North West England Research Articles

Maternity care for women from ethnic minority backgrounds in North-West England: A grounded theory study

AimTo understand the maternity experiences of women from minority ethnic groups who had given birth in an NHS trust in the North-West of England, and experiences of midwives caring for them. BackgroundWomen from minority ethnic groups have poorer maternity outcomes compared with other women. Research about maternity experiences of women from minority ethnic groups is limited but suggests that they have poorer experiences. MethodConstructivist grounded theory was used as the framework for the study. Thirteen women and sixteen midwives were interviewed to elicit views and maternity experiences of women from minority ethnic groups. Interviews were transcribed, analysed, and focused codes developed into theoretical codes resulting in an emergent grounded theory. FindingsFour sub-categories emerged: ‘I was feeling protected’, ‘it is just literally empowering them, ‘it will affect them more’, and ‘if people speak out it will help other people’. These sub-categories generated a substantive theory: ‘striving towards equity and women centred care’. DiscussionCulturally sensitive, relational care made women feel safe and trust their care providers. Information provision led to reassurance and enabled women to make choices about their care. Midwives’ workload compromised care provision and disproportionally affected women from minority ethnic groups, especially those who do not speak English. Women from minority groups are less likely to complain and be represented in feedback. ConclusionCulturally sensitive care is meeting the individual needs of many women; however, non– English speakers are disproportionally and negatively affected by midwives’ workload, attitudes, or service challenges, reducing their reassurance and choice.

E-cigarette knowledge of undergraduate pharmacy students

Abstract Introduction The use of e-cigarettes (known as vaping) is creating public health opportunities and challenges. E-cigarettes are effective as a smoking cessation tool. However, they are not without risk. E-cigarettes are relevant to pharmacists as they can provide advice about smoking cessation and they are well placed to provide more generic support and information about e-cigarettes, including side effects. Notifications about any issues with e-cigarettes can be done through the United Kingdom’s (UK’s) Medicines and Healthcare products Regulatory Agency (MHRA) Yellow Card Scheme. Vaping products can be considered as licensed, but not yet prescribed within the UK National Health Service (NHS). There are benefits in pharmacists being knowledgeable about the legal and regulatory status of e-cigarettes. It is currently unclear whether pharmacy students are knowledgeable about e-cigarettes and their role in smoking cessation. It is also unclear whether they are aware of the relevance to the Yellow Card scheme. Aim To examine e-cigarette knowledge of undergraduate pharmacy students studying at a large university in the northwest of England, some of which may be concurrently working within retail pharmacy. Methods A link to an online quantitative survey was distributed to all students (approximately 500) studying on the four-year undergraduate pharmacy (MPharm) programme by the programme leader. This was done by email in April 2023. The research was carried out as part of a public health student’s dissertation with a questionnaire designed and piloted by the student. Results were mainly descriptive and χ2 tests were carried out using SPSS where appropriate. Results A convenience sample of 55 students (approximately 10%) was achieved. Just over half the respondents stated they did not know if e-cigarettes were available on prescription or from the NHS. Only 12% of respondents knew that e-cigarettes were regulated for safety and quality in the UK, with 50% of all respondents stating that they were not. Just over half (58%, n=32) did not know whether medically licensed e-cigarettes were available. Less than 10% of all respondents (n=5) were aware that e-cigarettes users can report via Yellow Card Scheme if suspecting a side effect from using e-cigarettes. Interestingly, 46% of those currently working in retail pharmacy (n=11) wrongly stated “no” when asked about the Yellow Card Scheme. This compared to 19% (n=6) of those not currently working in retail settings (χ2=4.44, df=1, p=0.035), indicating that those with current retail experience were less knowledgeable about the Yellow Card Scheme in relation to e-cigarettes. All respondents agreed that pharmacists should be providing health-related advice on vaping to their clients/patients. Conclusion There may be merit in including relevant material on e-cigarettes, including the licensing and Yellow Card scheme, along with more general information on the benefits of switching from cigarettes to vaping and the need to stop vaping, within undergraduate programmes. A strength of this study was that it was one of the first that looked at knowledge of the Yellow Card scheme among pharmacy students, but a main weakness was that it was a small, self-selecting sample of students.

Evaluation of the indoor environment in a historic museum during the COVID-19 lockdown in Northwest England

ABSTRACT Monitoring the quality of the indoor environment is a practice commonly adopted by museums as part of operational risk management. Recorded environmental data are often used to assess the safety of the indoor environment for artefacts, and their suitability for visitors' comfort. Previous studies reported monitoring campaigns assessing the performance of museums and level of compliance with regulatory standards. These analyses were typically conducted in normal circumstances assessing indoor microclimate quality under normal operating procedures. Museum closures during the 2020 pandemic and the global lockdown measures, introduced by governments, presented the heritage sector with an unprecedented situation with empty galleries where collections, in several museums, were held ‘dormant’ in free-running environments. Assessing the indoor environment in such exceptional circumstances offers a unique insight into the performance of these heritage repositories in other unpredicted situations and potential opportunities for microclimate optimization. This paper reports the results of an extended pre and post-pandemic monitoring that was performed in a historic museum in Northwest England. It contributes to the ongoing universal debate about the application of standardized strict environmental guidelines and the shift towards more contextualized standards in museums in the face of the decline in heritage funding and the pledges for carbon reductions.

Increasing Help-Seeking Intentions for Mental Health Difficulties in Early Adolescence: The Role of Cumulative Promotive Factors

AbstractDespite evidence to suggest that receiving support for mental health difficulties can improve later outcomes, adolescents often do not seek help when needed. While factors that reduce the likelihood of help-seeking intentions are well established, little is known about the factors that may increase adolescents’ intentions to seek help. This study sought to identify promotive factors for general help-seeking intentions, as well as help-seeking intentions from formal and informal sources specifically, and to test the assumptions of cumulative promotion theory in relation to help-seeking. Participants comprised 290 early adolescents (aged 11–14) in Northwest England who completed a suite of online measures assessing their mental health, wellbeing, and help-seeking intentions. Candidate promotive factors were modelled, and a cumulative promotive index (CPI) score was generated for each participant. Hierarchical regression was used to analyse the data. A range of promotive factors were identified for help-seeking intentions. CPI scores were significant predictors of all three help-seeking outcomes, even after accounting for the variance explained by the individual promotive factors. Thus, this study confirms two key tenets of cumulative promotion theory in relation to help-seeking intentions amongst adolescents: (1) as the number of promotive factors increases, intentions to seek help for mental health difficulties also increase, and (2) the number of promotive factors is more important than their nature when increasing help-seeking intentions.

Impact of meteorological data factors and material characterization method on the predictions of leading edge erosion of wind turbine blades

Leading edge erosion of wind turbine blades is a major contributor to wind farm energy yield losses and maintenance costs. Presented is a multidisciplinary framework for predicting rain erosion lifetimes of wind turbine blades. Key aim is assessing the sensitivity of lifetime predictions to: modeling aspects (material erosion model, blade aerodynamics), input data and/or their preprocessing (joint frequency distribution of wind speed and droplet size based on synchronous site-specific measurements versus frequency distribution generated with partly site-agnostic modeling standards, wind speed records of nacelle anemometer or extrapolated at hub height from met masts), and environmental conditions (UV weathering). The analyses consider a Northwest England onshore site where a utility-scale turbine is operational, focus on a reference 5 MW turbine assumed operational at the site, and use a typical leading edge coating material. It is found that the largest variations in erosion lifetime predictions are due to material erosion model (based on rain erosion test data or fundamental material properties) and wind and rain model (measurement-based joint wind speed and droplet size distribution or standard-based modeled distribution). The use of joint wind and rain distribution also enables identifying wind/rain states with highest erosion potential, knowledge paramount to deploying erosion-safe turbine control.

P076 Exploring the correlation between body mass index and fracture risk in men

Abstract Background/Aims There has been an increase in interest in identifying patients with high risk of fracture, due to the high mortality. In De Laet et al. (2005) meta-analysis on 60000 women and men, which analysed the effect of body mass index (BMI), bone mineral density (BMD), age and gender on risk of any fracture; low BMI is linked to significantly higher fracture risk (two-fold at BMI of 20) when compared with a BMI 25. On the same comparison, high BMI (30) reduced risk of fractures by 17% (RR 0.83). This was significant in women, but not in men. No newer large-scale study focused on the correlation between BMI and fracture risks in men. Therefore, we set out to investigate the relationship between BMI and different fractures in male patients. Methods 5388 male patients referred for DEXA scan in the North West of England between 2004 and 2019 were included in the analysis. Logistic regression is performed for age, BMI, and BMD using R-4.3.1 for Windows. Results Prior to adjusting for BMD, low BMI is a significant risk factor for femur fracture. On the other hand, low BMI is a protective factor against tibia-fibula fractures. There was no significant correlation detected in spine, rib, humerus, forearm and elbow fractures. After adjusting for BMD, higher BMI is associated with significantly higher odds of humerus, tibia-fibula and wrist fractures, but no statistically significant association with spine, ribs and femur fractures. Conclusion Our results show the correlation between BMI, adjusted for BMD, and different fracture site. Our findings corroborated with previous literature, suggesting that BMI is likely a risk factor that is dependent on BMD. Furthermore, we highlighted that higher BMI is a protective factor for some fractures whilst being a risk factor for others. It is unclear whether the difference between the fracture types are due to the mechanism of fracture or the difference in disease progression at the different fracture sites - this is a potential area for future research. Disclosure M.H. Nguyen: None. M. Bukhari: None.

E040 Differences in clinical characteristics in patients with extremes of discordance in bone mineral density in the hips

Abstract Background/Aims Osteoporosis is a clinical condition which is characterised by low bone mineral density (BMD) and is associated with increased risk of fractures and subsequent increased morbidity and mortality. Usually BMD is measured at either the spine or the non-dominant hip (usually the left hip). However, our DEXA scanner routinely measures BMD at both hips and enables discordance in terms of BMD to be measured. This study aimed to ascertain whether patients with extremes of discordance in their BMD between both hips are more likely to have certain clinical characteristics and different risk for fractures. Methods Data from a dual-energy X-ray absorptiometry (DEXA) scanner in the North West of England were used. Patients who were referred between 2004-2011 were studied. Patients had both hips scanned as well as risk factors and presence of fracture recorded. Those that had a BMD T-score difference from 0 and upwards formed the positive discordance group. Those that had a BMD T-score difference of either less than or equal to -1SD formed the negative discordance group. These two groups were compared using independent sample t-tests for continuous variables and chi-squared tests for categorical variables. Logistic models were then fitted to look at the odds of fracture in each group. Results The hip BMD T-scores of 10,335 patients were measured. Mean age was 62.41 (±12.99) with 82.61% being female. The odds ratio for the measured risk factors and the association with fracture are shown in Table 1 below. Significant risk factors are highlighted Conclusion Patients that had a positive discordance had lower weight and BMI. Also, there was a higher proportion of females in the positive discordance group. These are important risk factors used in fracture risk assessment. It is possible that if BMD is only measured in one hip, patients may be misclassified as not having osteoporosis. However, if BMD is measured in both hips, discordance might be present suggesting osteoporosis in the right hip. This discordance in BMD in our study is associated with some risk factors like age and sex which may increase future fracture risk. Disclosure A. Saeed: None. M. Bukhari: None.

P156 Type I interferon is raised across connective tissue diseases and is associated with haematological abnormalities and specific autoantibody profiles

Abstract Background/Aims The overlapping clinical and serological features among connective tissue diseases (CTDs) suggest a shared molecular aetiology. A molecular taxonomy of CTDs offers new opportunities in clinical trial design, which can potentially be translated into targeted treatment. In a previous study of 164 patients, we identified a type I interferon (IFN) positive subgroup within an unselected CTD cohort associated with specific clinical and serological features. Here, we aim to investigate the relationship between type I IFN and the clinical and immunological phenotype in a larger CTD cohort and determine whether a distinct subpopulation of patients can be identified. Methods Adult patients with at least 1 CTD clinical feature and CTD-related autoantibody were recruited from five rheumatology centres in North West England into the Lupus Extended Autoimmune Phenotype (LEAP) cohort. A 24-gene interferon-stimulated gene (ISG) score was calculated using NanoString as described by Neasens et al. 2022. Results Most patients had lupus (36%). 160 of 344 (46.5%) patients had a positive ISG score across all CTDs with 64/125 (51%) of lupus patients (Fig.1). Patients with positive ISG score were younger and had longer disease duration (p < 0.005 for both). There were no differences in mucocutaneous or internal organ involvement between the ISG subgroups. The ISG-positive group had significantly increased frequency of specific autoantibodies (anti-Smith, anti-Chromatin, anti-RNP, anti-Ro) and Rheumatoid Factor, and haematological abnormalities (lower haemoglobin, and lower total white cell and neutrophil counts) in an adjusted model including the CTD subtype. Conclusion In CTD patients, IFN type I positivity was identified across a subset of patients of all CTDs and is associated with specific autoantibodies and haematological parameters; these results support the findings of our previous smaller study. The identification of an IFN I-positive subgroup within an unselected CTD regardless of clinical diagnosis supports a molecular-based approach to treatment. Disclosure A. Madenidou: Grants/research support; Janssen and UCB. G.I. Rice: None. S. Dyball: Grants/research support; UCB, Novartis,Eli Lilly. B. Parker: Honoraria; Fresenius-Kabi and AbbVie. Member of speakers’ bureau; Eli Lilly and Roche. Grants/research support; Genzyme/Sanofi and GlaxoSmithKline. T.A. Briggs: Grants/research support; Janssen. I.N. Bruce: Consultancies; AstraZeneca, Eli Lilly, GlaxoSmithKline, Merck Serono and UCB. Member of speakers’ bureau; AstraZeneca, GlaxoSmithKline and UCB. Grants/research support; Genzyme/Sanofi, GlaxoSmithKline, Roche, Novartis, Janssen and UCB.

OA37 Regional variations in adiposity is a strong predictor of fragility fractures in a large cohort: a cross sectional study

Abstract Background/Aims BMI is a core component of fracture risk estimation tools; however, it does not consider the body composition of patients. Emerging research is highlighting that total body fat percentage (TBF%) may be a superior predictor of fracture. Increases in TBF% is thought to be protective of hip fracture while associated with major fragility fractures. However, we have yet to see whether regional variations (abdominal vs hip) in fat deposition is even still a better predictor of fracture. Methods Patients were referred to a DEXA scanner in the northwest of England from 2004-2019. A multivariate logistic regression analysis reporting odds ratios was conducted looking at the fat percentage at the left and right hip (FPLH% and FPRH%), as well as abdominally (FPA%), as predictors of fracture. Results were adjusted for smoking, gender, BMI, steroid use and left femoral t-score. Statistical significance was set at p < 0.05 with STATA V12 used as the statistical package. Results 31,547 patients (5,390 males and 26,156 females) were included in our analysis. The mean age was 64.9 (95% CI 64.8-65.1), BMI 27.1 (95% CI 27.0-27.2), weight 71.1kg (95% CI 70.9-71.3) and height 162cm (95% CI 162.0 cm-162.1cm). 11,875 fractures were reported with 1,375 (11.6%) hip fractures. Table 1 demonstrates the results of our analysis. Conclusion The FPLH% was associated with both hip and all major fragility fractures, while FPA% and FPRH% was only associated with major fragility fractures. We would have expected to see a protective effect for hip fractures, considering our patients were clinically overweight; however, this was not observed. Hence, we report in the literature for the first time that FPLH% is predictive for both hip and major fragility fractures even in patients who are clinically overweight. Our approach of considering regional variations in body fat seems to be superior to methods currently used. Hence, we make the recommendation to conduct further research to validate our findings, as well as investigating ways to incorporate such methods into future iterations of fracture risk calculators. Disclosure H. Amin: None. A. Khan: None. Z. Sultan: None. M. Bukhari: None.

P050 Determining the feasibility of a multi-centre randomised clinical trial to test the effectiveness of integrated symptom tracking for managing rheumatoid arthritis

Abstract Background/Aims In a series of studies, we co-developed and piloted the remote monitoring of rheumatoid arthritis (REMORA) system. REMORA enables patients to daily track symptoms via their smartphone and integrates this data into their electronic health record for discussion during routine clinic visits. This offers the opportunity to make better, and shared, treatment decisions and improve disease management. The effectiveness of integrated daily symptom tracking on clinical and patient-reported outcomes will be tested in a multi-centre stepped wedge randomised clinical trial (RCT). Here, we present the results of the REMORA feasibility study to test trial procedures and intervention delivery. Methods Across two NHS sites in the Northwest of England we aimed to recruit 60 patients, aged ≥18 years with rheumatoid arthritis (RA) or inflammatory arthritis (IA), and access to an Android/iOS smartphone with daily internet access. Participants were asked to complete a baseline web-survey and use the REMORA app to collect daily symptom reports for up to six months. Clinical care teams extracted data from participants’ medical records for all baseline and follow-up appointments, including disease activity scores. To assess feasibility, we reported recruitment rates, participants’ uptake of and adherence to daily symptom tracking, and outcome data completeness. We also compared characteristics of a) those who consented vs. trackers (defined as submitting ≥1 symptom report, i.e., successful intervention uptake), and b) high adherers (symptoms reported on > 60% days) vs. low adherers (symptoms reported on < 25% days). Results A total of 130 patients were screened across study sites, and 52 were eligible and provided consent to take part (40.0%). Of those, 32 (61.5%) initiated symptom tracking; their demographic characteristics were broadly similar to those who consented, though more people of white ethnicity appeared higher in the tracker group (93.8% (95% CI 79.2-99.2) vs 86.5% (74.2-94.4), respectively). Participants completed at least one symptom report on 63.2% of study days (2384/3771 days). We observed few differences between low vs high adherers, though low adherers (n = 6) were younger (median (IQR) years: 41.5 (34.5-55.3)) than the high engagers (n = 20; 61.0 (50.5-65.3)) and had a shorter disease duration (years: 1.0 (0-5.8) vs 3.0 (0.8-10.8)). In total, 48 consented participants had at least one follow-up appointment during the study window; 46 (95.8%) had complete primary outcome data. Conclusion Across two clinical sites, we determined that the procedures and intervention delivery designed for use within a future multi-centre stepped wedge RCT of the REMORA system were feasible for recruitment, adherence to the intervention and completion of the primary outcome. However, uptake of the intervention was lower than we hoped. To enhance intervention uptake in the main trial, we clarified inclusion criteria, improved patient information on what is required to initiate symptom tracking and modified our supporting materials. Disclosure K.L. Druce: None. M. Parkes: None. R. Bravo: None. D. Griffiths-Jones: None. S.N. van der Veer: None. W. Dixon: Consultancies; consultancy fees from Google unrelated to this work. J. McBeth: None.

OA06 Regional differences in work productivity in patients with early rheumatoid arthritis in England and Wales

Abstract Background/Aims Inflammatory arthritis including rheumatoid arthritis (RA) causes significant work disability. Rapid diagnosis and early intervention can reduce the impact of disease. We have previously shown significant regional variation in care delivery. In this study we aim to study regional variation in work outcomes in early RA in England and Wales. Methods We used data from the UK National Early Inflammatory Arthritis Audit between April 2018 and March 2023 to identify patients with early-onset RA in England and Wales. At diagnosis, clinicians collected information on demographics and disease activity. Participants were invited to complete work outcome questionnaires at baseline and 3 months. Our analysis was restricted to patients with work data available at 3 months. The primary outcome was discontinuation of work due to arthritis. Patient characteristics were tabulated by region. Regression models (adjusted for age and gender) examined the associations between work discontinuation and region. Clustered standard errors were estimated to account for within-Trust correlations. Sensitivity models further explored the effects of deprivation and treatment delay. Results A total of 3,730 patients with confirmed RA provided work data. Mean age was 67, 62.3% were female and 7.8% from minority ethnic backgrounds. 14% were current smokers and 55.6% had one or more comorbidities. Median baseline DAS28 was 5.2 (IQR: 4.2-6.1). 363/3730 (10%) had stopped work due to RA by 3 months. 534/3,730 (14%) stopped work for any reason. In regression analysis, significant regional differences were seen in the odds of stopping work due to RA. The Midlands was the largest regional contributor of data and was used as the reference group. Patients from Northwest England were most likely to stop work by 3 months (age- and gender-adjusted OR 1.59, [95% CI 1.13-2.25]) with Midlands patients least likely. Sensitivity analysis showed that deprivation and treatment delay only partially attenuate the association between region and work outcome (OR for Northwest 1.57 [1.06-2.33]). Conclusion There is evidence of regional variation in the impact of new onset RA on work participation. Our analyses suggest that the associations are only partly explained by regional differences in care delivery or deprivation. Other factors such as job type and access to occupational health support warrant further investigation. Disclosure E. Alveyn: Other; Educational support from UCB. M. Adas: None. I. Sahbudin: None. A. Boonen: None. K. Bechman: Honoraria; UCB, Vifor Pharma. M.D. Russell: Honoraria; Abbvie, BioGen, Lilly, Galapagos, Menarini. Other; Educational grants from Lilly, Janssen, Pfizer, UCB. D. Nagra: Honoraria; Abbvie, Galapagos, Lilly. Other; Educational support from UCB. S. Gallagher: None. E. Price: None. K. Walker-Bone: None. S. Norton: None. J. Galloway: Honoraria; AbbVie, Celgene, Chugai, Gilead, Janssen, Eli Lilly, Pfizer, Roche and UCB.

P150 Diagnostic utility of anti-cN1A autoantibody testing in sporadic inclusion body myositis

Abstract Background/Aims Sporadic inclusion body myositis (sIBM) is the most common acquired myopathy in patients aged over 50 years. Diagnostic criteria encompass clinical, biochemical, and myopathological features. Certain myopathological features possess high specificity but low sensitivity; reliance on such findings may lead to delayed or misdiagnoses. The discovery of autoantibodies against cytosolic 5'-Nucleotidase 1A (cN1A) in sIBM patients suggests an autoimmune component in pathogenesis, but the inclusion of this autoantibody in diagnostic criteria remains uncertain. Additionally, optimal testing methodology has not been established, with varying techniques (e.g., ELISA/line-blot) in use. We assessed antibody profiles in an sIBM cohort and reviewed diagnoses in anti-cN1A positive patients. Methods This study was based at the Northern Care Alliance NHS Foundation Trust which hosts a tertiary neuromuscular referral service for the North-West of England. Data sources included myositis clinic and immunology results databases. All patients tested using a validated myositis line-blot immunoassay (EUROLINE 16 Antigen et cN1A [EUROIMMUN]) November 2021-April 2023 were included. Diagnoses of all tested patients were identified through case-note review. Sensitivity and specificity metrics were calculated based on diagnosis and anti-cN1A antibody status. Results The total number of patients tested for anti-cN1A was 495. Of these, 10 patients had a diagnosis of sIBM. The true-positive and false-negative rates were both 50% (n = 5 each). Of the 485 patients who did not have sIBM, true-negativity was 97.52% (n = 473) and false-positivity 2.47% (n = 12). Overall, anti-cN1A had a sensitivity of 50%, specificity of 97.52%, positive predictive value of 29.41% and negative predictive value of 98.95% for sIBM (Table 1). Patients with a false-positive anti-cN1A antibody had diagnoses of: primary Raynaud’s (n = 5); undifferentiated CTD (n = 3); systemic sclerosis (n = 2); non-sIBM myositis (n = 2). Conclusion Anti-cN1A detected using the EUROLINE 16 Antigen assay has high specificity but lacks sensitivity for sIBM, consistent with previous literature. These findings suggest that this assay performs similarly to other cN1A detection methodologies and has utility in confirming the diagnosis of sIBM where there is clinical suspicion. Further real-world analysis of antibody data in larger cohorts is required to clarify the role of serological testing in sIBM diagnostic criteria, to improve diagnostic delays and misclassifications. Disclosure M. Al-Attar: None. T. Khoo: None. J.B. Lilleker: None. H. Chinoy: None.

The use of FreeStyle libre improves glycaemic control along with reducing diabetes burden and hospital admissions in a socially deprived Northwest English population.

This retrospective study aimed to use mixed (qualitative and quantitative) methods to evaluate the role of FSL in reducing hospital admissions due to all causes, HbA1c, and reported hypoglycaemic episodes in people with diabetes living in a socially deprived region of Northwest England. Data were collected retrospectively from previous consultations, which coincided with the 6th -week, 6th -month and annual review including blood tests, hospital admissions due to any cause and reported hypoglycaemia. Also, FSL assessment and satisfaction semi-structured questionnaire was done to assess the impact of FSL on diabetes management and quality of life. Mixed-effects models were used to assess glycaemic control and reductions in hospital admissions and reported hypoglycaemic episodes. Just 127 patients met the inclusion criteria. A multivariate linear mixed model method that analyses HbA1c data longitudinally revealed mean differences (mmol/mol) between baseline and post-FSL measurements, estimated by restricted maximum likelihood method (REML) of 9.64 (six weeks), 7.68 (six months) and 7.58 (annual review); all with a corresponding p-value of < 0.0001. For DKA patients, the bootstrap method revealed a significant reduction in mean HbA1c of 25.5, 95% confidence interval (CI) [8.8, 42.6] mmol/mol. It is demonstrated that FSL use for one year resulted in 59% reduction in hospital admissions and 46% reduction in reported hypoglycaemic episodes. The use of FSL resulted in statistically significant reductions in hospital admissions, HbA1c and reported hypoglycaemic episodes among diabetics in a socially deprived Northwest region of England. These outcomes show a direct association with a higher questionnaire score. The online version contains supplementary material available at 10.1007/s40200-024-01424-4.

Coming of age: the assistant practitioner role 21 years on

In 2023, a milestone was reached, marking 21 years of education, training and development of the assistant practitioner (AP) role at the University of Bolton. This is the first of two articles looking at the development of the assistant practitioner (AP) role in the north-west of England and the involvement of the University of Bolton in it over the past 21 years. It looks at the history and background of the programme at Bolton, from the first cohort in 2002 to the present apprenticeship programme for assistant practitioners in health.

Providing holistic end-of-life care for people with a history of problem substance use: a mixed methods cohort study of interdisciplinary service provision and integrated care

Harmful use of illicit drugs and/or alcohol is linked to life-limiting illness and complex health and social care needs, but people who use substances and have complex needs do not receive timely palliative care and fail to achieve quality standards for a good death. They and their families often require support from multiple health and social care services which are shown to be poorly integrated and fail to deliver interdisciplinary care. This study aimed to identify the existing barriers and facilitators within and between services in providing this population with a good death. Using a mixed methods approach of survey, focus groups and semi-structured interviews, we explored the perspectives of practitioner and management staff across a range of health and social disciplines and organisations in one combined authority in a large city in the north west of England. Our findings indicate that practitioners want to provide better care for this client group, but face structural, organisational and professional boundary barriers to delivering integrated and shared care. Differences in philosophy of care, piecemeal commissioning and funding of services, and regulatory frameworks for different services, lead to poor and inequitable access to health and social care services. Ways forward for improving care are suggested as bespoke hostel-based accommodation for palliative care for this client group, and specialist link workers who can transcend professional and organisational boundaries to support co-ordination of services and support. We conclude that it is no longer adequate to call for more training, better communication and improved joint working. Complex care at the end of life requires creative and cohesive systemic responses that enable multi-disciplinary practitioners to provide the care they wish to give and enables individuals using substances to get the respect and quality service they deserve.

A Hyperactive Geomagnetic Field in the Late Visean (Early Carboniferous) From the Late Asbian Stratotype Section in Northwest England, UK

Plain Language SummaryNearly synchronous global changes in geomagnetic polarity give both a detailed irregular pacing to geological time and provide a glimpse into heat transfer processes across the core—mantle boundary which drives the Earth's geodynamo. Although the Late Carboniferous is characterized by some well‐studied reversals, details of the tempo of polarity changes in the Early Carboniferous are unknown. This work addresses this by providing a detailed record of polarity changes over a ∼2 million year interval at around 334.5–332.5 million years ago‐from the Trowbarrow Quarry section in NW England. We demonstrate that these limestones likely preserve magnetization from close to their time of formation and record at least 31 polarity reversals. These observations support the idea that the Earth's dynamo was in a hyperactive reversing state similar to those sustained for tens of Myr in the Late Jurassic, parts of the Cambrian and the Late Ediacaran. It further corroborates a ∼200 Myr cyclicity in paleomagnetic field behavior since the Precambrian, potentially linked to variable core heat flow forced by mantle convection.

Homelessness: challenges and opportunities in the “new normal”

Purpose This paper – the final paper of a series of three – aims to discuss the implications of the findings from a service user needs assessment of people experiencing homelessness in the Northwest of England. It will expand on the previous paper by offering a more detailed analysis and discussion of the identified key themes and issues. The service user needs assessment was completed as part of a review of local service provision in the Northwest of England against the backdrop of the COVID-19 pandemic. Design/methodology/approach Semi-structured questionnaires were administered and used by health-care professionals to collect data from individuals accessing the Homeless and Vulnerable Adults Service (HVAS) in Bolton. The questionnaires included a section exploring Adverse Childhood Experiences. Data from 100 completed questionnaires were analysed to better understand the needs of those accessing the HVAS. Findings Multiple deprivations including extensive health and social care needs were identified within the cohort. Meeting these complex needs was challenging for both service users and service providers. This paper will explore key themes identified by the needs assessment and draw upon further comments from those who participated in the data-gathering process. The paper discusses the practicalities of responding to the complex needs of those with lived experience of homelessness. It highlights how a coordinated partnership approach, using an integrated service delivery model can be both cost-effective and responsive to the needs of those often on the margins of our society. Research limitations/implications Data collection during the COVID-19 pandemic presented a number of challenges. The collection period had to be extended whilst patient care was prioritised. Quantitative methods were used, however, this limited the opportunity for service user involvement and feedback. Future research could use qualitative methods to address this balance and use a more inclusive approach. Practical implications This study illustrates that the needs of the homeless population are broad and varied. Although the population themselves have developed different responses to their situations, their needs can only be fully met by a co-ordinated, multi-agency, partnership response. An integrated service model can help identify, understand, and meet the needs of the whole population and individuals within it to improve healthcare for a vulnerable population. Social implications This study highlighted new and important findings around the resilience of the homeless population and the significance of building protective factors to help combat the multiplicity of social isolation with both physical and mental health problems. Originality/value The discussion provides an opportunity to reflect on established views in relation to the nature and scope of homelessness. The paper describes a contemporary approach to tackling current issues faced by those experiencing homelessness in the current context of the COVID-19 pandemic. Recommendations for service improvements will include highlighting established good practices including embedding a more inclusive/participatory approach.

The Hummingbird Project year 2: decreasing distress and fostering flourishing in a pragmatic pre-post study.

Multi-component Positive Psychology Interventions (mPPIs) in secondary schools have been shown to improve mental health outcomes for young people. The Hummingbird Project mPPI is a six-week program of workshops designed to introduce a variety of positive psychology (PP) concepts to secondary school-aged children in schools to improve well-being, resilience, and hope. The effects on mental distress, however, were not explored. The current study, therefore, was designed to replicate the effects of the Hummingbird Project mPPI on positive mental health and to also explore the effects on symptoms of mental distress. Secondary school-aged children (N = 614; mean age = 11.46 years) from a sample of secondary schools located across the North West of England (N = 7) participated in the study; the majority of children were in Year 7 (94%). The PP concepts explored included happiness, hope, resilience, mindfulness, character strengths, growth mindset, and gratitude. The results showed significant improvements associated with the mPPI in well-being (as measured by the World Health Organization Well-Being Index; WHO-5), hope (as measured by the Children's Hope Scale; CHS), and symptoms of mental distress (as measured by the Young Person's Clinical Outcomes in Routine Evaluation; YP-CORE) from pre- to post-intervention. While acknowledging the limits due to pragmatic concerns regarding the implementation of a control group, the effectiveness of the Hummingbird Project mPPI on well-being was replicated alongside reducing the symptoms of mental distress. Future evaluation, however, will need to implement more robust designs and consider follow-up duration to assess the longer-term effects of the Hummingbird Project mPPI.

Population Reinforcement of the Endangered Freshwater Pearl Mussel (Margaritifera margaritifera): Lessons Learned

Freshwater mussel populations are in sharp decline and are considered to be one of the most imperilled groups globally. Consequently, the number of captive breeding programmes has increased rapidly in recent years, coupled with subsequent reintroductions/population reinforcements to reverse these declines. The outcomes of mussel conservation translocations are seldom reported in the primary literature, hindering opportunities for learning and for population recovery at pace. Here, we describe the methods employed to carry out a successful conservation translocation of the freshwater pearl mussel (Margaritifera margaritifera) in a declining population in northwest England. Following a small-scale pilot release in 2017, four release sites were identified for a population reinforcement of over 1300 tagged mussels in 2021. Monitoring during 2022 showed high levels of retention of juveniles at three out of the four release sites, despite the occurrence of a significant flood event during October 2021. Subsequent releases of 1100 juveniles were carried out across the three successful sites in 2023. Ongoing and regular monitoring is essential in order to provide data on the longer-term fate of propagated juveniles in the wild. This will allow for adaptive management of release activities in this river. These data will be useful to design conservation translocation strategies for other imperilled pearl mussel populations in the UK and throughout Europe.

A history of the intermediate tier in the English NHS: Centre, region, periphery

AbstractCentre‐periphery relations have constituted a paradox for the English National Health Service (NHS) since its creation in 1948. Is it a top‐down national service organised locally, or a bottom‐up arrangement of local health systems managed nationally? North West England provides a regional case study which traces the changing organisational, relational and spatial dimensions of the intermediate tier. These reposition centre‐periphery tensions. In foregrounding, situating and conceptualising region in these terms, I offer new insight into existing narratives and centre‐periphery relations in the NHS.