Augmented Reality in education can support students in a wide range of cognitive tasks–fostering understanding, remembering, applying, analysing, evaluating, and creating learning-relevant information more easily. It can help keep up engagement, and it can render learning more fun. Within the framework of a multi-year investigation encompassing primary and secondary schools across Europe, the ARETE project developed several Augmented Reality applications, providing tools for user interaction and data collection in the education sector. The project developed innovative AR learning technology and methodology, validating these in four comprehensive pilot studies, in total involving more than 2,900 students and teachers. Each pilot made use of a different Augmented Reality application covering specific subjects (English literacy skills, Mathematics and Geography, Positive Behaviour, plus, additionally, an Augmented Reality authoring tool applied in a wide range of subjects). In this paper, we introduce the datasets collected during the pilots, describe how the data enabled the validation of the technology, and how the approach chosen could enhance existing augmented reality applications in data exploration and modelling.

Introduction Clinical trials evaluating the effectiveness of falls prevention interventions for people with Multiple Sclerosis (MS), Parkinson’s Disease (PD) and stroke measure heterogeneous outcomes, often omitting those meaningful to patients. A core outcome set (COS) is a standardised set of outcomes that should be assessed in all trials within a research area. The aim of this study was to develop a COS for evaluating mixed-diagnosis falls prevention interventions for people with MS, PD and stroke in non-acute and community settings, with input from relevant stakeholder groups. Methods Previously published research undertaken by the team, including a qualitative study with 20 patients and a review of the literature, were used to derive a longlist of potential outcomes. Outcomes were prioritised for inclusion in the COS using a three-round online Delphi survey. A multi-stakeholder, consensus meeting was conducted to agree upon the final COS and to provide a recommendation for a single outcome measure for each outcome in the COS. Results Forty-eight participants were recruited across four stakeholder groups (researchers, patients, clinicians, and service-planners/policymakers). A total of 42 participants (87.5%) completed all three rounds of the surveys. Sixty-two outcomes were considered for inclusion in the COS throughout the Delphi process. A total of 15 participants attended the consensus meeting where they agreed upon the final COS and accompanying measurement instruments: fall incidence, injurious fall incidence, quality of life, falls self-efficacy, fear of falling, activity curtailment due to fear of falling, and cost-effectiveness. Attendees at the consensus meeting recommended that the proposed mechanism of impact of an intervention is considered when selecting additional outcomes outside of those in the COS to assess. Conclusions This study identified a COS for evaluating the effectiveness of mixed-diagnosis falls prevention interventions for people with MS, PD and stroke. It is recommended that this COS and accompanying measurement instruments be used in all future trials in this research area so that findings can be combined and compared.

Abstract Background Model 2 hospitals provide in-patient and out-patient care for differentiated, low-risk medical patients, who are not likely to require full resuscitation. Smaller hospitals are generally very well regarded by the local population and general practitioners. Methods This is a prospective descriptive study. Data were collected from all patients admitted via the Medical Assessment Unit (MAU) or stepped-down from a model 4 hospital for six consecutive weeks. Data points included: route of admission, age, Rockwood Clinical Frailty Scale (CFS) on presentation, length of stay (LOS), long term care/community resident, if delirium was present, known cognitive impairment, number of medications, hospital admissions in the past year and discharge destination. Results 144 patients were recruited to the study—79 via the MAU, 64 stepped down from a model 4 hospital and 1 via outpatient clinic, 95 of whom had a hospital admission within the previous year. The average age of patients was 72 years with a mean CFS of 4. 38% of patients were felt to be delirious on presentation to hospital, with 14% having a formal diagnosis of cognitive impairment prior to admission. Over 80% of patients were prescribed 5 or more medications in the community. Average overall LOS at the module 2 hospital was 9 days; 8 days for patients admitted via the MAU and 12 days for those stepped down from a model 4 hospital. The mean LOS at module 4 hospital prior to transfer was 6 days. 92% were living in the community prior to admission, 82% of which returned home. Conclusion Model 2 hospitals are a vital resource, particularly catering for the geriatric population. Patients are often multimorbid and admissions are often complicated with polypharmacy, delirium and discharge planning. Further exploration is required to assess how best to appropriately staff and resource them.

A novel method of providing education and support to GP's was developed. The goal was to create a rapidly accessed peer advisory community to empower GP HRT prescribing. A core group of doctors with special expertise in HRT were assembled on a GP interest group on the Telegram messaging platform. It is called 'HRT prescribers', an educational community with entrance by peer invitation. Most are GPs and number between 800 and 1000. Members post clinical questions and receive evidence-based responses to their dilemmas. A survey of members was overwhelmingly positive. 98% agreed the group empowered them to be confident and feel supported in their HRT prescribing. 90% agreed the group helped improve access to HRT for women who needed it in their practice. This project developed, with the cooperation of specialists, a cost-effective rapid method of educating and empowering GP's to be supported to safely treat their patients in their menopause transition. With further support and development, we believe it is the model that could be adopted in many countries.

The latest guidelines for heart failure with reduced ejection fraction (HFrEF) recommend concurrent treatment with four drug classes to improve patient outcomes. While physicians likely have the skillsets needed to navigate the complexities of multiple drug interactions, HF nurse prescribers lack experience needed to implement the latest guideline-directed medical therapy (GDMT). As nurse-led HF services continue to expand, implementing GDMT is essential for gold-standard care. We describe and compare the abilities of physician-led and nurse-led HF clinics in implementing GDMT in HFrEF within the outpatient setting. A retrospective multi-centre cohort study was performed on the pharmacotherapy patterns of HFrEF patients attending either a physician-led or nurse-led HF clinic in 2021. Pharmacotherapy patterns of prescribing on the pillars of HFrEF therapy were collected: ACEi/ARB/ARNi, BB, MRA, SGLT2i. 164 and 231 HFrEF patients were reviewed in a physician-led and nurse-led group respectively. Compared to physicians, there were significantly lower rates of MRA (42.0% vs 62.8%, P < 0.001) and SGLT2i (7.8% vs 24.4%, P < 0.001) prescribed by nurses. Most patients seen by physicians were treated with three drug classes (45.7%) versus two drug classes (50.2%) when seen by nurses. Ongoing gaps in GDMT implementation are driven by the suboptimal MRA and SGLT2i use. Patients seen by nurses were treated with less drug classes and less likely to be treated with MRA and SGLT2i compared to physicians. These findings highlight the ongoing difficulties autonomous nurse prescribers face in HF prescribing and the need for further educational supports.

As prevalence of multimorbidity and polypharmacy rise, healthcare systems must respond to these challenges. Data are needed from general practice on specific metrics of healthcare utilisation. This research aims to establish the rates of attendance to general practice and referral to hospital; and how age, multi-morbidity and polypharmacy affect them. This was a retrospective study of general practices in a university-affiliated education and research network, consisting of 72 practices. Records from a random sample of 100 patients aged 50 years and over who attended each participating practice in the previous 2 years were analysed. Through manual record searching, data were collected on patient demographics, number of chronic illnessesand medications, numbers of attendances to the general practitioner (GP), practice nurse, home visits and referrals to a hospital doctor. Attendance and referral rates were expressed per person-years for each demographic variable and the ratio of attendance to referral rate was also calculated. Of the 72 practices invited to participate, 68 (94%) accepted, providing complete data on a total of 6603 patients' records and 89,667 consultations with the GP or practice nurse; 50.1% of patients had been referred to hospital in the previous 2 years. The attendance rate to general practice was 4.94 per person per year and the referral rate to the hospital was 0.6 per person per year, giving a ratio of over eight attendances for every referral. Increasing age, number of chronic illnesses and number of medications were associted with increased attendance rates to the GP and practice nurse and home visits but did not significantly increase the ratio of attendance to referral rate. As age, morbidity and number of medications rise, so too do all types of consultations in general practice. However, the rate of referral remains relatively stable. General practice must be supported to provide person-centred care to an ageing population with rising rates of multi-morbidity and polypharmacy.

BackgroundHeart failure with reduced ejection fraction (HFrEF) is a complex disease, with multiple comorbidities, making management with guideline-directed medical therapy (GDMT) a challenging feat. Nurse-led outpatient HF clinics play a pivotal role in the optimisation of GDMT in HFrEF patients, with established benefits in reducing hospitalization and mortality. The recent addition of sodium-glucose transport protein 2 inhibitors (SGLT2i) to the backbone of HFrEF disease-modifying therapy has further increased the complexities of HF management. Prescriber hesitancy of SGLT2i in nurse-prescribers is compounded by concerns of treatment side effects, comorbidities, polypharmacy, and patient hesitancy. The lack of SGLT2i initiation in nurse-led clinics is under-investigated and may result in lower rates of patients receiving appropriate GDMT. Considering the widespread use of nurse-led outpatient HF clinics in Ireland, this trend could have widespread implications depending on the rate of SGLT2i initiation by nurse-prescribers.PurposeTo describe the rate of SGLT2i use in a nurse-led outpatient HF clinic (HFSU) and the impact of developing local nurse-prescriber guidelines on improving SGLT2i initiation rates.MethodsA retrospective closed-loop clinical audit was performed on HFrEF patients actively attending the HFSU. HFrEF was defined as left ventricular ejection fraction (LVEF) ≤40% and active attendance was defined as a single HFSU engagement within one year, and patients who have not died, been transferred to another service, or lost to follow-up. Patients who attended the HFSU during the respective phases had information on patient demographic, comorbidities, baseline investigations, and pharmacotherapy patterns collected and compared: Pre-intervention (January 2021 to December 2021), and Post-intervention (January 2022 to April 2022). Nurse-prescriber guidelines and patient information leaflets were developed and initiated as an intervention in January 2022.ResultsA total of 320 HFrEF patients were actively attending the HFSU during the Pre- and Post-intervention phases (160 Pre-intervention vs 160 Post-intervention) (table 1). During the Pre-intervention phase, SGLT2i was used in 9 patients (5.6%) who were all comorbid with type 2 diabetes mellites (T2DM). After intervention, SGLT2i use was significantly higher in the Post-intervention group when compared to the Pre-intervention group (9 (5.6%) vs 34 (21.3%), P <0.0001) (table 1). 16 of the 34 patients on SGLT2i in the Post-intervention group were comorbid with T2DM. 58 Table 1Comparison of patient characteristicsConclusionsPrescriber hesitancy of SGLT2i is an ongoing issue in nurse-led outpatient HF clinics. Auditing pharmacotherapy patterns can identify current rates of SGLT2i initiation, alerting clinicians to inadequate GDMT rates. Local nurse-prescriber guidelines and patient information leaflets can effectively increase the rate of SGLT2i initiation by non-physician prescribers and extend its licensed use beyond the diabetic cohort.

AbstractBackgroundStrategies to reduce antibiotic overuse in hospitals depend on clinicians taking decisions to stop unnecessary antibiotics. There is a lack of evidence on how support clinicians do this effectively. We evaluated a multifaceted behaviour change intervention (ARK) which aims to reduce antibiotic consumption in hospitals by increasing decisions to stop antibiotics at clinical review.MethodsWe performed a stepped-wedge, hospital-level, cluster-randomised controlled trial using computer-generated sequence randomisation of 39 acute hospitals to 7 calendar-time blocks (12/February/2018–01/July/2019). Co-primary outcomes were monthly antibiotic defined-daily-doses (DDD) per acute/medical admission (organisation-level, superiority) and all-cause 30-day mortality (patient-level, non-inferiority, margin 5%). Clusters were eligible if they admitted non-elective medical patients, could identify an intervention “champion” and provide pre-intervention data from February/2016. Sites were followed up for a minimum of 14 months. Intervention effects were assessed using interrupted time series analyses in each cluster. Overall effects were derived through random-effects meta-analysis, using meta-regression to assess heterogeneity in effects across prespecified factors. Trial registration was ISRCTN12674243.FindingsAdjusted estimates showed a year-on-year reduction in antibiotic consumption (−4.8%, 95%CI: -9.1%,-0.2%, p=0.042) following the ARK intervention. Among 7,160,421 acute/medical admissions, we observed a -2.7% (95%CI: -5.7%,+0.3%, p=0.079) immediate and +3.0% (95%CI: - 0.1%,+6.2%, p=0.060) sustained change in adjusted 30-day mortality. This mortality trend was not related to the magnitude of antibiotic reduction achieved (Spearman’s ρ=0.011, p=0.949). Whilst 90-day mortality odds appeared to increase over time (+3.9%, 95%CI:+0.5%,+7.4%, p=0.023), this was not observed among admissions before COVID-19 onset (+3.2%, 95%CI:-1.5%,+8.2%, p=0.182). Length of hospital stay was unaffected.InterpretationThe weak, inconsistent effects of the intervention on mortality are likely to be explained by the COVID-19 pandemic onset during the post-implementation phase. We conclude that the ARK-intervention resulted in sustained, safe reductions in hospital antibiotic use.FundingNIHR Programme Grants for Applied Research, RP-PG-0514-20015.Research in contextEvidence before this studyAcutely ill patients often need to receive antibiotics before full diagnostic information is available. Consequently, reducing overuse of antibiotics in hospitals requires clinicians to review and where appropriate, stop unnecessary antibiotic prescriptions. Evidence-based tools to support clinicians stop unnecessary antibiotics do not exist.We searched PubMed, with no language or date restrictions, on 31/January/2022 for clinical studies focused on improving antibiotic use for hospitalised adults using the terms “anti-bacterial agents therapeutic use” AND “antibiotic stewardship”. Among the 427 studies found, the great majority were uncontrolled evaluations of different approaches to education, decision support and feedback. These included one before-after study, which found no impact of unsupported clinician-led prescription review. Three small, hospital-level cluster-randomised trials were identified. One evaluated different approaches to feedback, one compared different hospital specialties and one found intense feedback to be effective. All were small and none considered clinical outcomes or sustainability. There is a need for research to deliver proven interventions ready for implementation into practice.Added value of this studyWe evaluated a multifaceted “Antibiotic Review Kit” (ARK) intervention to support prescribers to appropriately stop antibiotics at clinical review. ARK comprises a prescription decision-aid supported by a brief online training tool, guidance on implementation (including regular data collection and feedback) and a patient information leaflet. We found that the intervention was associated with a sustained reduction in hospital-level antibiotic use overall and of oral and narrow-spectrum antibiotics specifically. Weak trends were observed for 30-day mortality in opposite directions for immediate and sustained impact. Although there was a sustained increase in 90-day mortality after the intervention, this was only seen when analyses included patients admitted after the start of the COVID-19 pandemic. Taken together we conclude that these mortality effects are unrelated to the intervention.Implications of all available evidenceThe ARK intervention is safe and effective in reducing antibiotic use among adult medical hospital admissions. The tools used are now freely available for adoption into practice.

Abstract Background: The ongoing pandemic of COVID-19, caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), poses a serious threat to global public health and imposes a severe burden on the entire human population. Faced with a virus that can mutate its structure while immunity is incapacitated, a need to develop a universal vaccine that can boost immunity to coronaviruses is highly needed.Design: Five formulations of two types (CRCx2 and CRCx3) of immune complexes with an immunogen adjuvant were evaluated in a mouse model as candidate SARS CoV-2 vaccines in a pretrial prior to clinical trials in humans. CRCx3 comprises 3 different formulas and CRCx2 comprises 2. Balb/c mice were vaccinated intraperitoneally on days 0/7 with a high or low dose of CRCx2 or on days 0/7/14 with a high, medium, or low dose of CRCx3 series, and their blood was sampled for serum antibody measurements. Mice were challenged with live virus after immunization with either vaccine to evaluate prophylaxis ability or treated with them after challenge to evaluate therapeutic ability on day 15. Immunological markers and histopathological studies as well as titration of neutralizing antibodies to the vaccines were evaluated and analyzed.Results: CRCx 3 and CRCx 2 vaccine candidates induced elevated levels of positive neutralizing antibodies as well as a cellular immune response with safety, efficient productivity, and good genetic stability for vaccine manufacturing to provide protection against SARS-CoV-2 with relatively higher levels with the high dose CRCx2 candidate combination.Conclusions: Highly efficient protection and therapeutic effect against SARS-CoV-2 were obtained with a double-dose immunization schedule spaced at 7-day intervals using injections of 0.25 or 0.40 ml of CRCx2 vaccine formulations with a 25-mm needle. These results support further evaluation of CRCx in a clinical trial on humans.

Abstract Background: The ongoing pandemic of COVID-19, caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), poses a serious threat to global public health and imposes a severe burden on the entire human population. Faced with a virus that can mutate its structure while immunity is incapacitated, a need to develop a universal vaccine that can boost immunity to coronaviruses is highly needed.Design: Five formulations of two types (CRCx2 and CRCx3) of immune complexes with an immunogen adjuvant were evaluated in a mouse model as candidate SARS CoV-2 vaccines in a pretrial prior to clinical trials in humans. CRCx3 comprises 3 different formulas and CRCx2 comprises 2. Balb/c mice were vaccinated intraperitoneally on days 0/7 with a high or low dose of CRCx2 or on days 0/7/14 with a high, medium, or low dose of CRCx3 series, and their blood was sampled for serum antibody measurements. Mice were challenged with live virus after immunization with either vaccine to evaluate prophylaxis ability or treated with them after challenge to evaluate therapeutic ability on day 15. Immunological markers and histopathological studies as well as titration of neutralizing antibodies to the vaccines were evaluated and analyzed.Results: CRCx 3 and CRCx 2 vaccine candidates induced elevated levels of positive neutralizing antibodies as well as a cellular immune response with safety, efficient productivity, and good genetic stability for vaccine manufacturing to provide protection against SARS-CoV-2 with relatively higher levels with the high dose CRCx2 candidate combination.Conclusions: Highly efficient protection and therapeutic effect against SARS-CoV-2 were obtained with a double-dose immunization schedule spaced at 7-day intervals using injections of 0.25 or 0.40 ml of CRCx2 vaccine formulations with a 25-mm needle. These results support further evaluation of CRCx in a clinical trial on humans.