Analysis 2.10. Comparison 2: Cognitive behaviour therapy versus other psychological therapies, Outcome 10: Clinical response at follow-up (short/medium-term

a b s t r a c tDifferences between training and working contexts have the potential to be a major cause of deficits in performance of searching animals. Detection responses of individuals trained with high rates of target stimulus presentation tend to extinguish when moved to a new context where their rate of target encountering is low. This problem is acute with some contraband and people detection dogs where the rate of target encountering in the work context is significantly lower than during training. While the rate of extinction can be mitigated by planting known targets in the working contexts, this is often logistically difficult, dangerous, or impractical; an alternative solution would therefore be beneficial. Here, we explore the novel approach of adding non-contraband target stimuli to the training set and then presenting these innocuous targets periodically in the work context, thereby avoiding the logistic difficulties attached to the use of real contraband targets. Our rationale is that the search persistence caused by the innocuous targets could generalise to the real targets, thus increasing resistance to extinction in the latter. The potential problem with this approach is that dogs may learn to focus on the innocuous targets in the work context to the detriment of the real targets. In our experiments, 21 dogs were trained with three contraband (explosive) and one innocuous (non-explosive) odours. When they were transferred to a "work" context, they were separated into three groups, as follows: Group "0T" (zero target) were not exposed to any targets in the work environment; Group 1T (one target) were exposed to and rewarded on one innocuous target in the work environment; and Group 3T (three target) were exposed to and rewarded on three contraband targets in the work location. These regimens continued for six weeks during which time all dogs received two refresher training days away from their work location, where they were rewarded on all four target odours. Following this work phase, search and detection performance was tested in the work location for all stimuli. In the work phase, search vigilance in the 0T group dropped considerably compared with the 1T and 3T groups. Critically, when dogs were reexposed to all four targets in the work location at the end of the work phase, detection rates were significantly reduced for the 0T group, but were maintained on all targets for the 1T Abbreviations: SDD, scent detecting dogs; NE, non-explosive; DR, detection rate. 113 and 3T group. Our results show that rewarding search persistence with innocuous stimuli is potentially a successful strategy to maintain detection-dog performance across a range of trained contraband odours.Crown

by some authors that the tip of the cannula should be withdrawn outside the lumen of the vein and sited subcutaneously to avoid the rare complication of air embolism. 4 It has also been suggested that this method will protect the catheter from kinking. The circumstances of this case challenge that assumption, and suggest that it may be preferable to leave the cannula inside the vein during catheter insertion. Knotting of a PICC is a potential complication which one must consider whenever there is difficulty in advancing the catheter, or when there is difficulty in removing the stylet. When this complication is suspected, the course of the catheter should be confirmed radiologically, and the catheter removed surgically, as excessive traction on the catheter could lead to further complications.

Mitchell question the validity of the Quality and Outcomes Framework and suggest how it should change in the future Martin McShane medical director, long term conditions 1 , Edward Mitchell core trainee 2 1 NHS England, Medical Directorate, Leeds LS2 7UE, UK; 2 Oxford Health NHS Trust, Warneford Hospital, Oxford OX3 7JX, UK The Quality and Outcomes Framework (QOF) is a pay for performance programme that was introduced in 2004 to improve care in general practice. It now constitutes roughly 13% of practice income-QOF payments in 2013-14 were £1057m (€1451m; $1613m) (fig⇓). 1 The arguments for and against the QOF (and pay for performance schemes in general) have been hotly debated over the past decade. Its seminal impact on UK general practice is undeniable, but its influence is such that it has affected our idea of what constitutes quality improvement. It has been suggested, for example, that we equate (or perhaps conflate) good care with the recording of disease specific biomedical or process markers. 2The QOF is facing change. The 2014-15 GP contract deal has seen a 30% reduction in QOF points. 3 After eleven years, and billions of pounds in QOF payments, we take stock of the QOF and discuss three changes in the healthcare system that mean QOF must change.

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