Most patients with long-term conditions (LTC) receive regular blood tests to monitor disease progression and response to treatment and to detect complications. There is currently no robust evidence to inform recommendations on monitoring. Creating this evidence base is challenging because the benefits and harms of testing are dependent on what is done in response to the test results.

We identified a list of commonly used tests. We defined a series of filtering questions to determine whether there was evidence to support the rationale of monitoring, such as “Can the general practitioner do anything in response to an abnormal test result?” Through a series of rapid reviews we identified evidence to answer each question. The evidence was presented at a consensus meeting where clinicians and patients voted for inclusion, exclusion, or further analysis. A process evaluation was performed alongside this. Further analyses were performed using routinely collected healthcare data and by performing incidence analyses, emulating randomized controlled trials (RCTs), and modeling disease progression.

We tested this methodology on three common LTCs: chronic kidney disease (CKD), type 2 diabetes mellitus (T2DM), and hypertension. We found sufficient evidence to include hemoglobin A1C and estimated glomerular filtration rate (eGFR) for monitoring patients with T2DM; hemoglobin and eGFR for patients with CKD; and eGFR for patients with hypertension. The consensus panel excluded four tests, while 10 tests were selected for further analysis. The emulated RCTs will investigate the effect of regular monitoring with certain tests on health outcomes among routinely monitored patients. In addition, we will investigate the signal-to-noise ratio of each test over time using a modeling approach.

The cost effectiveness of the evidence-based testing panels needs to be tested in clinical practice. We are currently developing an intervention package and are planning to run a feasibility trial. This program of work has the potential to change how LTCs are monitored in primary care, ultimately improving patient outcomes and leading to more efficient use of healthcare resources.

This study evaluates the safety and utility of Eustachian tube balloon dilatation in treating Eustachian tube dysfunction symptoms in adults without middle-ear disease.

A prospective cohort study was performed. Adults with dilatory Eustachian tube dysfunction symptoms and no middle-ear disease underwent Eustachian tube balloon dilatation. A clinical assessment including tympanometry, pure tone audiometry, otoscopy, ability to Valsalva, and Eustachian Tube Dysfunction Questionnaire-7 was performed pre-operatively and repeated during a 12-month follow-up period.

Fifteen participants were enrolled. The mean pre-operative Eustachian Tube Dysfunction Questionnaire-7 score of 4.6 reduced to 2.5 at six weeks (P < 0.01), 3.0 at six months (P = 0.02) and 2.6 at 12 months (P < 0.01) post-operatively. All patients without evidence of negative middle-ear pressure had Eustachian Tube Dysfunction Questionnaire-7 score improvements. There were no post-operative complications.

Eustachian tube balloon dilatation is safe and effective at treating Eustachian tube dysfunction in patients with no middle-ear disease or evidence of negative middle-ear pressure.

Individuals with Parkinson's disease (PD) have varying trajectories of cognitive decline. One reason for this heterogeneity may be "cognitive reserve": where higher education/IQ/current mental engagement compensates for increasing brain burden (Stern et al., 2020). With few exceptions, most studies examining cognitive reserve in PD fail to include brain metrics. This study's goal was to examine whether cognitive reserve moderated the relationship between neuroimaging indices of brain burden (diffusion free water fraction and T2-weighted white matter changes) and two commonly impaired domains in PD: executive function and memory. We hypothesized cognitive reserve would mitigate the relationship between higher brain burden and worse cognitive performance.

Participants included 108 individuals with PD without dementia (age mean=67.9±6.3, education mean=16.6±2.5) who were prospectively recruited for two NIH-funded projects at the University of Florida. All received neuropsychological measures of executive function (Trails B, Stroop, Letter Fluency) and memory (delayed recall: Hopkin's Verbal Learning Test-Revised, WMS-III Logical Memory). Domain specific z-score composites were created using data from age/education matched non-PD peer controls (N=62). For the Cognitive Reserve (CR) proxy, a z-score composite included years of education, WASI-II Vocabulary, and Wechsler Test of Adult Reading. At the time of testing, participants completed multiple MRI scans (T1-weighted, diffusion, Fluid Attenuated Inversion Recovery) from which the following were extracted: 1) whole-brain free water within the white matter (a measure of microstructural integrity and neuroinflammation), 2) white matter hyperintensities/white matter total volume (WMH/WMV), and bilaterally-averaged edge weights of white matter connectivity between 3) dorsolateral prefrontal cortex and caudate and 4) entorhinal cortex and hippocampi. Separate linear regressions for each brain metric used executive function and memory composites as dependent variables; predictors were age, CR proxy, respective brain metric, and a residual centered interaction term (brain metric*CR proxy). Identical models were run in dichotomized short and long disease duration groups (median split=6 years).

In all models, a lower CR proxy significantly predicted worse executive function (WMH/WMV: beta=0.49, free water: beta=0.54, frontal edge weight: beta=0.49, p's<0.001) and memory (WMH/WMV: beta=0.42, free water: beta=0.35, temporal edge weight: beta=0.39, p's <0.01). For neuroimaging metrics, higher free water significantly predicted worse executive function (beta=-0.39, p=0.002) but not memory. No other brain metrics were significant predictors of either domain. Accounting for PD duration, higher free water predicted worse executive function for those with both short (beta=-0.49, p=0.04) and long disease duration (beta=-0.48, p=0.02). Specifically in those with long disease duration, higher free water (beta=-0.57 p=0.02) and lower edge weights between entorhinal cortex and hippocampi (beta=0.30, p=0.03) predicted worse memory. Overall, no models contained significant interactions between the CR proxy and any brain metric.

Results replicate previous work showing that a cognitive reserve proxy relates to cognition. However, cognitive reserve did not moderate brain burden's relationship to cognition. Across the sample, greater neuroinflammation was associated with worse executive function. For those with longer disease duration, higher neuroinflammation and lower medial temporal white matter connectivity related to worse memory. Future work should examine other brain burden metrics to determine whether/how cognitive reserve influences the cognitive trajectory of PD.

The COVID-19 pandemic has been a catalyst for a shift towards virtual forms of working, and specific support for the provision of virtual therapy (BPS, 2020). Remotely delivered therapy has known potential benefits, such as improving access to people living in underserved areas and for those who struggle to attend face-to-face appointments due to psychosocial, physical or geographical constraints. Those with neurological conditions frequently fall in these groups.

Acceptance and Commitment Therapy (ACT) is an evidence-based psychological intervention which aims to improve the physical and mental health of people living with neurological conditions. However, there are several considerations to translating this into a virtual therapy for this clinical group that have not yet been thoroughly empirically evaluated. Such considerations include: fatigue, cognitive difficulties in the context of virtual communication, adaptations within the therapeutic alliance, and translation of dynamic and interactive therapeutic exercises within a virtual medium.

This study aimed to describe the experiences of Clinical Psychologists delivering ACT remotely in the context of two randomised controlled feasibility and acceptability clinical trials for young people (aged 11 to 24) who have experienced a brain tumour or Tuberous Sclerosis Complex. Exploring therapist perceptions and experiences provides valuable insights into potential barriers and facilitators to engagement with remote ACT delivery.

Clinical Psychologists who were trained to deliver ACT via videoconferencing were invited to take part in virtual interviews. The semi-structured interview guide aimed to draw on their experience of ACT training, supervision, remote delivery, and perceived impact of ACT. Interviews were audio-recorded, transcribed verbatim and analysed using inductive thematic analysis.

Five Clinical Psychologists were interviewed. Interview data were coded into broad themes around the experience of delivering ACT, engaging with remote systems, the wider perceived impact of ACT and the adaptability of ACT. ACT training was reported to be an effective, positive experience and the opportunity for regular peer and group supervision worked to solidify the training and support fidelity to the ACT processes. It was largely acknowledged that while remote delivery of the intervention did create some initial challenges to the therapeutic process, this approach created opportunity for the young people to access psychological support that they might not have been able to engage with due to logistical considerations. Clinical Psychologists also shared that training in and experience of delivering ACT had a positive and meaningful impact on their clinical practice and personal conduct. They also reported that ACT was adaptable to the needs of the young people in the clinical trials and felt appropriate to deliver in this context.

This in-depth, qualitative study demonstrated the clinical promise of remotely delivered ACT. Clinical Psychologists viewed remotely delivered ACT as an appropriate, acceptable and feasible intervention for young people with experience of brain tumour and Tuberous Sclerosis Complex within the context of research, that would be generalisable to everyday clinical practice.

Maternal anxiety, depression, and stress during and after pregnancy are negatively associated with child cognitive development. However, the contribution of positive maternal experiences, such as social support, to child cognitive development has received less attention. Furthermore, how maternal experience of social support during specific developmental periods impacts child cognitive development is largely unknown.

Using data from the Avon Longitudinal Study of Parents and Children (ALSPAC; n = 5784) and the Prediction and Prevention of Preeclampsia and Intrauterine Growth Restriction study (PREDO; n = 420), we investigated the associations between maternal perceived social support during and after pregnancy and child's general cognitive ability at 8 years of age, assessed with the Wechsler Intelligence Scale for Children (WISC). Bayesian relevant life course modeling was used to investigate timing effects of maternal social support on child cognitive ability.

In both cohorts, higher maternal perceived social support during pregnancy was associated with higher performance on the WISC, independent of sociodemographic factors and concurrent maternal symptoms of depression and anxiety. In ALSPAC, pregnancy emerged as a sensitive period for the effects of perceived social support on child cognitive ability, with a stronger effect of social support during pregnancy than after pregnancy on child cognitive ability.

Our findings, supported from two prospective longitudinal cohorts, suggest a distinct role of maternal perceived social support during pregnancy for cognitive development in children. Our study suggests that interventions aimed at increasing maternal social support during pregnancy may be an important strategy for promoting maternal and child well-being.

Choosing an appropriate electronic data capture system (EDC) is a critical decision for all randomized controlled trials (RCT). In this paper, we document our process for developing and implementing an EDC for a multisite RCT evaluating the efficacy and implementation of an enhanced primary care model for individuals with opioid use disorder who are returning to the community from incarceration.

Informed by the Knowledge-to-Action conceptual framework and user-centered design principles, we used Claris Filemaker software to design and implement CRICIT, a novel EDC that could meet the varied needs of the many stakeholders involved in our study.

CRICIT was deployed in May 2021 and has been continuously iterated and adapted since. CRICIT’s features include extensive participant tracking capabilities, site-specific adaptability, integrated randomization protocols, and the ability to generate both site-specific and study-wide summary reports.

CRICIT is highly customizable, adaptable, and secure. Its implementation has enhanced the quality of the study’s data, increased fidelity to a complicated research protocol, and reduced research staff’s administrative burden. CRICIT and similar systems have the potential to streamline research activities and contribute to the efficient collection and utilization of clinical research data.

Raising a concern is an integral duty for a doctor. The General Medical Council guidelines on Good Medical Practice state that a culture should be promoted that allows “all staff to raise concerns openly and safely”. Appointment of Postgraduate Doctors in Training to Representative (Rep) positions can be an effective way to allow trainee voices to be heard. Here we present the results of a Development Half-Day created to empower Reps with the knowledge and confidence to represent peers effectively within a large mental health Trust. The training session was identified as a ”change idea” in a wider Quality Improvement Project (QIP) seeking to improve trainee confidence in raising concerns.

16 Postgraduate Doctors in Training Reps were invited to attend a Development Half-Day in November 2022. The day included talks on their roles and responsibilities, respectful challenge and maintaining well-being.

Quantitative and qualitative data were gathered using anonymous questionnaires completed before and after the session. The questionnaire contained 4 questions asking them to rate their knowledge of their role as a rep and confidence in raising trainee concerns. This was quantified using a 1-10 scale for each question with 1 being lowest confidence/knowledge and 10 being highest. Mean scores and standard deviations were calculated. A paired one-tailed t-test was used to assess the statistical significance of the difference in pre- and post-session scores.

9 Reps attended the Development Half-Day and completed the pre- and post-session questionnaires.

There was a statistically significant improvement between pre- and post-session scores for all questions (all p values <0.05). Importantly there was a significant increase in the confidence felt by reps in knowing where and who to raise trainee concerns to (p < 0.05).

Qualitative feedback indicated that attendees found the session useful and they appreciated that it was in-person. The only suggestion for improvement was for the session to have been held earlier, closer to when reps were initially appointed; this will be a change that will be implemented in the next “Plan, Do, Study, Act” cycle of the QIP.

Implementation of a Development Half-Day for Trainee Reps was shown to have a significantly positive impact on their confidence in their roles and their ability to respectively challenge seniors. The Reps additionally reported being better equipped at knowing where and who to raise concerns to. This will hopefully aid in their ability to signpost and empower other trainees to do the same.

Raising concerns is a duty for all doctors. However, a scoping exercise within a large mental health Trust demonstrated that trainees experience difficulties in raising both patient safety and training concerns. As part of a trainee-led quality improvement (QI) project within this Trust, our aim was to develop a pulse survey to capture the current likelihood of trainees raising concerns and factors influencing this.

An online survey was developed using ‘plan do study act’ (PDSA) methodology. The initial draft was informed by data from the Autumn 2021 scoping exercise. The survey was refined using a collaborative trainee-led approach. It was tested by trainees involved in the QI project followed by two other trainees and was revised accordingly.

Trainees across all training grades were invited to complete the survey through various communication channels. The pulse survey will be repeated monthly with a two-week response window.

Ten trainees out of 103 responded to the first pulse survey open from 18th to 31st January 2023 (response rate 9.7%). Seven respondents were core trainees and three were higher trainees.

Respondents were more likely to raise patient safety concerns than training concerns (average score of 3.8 out of 5, where 5 equals ‘very likely’, versus 3.4 out of 5 respectively). Of the three respondents who had experienced a patient safety concern in the past 2 weeks, only two had used any existing process to raise it. These data were replicated for training concerns.

No respondents were confident that effective action would be taken if they raised a training concern, while less than half of respondents were confident that effective action would be taken if it were a patient safety concern.

The reasons for the low response rate are likely varied. However, there may be some similar underlying reasons for low engagement in surveys and low engagement in raising concerns. Given this, a more negative picture of trainees’ likelihood of raising concerns may have been portrayed if more trainees engaged in the survey.

Engaging trainees to provide insight into their likelihood of raising concerns is challenging. Despite the low response rate, this initial pulse survey demonstrated that trainees continue to experience barriers to raising concerns. PDSA methodology will continue to be used to optimise the monthly pulse survey response rate. The key QI outcome measures will also be integrated into pre and post intervention surveys as a pragmatic approach to evaluate specific change ideas.