimplementation process steps were mapped. Randomized AWS tray audits were conducted to assess patient safety, and AWS tray restocking efficiency was measured through stopwatch studies. Time and costs associated with purchase of manufacturer RFID tagged medications versus manually tagging medications on-site were estimated. Pre-post comparisons were completed using descriptive statistics. Prior to implementation, manual AWS restocking took a mean (SD) of 37.9 (24.7) seconds (range, 4.6-135.9 seconds), compared to 145.9 (50.6) seconds (range, 43.4-314.3 seconds) after implementation. The automated workflow took technicians an average of 108 seconds (1.8 minutes) longer than the baseline time. However, restocking errors were reduced by 64.7% and outdated and missing medications eliminated. Manually applying tags to packages containing 25 vials took a mean (SD) of 174.8 (19.8) seconds (range, 131-218 seconds) for smaller vials, compared to 128.1 (21.6) seconds (range, 102-166 seconds) for larger vials. Manual tag application was also more expensive than purchasing of pretagged vials. CONCLUSION: Automated RFID technology for AWS restocking decreased restocking errors but increased the length of time to complete the restocking process.

Study protocol for the Multiple Symptoms Study 3: a pragmatic, randomised controlled trial of a clinic for patients with persistent (medically unexplained) physical symptoms.

INTRODUCTION: Persistent physical symptoms (which cannot be adequately attributed to physical disease) affect around 1 million people (2% of adults) in the UK. They affect patients' quality of life and account for at least one third of referrals from General Practitioners (GPs) to specialists. These referrals give patients little benefit but have a real cost to health services time and diagnostic resources. The symptoms clinic has been designed to help people make sense of persistent physical symptoms (especially if medical tests have been negative) and to reduce the impact of symptoms on daily life. METHODS AND ANALYSIS: This pragmatic, multicentre, randomised controlled trial will assess the clinical and cost-effectiveness of the symptoms clinic intervention plus usual care compared with usual care alone. Patients were identified through GP searches and mail-outs and recruited by the central research team. 354 participants were recruited and individually randomised (1:1). The primary outcome is the self-reported Physical Health Questionnaire-15 at 52 weeks postrandomisation. Secondary outcome measures include the EuroQol 5 dimension 5 level and healthcare resource use. Outcome measures will also be collected at 13 and 26 weeks postrandomisation. A process evaluation will be conducted including consultation content analysis and interviews with participants and key stakeholders. ETHICS AND DISSEMINATION: Ethics approval has been obtained via Greater Manchester Central Research Ethics Committee (Reference 18/NW/0422). The results of the trial will be submitted for publication in peer-reviewed journals, presented at relevant conferences and disseminated to trial participants and patient interest groups. TRIAL REGISTRATION NUMBER: ISRCTN57050216.

Liver disease management as routine work in primary care: a qualitative interview study to guide implementation.

BACKGROUND: Morbidity from liver disease is rising in the UK. Most cases are caused by alcohol or non-alcoholic fatty liver disease (NAFLD) and treatable if caught early. Liver disease pathways have been shown to increase detection in the community, but have not been adopted into routine primary care work. AIM: To explore primary care healthcare professional (HCP) experiences and understanding of chronic liver disease, and where it might fit into management of long-term conditions. DESIGN AND SETTING: Qualitative interview study with 20 HCPs in primary care in the north of England. METHOD: A semi-structured approach informed by a theory of implementation (normalisation process theory [NPT]). Data collection and analysis were concurrent. Interview data were analysed using thematic analysis. RESULTS: Participants identified the following key areas for action: incentivised frameworks and protocols to drive understanding, organise, and sustain practice; inclusion of common liver diseases into multimorbidity care to reduce complexity and workload; a need to define the GP role within a lifestyle-focused treatment pathway; and education/local champions to initiate and legitimise individual and organisational participation in change. CONCLUSION: To embed chronic liver disease management in routine primary care work, researchers and policymakers must be aware of the implementation challenges. These findings can guide the adoption of effective pathways and help bridge the implementation gap.

Changing healthcare professionals' non-reflective processes to improve the quality of care.

RATIONALE: Translating research evidence into clinical practice to improve care involves healthcare professionals adopting new behaviours and changing or stopping their existing behaviours. However, changing healthcare professional behaviour can be difficult, particularly when it involves changing repetitive, ingrained ways of providing care. There is an increasing focus on understanding healthcare professional behaviour in terms of non-reflective processes, such as habits and routines, in addition to the more often studied deliberative processes. Theories of habit and routine provide two complementary lenses for understanding healthcare professional behaviour, although to date, each perspective has only been applied in isolation. OBJECTIVES: To combine theories of habit and routine to generate a broader understanding of healthcare professional behaviour and how it might be changed. METHODS: Sixteen experts met for a two-day multidisciplinary workshop on how to advance implementation science by developing greater understanding of non-reflective processes. RESULTS: From a psychological perspective 'habit' is understood as a process that maintains ingrained behaviour through a learned link between contextual cues and behaviours that have become associated with those cues. Theories of habit are useful for understanding the individual's role in developing and maintaining specific ways of working. Theories of routine add to this perspective by describing how clinical practices are formed, adapted, reinforced and discontinued in and through interactions with colleagues, systems and organisational procedures. We suggest a selection of theory-based strategies to advance understanding of healthcare professionals' habits and routines and how to change them. CONCLUSION: Combining theories of habit and routines has the potential to advance implementation science by providing a fuller understanding of the range of factors, operating at multiple levels of analysis, which can impact on the behaviours of healthcare professionals, and so quality of care provision.

Integrating mental health care into home-based nursing services: A qualitative study utilising normalisation process theory.

AIMS AND OBJECTIVES: To identify barriers and facilitators to implementing community nurses being trained as psychological wellbeing practitioners and integrating this practice into home-based primary care nursing, through key stakeholders' perceptions. BACKGROUND: Current drivers in UK primary care aim to increase access to mental health services and treatment, to achieve parity of esteem between physical and mental health care for patients who are housebound. However, there remains limited evidence on how to successfully implement this. Training community nurses as psychological wellbeing practitioners to offer mental health care alongside their current home-based services is one option. DESIGN: A pluralistic qualitative study. This study followed the COREQ checklist for reporting qualitative research. METHODS: Twenty key stakeholders were purposively recruited and interviewed including twelve health professionals and eight patients. Semi-structured interviews were analysed using a theoretical thematic analysis informed by normalisation process theory concepts of coherence, cognitive participation, collective action and reflexive monitoring, to explore the barriers and facilitators to implementation. RESULTS: Staff and patients reported high coherence and cognitive participation, valuing the integrated roles. Facilitators included the development of clearer referral pathways and increased mental health knowledge in the wider team. However, sustainability and current siloed healthcare systems were identified as barriers to implementation. CONCLUSIONS: A key obstacle to long-term implementation was the practical structures and financial boundaries of siloed healthcare systems, making long-term sustainability unviable. RELEVANCE TO CLINICAL PRACTICE: Community nurses with additional mental health training can integrate these skills in practice and are valued by their team and patients offering holistic care to patients within their home and informal knowledge transfer to the wider team. However, long-term sustainability is required if this is to be adopted routinely. Further evidence is needed to better understand the positive outcomes to patients and potential cost savings.

Plasticity in gustatory and nociceptive neurons controls decision making in C. elegans salt navigation.

A conventional understanding of perception assigns sensory organs the role of capturing the environment. Better sensors result in more accurate encoding of stimuli, allowing for cognitive processing downstream. Here we show that plasticity in sensory neurons mediates a behavioral switch in C. elegans between attraction to NaCl in naïve animals and avoidance of NaCl in preconditioned animals, called gustatory plasticity. Ca2+ imaging in ASE and ASH NaCl sensing neurons reveals multiple cell-autonomous and distributed circuit adaptation mechanisms. A computational model quantitatively accounts for observed behaviors and reveals roles for sensory neurons in the control and modulation of motor behaviors, decision making and navigational strategy. Sensory adaptation dynamically alters the encoding of the environment. Rather than encoding the stimulus directly, therefore, we propose that these C. elegans sensors dynamically encode a context-dependent value of the stimulus. Our results demonstrate how adaptive sensory computation can directly control an animal's behavioral state.

Shortcuts in knowledge mobilization: An ethnographic study of advanced nurse practitioner discharge decision-making in the emergency department.

AIM: To understand how advanced nurse practitioners use knowledge to inform their discharge decision-making in the emergency department. BACKGROUND: Advanced nurse practitioner roles have developed globally in a wide range of healthcare settings, including the emergency department, over the past few years. The scope of practice and training vary widely between countries. Little is known about how they use clinical knowledge in the emergency department. DESIGN: An ethnographic study was undertaken in an emergency department in the North of England. METHOD: Data were collected by observation (n = 5) and semi-structured interviews (n = 13) between September 2016 and June 2017. Interview transcripts and field notes were coded using Quirkos software. Thematic analysis was used to identify key themes. FINDINGS: In boundary blurring with medicine, advanced nurse practitioners in the emergency department need to make timely, autonomous discharge decisions. Knowledge mobilization is messy and complex; however, shortcuts facilitate autonomous discharge decision-making. More experienced advanced nurse practitioners rely less on shortcuts as they draw on experiential knowledge. DISCUSSION: Boundary blurring in the advanced nurse practitioner role in the emergency department, requires reliable knowledge shortcuts. Support from senior colleagues and accessible smartphone apps enable advanced nurse practitioners to efficiently make discharge decisions. This study adds to previous research on how knowledge is managed in boundary blurring. CONCLUSION: Advanced nurse practitioners in the emergency department require timely access to relevant, up to date knowledge. This study has highlighted their preferred knowledge sources to inform discharge decision-making. In boundary blurring, shortcuts enable ANPs to use knowledge efficiently to inform patient care in the emergency department. IMPACT: The findings increase our understanding of how to equip advanced nurse practitioners with knowledge to facilitate clinical decision-making. Clinical managers should provide mentorship and relevant up to date knowledge shortcuts to ensure efficient, evidence-based discharge decision-making.

A systematic scoping review of asset-based approaches to promote health in communities: development of a framework.

Asset-based approaches to health promotion have become increasingly popular as a way to tackle health inequalities by empowering people in more disadvantaged communities to use local resources and increase control over health and its determinants. However, questions remain about how they work in practice. This article presents the findings from a systematic scoping review of the empirical literature on asset-based approaches in communities. The aim was to identify the key elements of asset-based approaches, and how they are operationalised in interventions aimed at promoting health and reducing inequalities in local communities. Four databases were searched (Medline, PsycINFO, CINAHL, ASSIA) and papers were included if they described interventions explicitly adopting an asset-based approach but excluded if limited to asset identification. Thirty articles were included in the review. Data were extracted on the type of assets that the intervention built upon, how assets were mobilised, the expected outcomes and evaluation methods. A framework is presented that synthesises the key characteristics of asset-based interventions to promote health in communities. Three main approaches to mobilising assets were identified in the literature: (A) connecting assets, (B) raising awareness of assets and (C) enabling assets to thrive. It is argued that asset-based approaches to health promotion take a wide variety of forms, making it difficult to anticipate outcomes and to evaluate interventions. The framework presented here can be used to better understand the processes through which asset-based approaches work in practice to promote health and reduce inequalities.

Living with multimorbidity? The lived experience of multiple chronic conditions in later life.

Multimorbidity is defined biomedically as the co-existence of two or more long-term conditions in an individual. Globally, the number of people living with multiple conditions is increasing, posing stark challenges both to the clinical management of patients and the organisation of health systems. Qualitative literature has begun to address how concurrency affects the self-management of chronic conditions, and the concept of illness prioritisation predominates. In this article, we adopt a phenomenological lens to show how older people with multiple conditions experience illness. This UK study was qualitative and longitudinal in design. Sampling was purposive and drew upon an existing cohort study. In total, 15 older people living with multiple conditions took part in 27 in-depth interviews. The practical stages of analysis were guided by Constructivist Grounded Theory. We argue that the concept of multimorbidity as biomedically imagined has limited relevance to lived experience, while concurrency may also be erroneous. In response, we outline a lived experience of multiple chronic conditions in later life, which highlights differences between clinical and lay assumptions and makes the latter visible.

Disruptive illness contexts and liminality in the accounts of young people with type 1 diabetes.

We utilise Bury's (1982) biographical disruption to examine young people's experiences of type 1 diabetes. Our findings show that young adults adopted various 'subject positions' across different illness contexts. The subject positions deployed are intended to produce a particular kind of normal embodied identity unaffected by diabetes. First, participants concealed their illness in public spaces and challenged cultural stereotypes of diabetes to maintain a normal illness biography. Disruption was ever present and required careful negotiation to avoid exposure of illness in public. Young adults upheld a 'normal public presentation'. Second, they resisted the medical system's pressure to adhere to glucose targets asserting and maintaining a subject position of 'independent and autonomous young adults'. Here, disruption was transient and temporary, present in the clinic but not always beyond. It remained in the background for much of the time until it was reinforced by parents or at meal times. Third, young adults acquired a 'pragmatic subject position' with diabetes viewed as complex but manageable, no longer a target for resistance. Frank's (1995) 'narrative restitution' is adopted to describe the transition to life with 'normal' illness. We argue that illness experience was 'liminal' and reflected the subject positions adopted by young adults.

Acceptability of a vocational advice service for patients consulting in primary care with musculoskeletal pain: A qualitative exploration of the experiences of general practitioners, vocational advisers and patients.

AIMS: Using qualitative interviews, this study explored the experiences of GPs, vocational advisers and patients towards a new vocational advice (VA) service in primary care. METHODS: This study was nested within the Study of Work and Pain (SWAP) cluster randomised controlled trial. The SWAP trial located a VA service within three general practices in Staffordshire. Interviews took place with 10 GPs 12 months after the introduction of the VA service, four vocational advisers whilst the VA service was running and 20 patients on discharge from the VA service. The data were analysed using the constant comparative method, which is a variation of grounded theory. RESULTS: The key factors determining the acceptability and perceived effectiveness of the VA service from the perspective of the three groups of stakeholders were (1) the timing of referrals to the VA, (2) the perceived lack of patient demand for the service and (3) role uncertainty experienced by VAs. CONCLUSIONS: Early vocational intervention may not be appropriate for all musculoskeletal patients with work difficulties. Indeed, many patients felt they did not require the support of a VA, either because they had self-limiting work difficulties and/or already had support mechanisms in place to return to work. Future VA interventions may be better implemented in a targeted way so that appropriate patients are identified with characteristics which can best be addressed by the VA service.

Challenges of Eye Health Care in Children and Strategies to Improve Treatment Uptake: A Qualitative Study from the Perspective of Eye Care Professionals in the UK.

Follow up from universal vision screening at four to five years has been shown to be low in England, potentially increasing the risk of vision disorders not being treated. This study explores vision specialists' views on the perceived barriers and facilitators encountered when engaging with parents and young children, and the strategies adopted to improve child/parent centred care. Fifteen semi-structured qualitative interviews were conducted with eye care professionals to explore perspectives on the challenges of treating children. Thematic analysis was performed to identify key barriers and the strategies eye care professionals adopt to enhance person-centred eye care when working with young children and their families. Two overarching themes were identified related to the professional-patient relationship. The first reflects the challenges which vision specialists experience when treating children, considering lack of eye health education and negative attitudes to diagnosis and treatment as major barriers. The second discusses the strategies adopted to tackle those barriers. Three strategies are proposed to enhance child-centred eye care: more eye health education, more personalised communication to enhance referral uptake and the development of better coordinated pathways of care between schools, communities and hospital services.

APOE4 Genotype Exerts Greater Benefit in Lowering Plasma Cholesterol and Apolipoprotein B than Wild Type (E3/E3), after Replacement of Dietary Saturated Fats with Low Glycaemic Index Carbohydrates.

We examined the impact of APOE genotype on plasma lipids and glucose in a secondary analysis of data from a five-arm, randomised controlled, parallel dietary intervention trial ('RISCK' study), to investigate the impact of replacing saturated fatty acids (SFA) with either monounsaturated fat (MUFA) or carbohydrate of high or low glycaemic index (GI) on CVD risk factors and insulin sensitivity. We tested the impact of APOE genotype (carriage of E2 and E4 alleles versus E3/E3), determined retrospectively, on plasma lipids, lipoproteins and glucose homeostasis at baseline (n = 469), and on the change in these variables after 24 weeks of dietary intervention (n = 389). At baseline, carriers of E2 (n = 70), E4 (n = 125) and E3/E3 (n = 274) expressed marked differences in total plasma cholesterol (TC, p = 0.001), low density lipoprotein cholesterol (LDL-C, p < 0.0001), apolipoprotein B (apo B, p < 0.0001) and total to high density lipoprotein cholesterol ratio (TC:HDL-C, p = 0.002), with plasma concentrations decreasing in the order E4 > E3/E3 > E2. Following intervention, there was evidence of a significant diet x genotype interaction with significantly greater decreases in TC (p = 0.02) and apo B (p = 0.006) among carriers of E4 when SFA was replaced with low GI carbohydrate on a lower fat diet (TC -0.28 mmol/L p = 0.03; apo B -0.1 g/L p = 0.02), and a relative increase in TC (in comparison to E3/E3) when SFA was replaced with MUFA and high GI carbohydrates (TC 0.3 mmol/L, p = 0.03). Among carriers of E2 (compared with E3/E3) there was an increase in triacylglycerol (TAG) when SFA was replaced with MUFA and low GI carbohydrates 0.46 mmol/L p = 0.001). There were no significant interactions between APOE genotype and diet for changes in indices of glucose homeostasis. In conclusion, variations in APOE genotype led to differential effects on the lipid response to the replacement of SFA with MUFA and low GI carbohydrates.

Qualitative study investigating the perceptions of parents of children who failed vision screening at the age of 4-5 years.

OBJECTIVE: To explore in depth parents' experiences and understanding of their children's eye care in order to better comprehend why there is relatively low uptake of services and variable adherence to treatment. DESIGN: Semistructured interviews, informed by the Health Belief framework, were conducted with parents of children who had failed vision screening at age 4-5 years. Four were parents of children who never attended follow-up, 11 had children who attended but did not adhere to spectacle wear and 5 parents of children who had attended and adhered. Interviews were recorded and transcribed verbatim; thematic analysis based on the constant comparative method was undertaken. RESULTS: Parents' beliefs led to uncertainty about the benefit of treatment, with parents testing their children to confirm the presence of a vision deficit and seeking advice from other family and community members. The stigma of spectacle wear explained the resistance of some to their child's treatment with the maintenance of 'normality' often more important than clinical advice. The combination of parents' own health beliefs, stigma and the practicalities of attending appointments together influenced parental decisions. Attendance following vision screening and the decision to adhere to spectacle wear were primarily based on the perceived severity of the visual reduction with the perceived benefit of spectacle wear outweighing any negative consequences. CONCLUSIONS: Healthcare professionals require a greater understanding of parents' decision-making processes in order to provide personalised information. Knowledge of the cues to attendance and adherence provides policy makers a framework with which to review the barriers, develop strategies and redesign children's eye care pathways.

Non-disclosure of symptoms in primary care: an observational study.

Background: Symptoms form a major component of patient agendas, with the need for an explanation of symptoms being a prominent reason for consultation. Objectives: To estimate the prevalence of different symptoms pre-consultation, to investigate whether intention to mention a symptom in the consultation varied between patients and across symptoms, and to determine how patients' intended agendas for mentioning symptoms compared with what was discussed. Method: We videorecorded consultations of an unselected sample of people aged 45 and over consulting their GP in seven different practices in UK primary care. A pre-consultation questionnaire recorded the patient's agenda for the consultation, current symptoms and symptoms the patient intended to discuss with their GP. The videorecorded consultation was viewed and all patient agendas and 'symptoms with intention to discuss' were compared with the actual topics of discussion. Results: Totally, 190 patients participated. Eighty-one (42.6%) were female and the mean age was 68 (range 46-93). Joint pain was the most commonly reported symptom. One hundred thirty-nine (81.8% of those reporting symptoms) patients reported intention to discuss a symptom. In 43 (22.6%) consultations, 67 symptoms (27.2%), where an intention to discuss had been expressed, remained undisclosed. Tiredness and sleeping difficulty were more likely to be withheld than other symptoms after an intention to discuss had been expressed. Of the more physically located symptoms, joint pain was the most likely to remain undisclosed. Conclusion: This study suggests that the extent of symptom non-disclosure varies between patients, physicians and symptoms. Further work needs to explore the consequences of non-disclosure.