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By O. Tjalf. The College of New Jersey.

ADHD buy discount procyclidine 5 mg on-line, attention deficit hyperactivity disorder; fMRI purchase procyclidine 5 mg free shipping, functional magnetic resonance imaging; MCA cheap 5 mg procyclidine amex, middle cerebral artery; MHPG purchase 5 mg procyclidine with visa, XXX; MT buy procyclidine 5 mg otc, XXX; PET, positron emission tomography; PT, planum temporale; rCBF, regional cerebral blood flow; RD, reading disorder. Chapter 44: Learning Disorders 605 striate visual magnocellular pathways and specific phono- and early elementary years can reduce the overall rate of logic processing pathways in the left hemisphere are in- RDs (36,37) and can improve outcomes for children who volved in dyslexia, a finding possibly reflecting different are at high risk of RD (38,39). One metaanalysis reported subtypes at the behavioral level. As noted earlier, cognitive a combined effect size for phonologic awareness training of behavioral analysis suggests that distinctive mechanisms for 1. For example, in deep dyslexia, it is difficulty (40). Thus, a between normal and impaired readers appears to reflect the patient may read 'spirit' as 'whiskey,' or 'church' as difficulty many poor readers have in mastering phonologic 'priest. Torgesen exam- dyslexia, deep dyslexia may reflect a right-hemi- ined results from five large-scale early reading intervention sphere—based processing mechanism (31). Such findings point to the need language system, involving the segmentation and synthesis for the development of even more powerful intervention of phonemes (20), others find evidence that magnocellular techniques to facilitate the acquisition of early reading skills. As noted by Filipek, cognitive neurosci- phonologic awareness as a necessary, but not sufficient con- ence identifies specific computational tasks that should be dition for the development of skilled reading (15). Fluent used to provide more homogeneous samples at the behav- reading requires the development of orthographic reading ioral level for further advances in the neurobiology of devel- skills or the ability to recognize words by sight (41). For example, rather than using paired readers generally show deficits in this area that persist classic clinical criteria for dyslexia, which leads to samples into adulthood (41,42). Interventions to improve fluency with diverse subtypes, neuroimaging studies may do better are less well developed than interventions for the develop- to select samples by visual, lexical, and semantic criteria ment of decoding skills (i. The repeated readings technique, which involves mul- tiple readings of the same passages, is the most researched approach to improving fluency (43), and it has shown lim- EDUCATIONAL MANAGEMENT ited but positive effects on fluency (44). The increased atten- tion to issues of fluency in reading research has resulted in Various educational treatments have been developed for the development of new, comprehensive intervention ap- LD. In general, the most effective treatment approach is proaches that ultimately may be more effective than existing one that involves careful delineation of the specific academic techniques in addressing fluency deficits (23). At present, deficits evidenced by the child and intensive instruction in however, fluency deficits remain one of the most persistent the skill areas in which deficiencies are documented (34). Response to treatment varies by individuals, so it is impor- tant that careful monitoring take place throughout treat- Although most children with RDs show deficits in word ment to ensure that an intervention is effective for a particu- recognition skills, comprehension deficits are also common. In this section, we briefly summarize the These may occur alone or in the presence of impaired word educational treatment literature by academic area and then recognition skills (45). When impaired word recognition is summarize research related to treatment monitoring or the primary source of the comprehension deficit, decoding formative evaluation of interventions. However, interven- tions have also been developed to address comprehension Reading deficits directly. Two metaanalyses found substantial im- Considerable progress has been made in the development of provements for disabled readers who receive intensive in- preventive and early intervention approaches for beginning struction in reading comprehension (47,48). Several studies have demonstrated that explicit in- ies, metacognitive approaches (e. There were no improvements in composition skills Geary characterized research in the area of MDs as 'primi- in any of the treatment groups. Nevertheless, effective remediation techniques for MDs have been devel- oped. Slopes that do not differ from zero are an obvious Written Expression indicator of the need for a new treatment approach. How- Difficulties with composition and writing fluency are com- ever, estimates of typical response to treatment for students mon in children with LDs. Several researchers have shown with LDs are also available and can be used as a basis for that cognitive strategy instruction is effective in improving deciding whether a given treatment is producing sufficient the composition skills of children with written language progress (65). When formative evaluation strategies such as deficits (52–54). Generally, such interventions provide CBM are incorporated into treatment strategies, outcomes students with explicit instruction in thinking and problem- for students with disabilities improve markedly (66). PSYCHOPHARMACOLOGY Difficulties with handwriting fluency appear not only to Psychostimulants impair the speed with which children can take notes or copy but also to affect compositional fluency and quality (55). Early studies of psychostimulants in children with LDs sug- For example, Berninger et al. However, reviews concluded that lasting With more widespread use of computers in classrooms, educational gains resulting from psychotropic drugs have word processing tools are increasingly being used to address not been demonstrated (72,73). Stimulant drug effects have the writing problems of children with LDs (57). When writ- generally been dose related, with linear increases in perfor- ing fluency is a problem, word processing may be used as mance with higher doses (74–77). Drug-induced changes a text entry strategy on its own, or it can be combined with reflect increased output, accuracy, efficiency, and improved word prediction programs (58). There is also evidence of increased ef- has improved to the point that it may be a practical text fort and self-correcting behaviors (78).

Lactate released byMuller genolysis in mouse cerebral cortex: a possible coupling mecha- glial cells is metabolized byphotoreceptors from mammalian nism between neuronal activityand energymetabolism buy procyclidine 5mg mastercard. Characterization of the glycogenolysis function and survival in CNS white matter during glucose dep- elicited byvasoactive intestinal peptide procyclidine 5mg with mastercard, noradrenaline and aden- rivation? Selective distribution zation: theory cheap procyclidine 5mg visa, procedure discount 5 mg procyclidine free shipping, and normal values in the conscious of lactate dehydrogenase isoenzymes in neurons and astrocytes and anesthetized albino rat procyclidine 5mg overnight delivery. Comparison of lactate cytes: blockade by protein synthesis inhibition. J Neurosci 1992; transport in astroglial cells and monocarbosylate transporter 1 12:4923–4931. Vasoactive intestinal peptide, cortex of rats reared in a complex environment. Psychoneuroen- pituitary adenylate cyclase-activating peptide, and noradrenaline docrinology 1996;21:189–201. Ultrastructural evidence for in- tein (C/EBP)- and C/EBPd in mouse cortical astrocytes: in- creased contact between astrocytes and synapses in rats reared volvement in cAMP-regulated glycogen metabolism. Glial hypertrophy is and induction of mouse brain glycogen synthase. Brain Res Mol associated with synaptogenesis following motor-skill learning, Brain Res 1996;38:191–199. Spatial learning and physical in mouse cortical astrocytes. Glutamate neural substrates for increased cognition associated with exer- induces calcium waves in cultured astrocytes: long-range glial cise. Mechanisms and anatomical substrates of place learning. Neurobiol Learn Memory function of intercellular calcium signaling. Neuronal activitytriggers term potentiation on the spatial relationship between astrocyte calcium waves in hippocampal astrocyte networks. Neuron processes and potentiated synapses in the dentate gyrus neuropil 1992;8:429–440. Glial cell functions and activity-dependent plastic- 39–49. Direct signaling from astrocytes to neurons in brain: angiogenesis in the adult rat cerebellum after vigorous cultures of mammalian brain cells. Science 1994;263: physical activity and motor skill learning. Metabolic mapping glutamate-mediated activation of hippocampal neurons byglial of chick brain after imprinting using [14C]2-deoxyglucose tech- calcium waves. Local cerebral alterations cyte-neuron signalling [see comments]. Nature 1994;369: in [14C-2]deoxyglucose uptake following memory formation. Time-dependent sequential increases in synaptic plasticity. Long-term potentiation and spatial tures during memoryconsolidation of an operant training in training are both associated with the generation of new excita- mice. Curr Biol 1998;8: duces reversible changes of representational maps of vibrissae R151–R153. Factors govern- lism induced byrepeated spatial discrimination training in mice: ing activity-dependent structural plasticity of the hypothalamo- visualization of the memoryconsolidation process? Differential rearing effects on rat 1998;95:13290–13295. Increased volume area in visual cortex of young rats. Rapid laminar-depen- chronic antipsychotic drug exposure. Biol Psychiatry 1999;46: dent changes in GFAP immunoreactive astrocytes in the visual 161–172. MALENKA The most fascinating and important property of the mam- SHORT-TERM SYNAPTIC PLASTICITY malian brain is its remarkable plasticity, which can be thought of as the ability of experience to modify neural Virtually every synapse that has been examined in organisms circuitry and thereby to modify future thought, behavior, ranging from simple invertebrates to mammals exhibits nu- and feeling. Thinking simplistically, neural activity can merous different forms of short-term synaptic plasticity that modify the behavior of neural circuits by one of three mech- last on the order of milliseconds to a few minutes (for de- anisms: (a) by modifying the strength or efficacy of synaptic tailed reviews, see 1 and 2). In general, these result from a transmission at preexisting synapses, (b) by eliciting the short-lasting modulation of transmitter release that can growth of new synaptic connections or the pruning away occur by one of two general types of mechanisms. One of existing ones, or (c) by modulating the excitability prop- involves a change in the amplitude of the transient rise in erties of individual neurons. Synaptic plasticity refers to the intracellular calcium concentration that occurs when an ac- first of these mechanisms, and for almost 100 years, activity- tion potential invades a presynaptic terminal. This occurs dependent changes in the efficacy of synaptic communica- because of some modification in the calcium influx before tion have been proposed to play an important role in the transmitter release or because the basal level of calcium in remarkable capacity of the brain to translate transient expe- the presynaptic terminal has been elevated because of prior riences into seemingly infinite numbers of memories that activity at the terminal.

The abnorm al glom eruli exhibit glom erulosclerosis (FSGS) generic procyclidine 5 mg line. Patients with FSGS exhibit m assive segm ental obliteration of capillaries by increased extracellular proteinuria (usually nonselective) order 5 mg procyclidine amex, hypertension buy discount procyclidine 5 mg line, hem aturia purchase procyclidine 5mg overnight delivery, and m atrix–basem ent m em brane m aterial cheap procyclidine 5 mg with amex, collapsed capillary walls, renal functional im pairm ent. Patients with nephrotic syndrom e or large insudative lesions. These lesions are called hyalinosis often are not responsive to corticosteroid therapy. Progression to (arrow) and are com posed of im m unoglobulin M and com ple- chronic renal failure occurs over m any years, although in som e m ent C3 (B, IgM im m unofluorescence). The other glom eruli patients renal failure m ay occur in only a few years. A, This usually are enlarged but may be of normal size. In some patients, glom erulopathy is defined prim arily by its appearance on light m esangial hypercellularity m ay be a feature. O nly a portion of the glom erular population, initially atrophy with interstitial fibrosis invariably is present. The elec- tron microscopic findings in the involved glomeruli mirror the light microscopic features, with capillary obliteration by dense hyaline “deposits” (arrow) and lipids. The other glomeruli exhibit primarily foot process effacement, occasionally in a patchy distribution. CLASSIFICATION OF FOCAL SEGM ENTAL CLASSIFICATION OF M EM BRANOUS GLOM ERULOSCLEROSIS W ITH HYALINOSIS GLOM ERULONEPHRITIS Primary (Idiopathic) Primary (Idiopathic) Classic Secondary Tip lesion Neoplasia (carcinoma, lymphoma) Collapsing Autoimmune disease (systemic lupus erythematosus thyroiditis) Secondary Infectious diseases (hepatitis B, hepatitis C, schistosomiasis) Human immunodeficiency virus–associated Drugs (gold, mercury, nonsteroidal anti-inflammatory drugs, probenecid, captopril) Heroin abuse Other causes (kidney transplantation, sickle cell disease, sarcoidosis) Vesicoureteric reflux nephropathy Oligonephronia (congenital absence or hypoplasia of one kidney) Obesity FIGURE 2-11 Analgesic nephropathy Hypertensive nephrosclerosis M ost adult patients (75% ) have prim ary or idiopathic disease. M ost children have som e underlying disease, especially viral infection. It Sickle cell disease is not uncom m on for adults over the age of 60 years to have an Transplantation rejection (chronic) underlying carcinom a (especially lung, colon, stom ach, or breast). Vasculitis (scarring) Immunoglobulin A nephropathy (scarring) FIGURE 2-10 N ote that a variety of disease processes can lead to the lesion of focal segm ental glom erulosclerosis. Som e of these are the result of infections, whereas others are due to loss of nephron population. Focal sclerosis m ay also com plicate other prim ary glom erular dis- eases (eg, Im m unoglobulin A nephropathy). Som e investigators have described a m ore favorable Two im portant variants of FSGS exist. In contrast to the histologic response to steroids and a m ore benign clinical course. In this form of FSGS, characterized by segm ental sclerosis at an early stage of evolution, m ost visceral epithelial cells are enlarged and coarsely vacuolated at the tubular pole (tip) of all affected glom eruli (arrow). These Capillaries contain m onocytes with abundant cytoplasm ic lipids features indicate a severe lesion, with a corresponding rapidly pro- (foam cells), and the overlying visceral epithelial cells are enlarged gressing clinical course of the disease. Integral and concomitant acute and adherent to cells of the m ost proxim al portion of the proxim al abnormalities of tubular epithelia and interstitial edema occur. This graph com pares the renal functional survival rate of patients with FSGS FIGURE 2-14 to that seen in patients with m inim al change disease (in adults and The outcom e of focal segm ental glom erulosclerosis according to the children). N ote the poor prognosis, with about a 50% rate of renal degree of proteinuria at presentation is shown. Spontaneous or therapeutically induced rem issions have a sim ilar beneficial effect on long-term outcom e. In the rem ain- der, m em branous glom erulonephritis is associated with well- defined diseases that often have an im m unologic basis (eg, system ic lupus erythem atosus and hepatitis B or C virus infection); som e solid m alignancies (especially carcinom as); or drug therapy, such as gold, penicillam ine, captopril, and som e nonsteroidal anti-inflam - m atory reagents. The changes by light and electron m icroscopy m irror one anoth- er quite well and represent m orphologic progression that is likely dependent on duration of the disease. A, At all stages im m uno- fluorescence discloses the presence of uniform granular capillary wall deposits of immunoglobulin G and complement C3. B, In the early stage the deposits are small and without other capillary wall changes; hence, on light microscopy, glomeruli often are normal in appearance. C, O n electron m icroscopy, sm all electron-dense E deposits (arrows) are observed in the subepithelial aspects of capillary walls. D, In the intermediate stage the deposits are partially encircled FIGURE 2-15 (see Color Plate) by basem ent m em brane m aterial. E, W hen viewed with periodic Light, im m unofluorescent, and electron m icroscopy in m em bra- acid-m ethenam ine stained sections, this abnorm ality appears as nous glom erulonephritis. M em branous glom erulonephritis is an spikes of basem ent m em brane perpendicular to the basem ent im m une com plex–m ediated glom erulonephritis, with the im m une m em brane, with adjacent nonstaining deposits. Sim ilar features deposits localized to subepithelial aspects of alm ost all glom erular are evident on electron m icroscopy, with dense deposits and inter- capillary walls. M em branous glom erulonephritis is the m ost com - vening basem ent m em brane (D). Late in the disease the deposits m on cause of nephrotic syndrom e in adults in developed countries. This schem atic illustrates the sequence of im m une deposits in red; base- m ent m em brane (BM ) alterations in blue; and visceral epithelial cell changes in yellow.

Relationship between plasma concentrations of lamotrigine and its early therapeutic effect of lamotrigine augmentation therapy in treatment-resistant depressive disorder generic procyclidine 5 mg online. Journal of Clinical Psychiatry 1998; 59 (Suppl 2):41-52) buy 5mg procyclidine otc. Valproate for acute mood episodes in bipolar disorder cheap 5mg procyclidine with amex. Aripiprazole adjusnct treatment in bipolar I or II disorder buy procyclidine 5 mg amex, depressed state: 2-year clinical study procyclidine 5 mg low cost. Mood stabilisers and antipsychotics for acute mania: systematic review and meta-analysis of combination/augmentation therapy versus monotherapy. Effectiveness and medical costs of divalproex versus lithium in the treatment of bipolar disorder: results of a naturalistic clinical trial. The effects of carbamazepine on prefrontal activation in manic you with bipolar disorder. Psychiatry Research 2014; 223: 268- 270 Seo M, Scarr E, Lai C, Dean B. Potential molecular and cellular mechanism of psychotropic drugs. Quetiapine for acute bipolar depression: systematic review and meta-analysis. Olanzapine versus lithium in the maintenance treatment of bipolar disorder: a 12 month randomized double-blind controlled clinical trial. Last century the emphasis in child care was on the avoidance of contagious diseases. There has been a subsequent explosion in our understanding of the emotional development and needs of children. Introduction Child psychiatry is a specialized area. Textbooks are devoted to the field, and even to particular aspects of the field. In an earlier chapter, mental health (of adults) was identified as a utopian/optimal state. By contrast, the stated aim of the DOP is to provide a guide to the treatment of mental disorder, rather than a guide to the achievement/maintenance of mental health. With children, however, the distinction between mental health and a mental disorder is less clear, and child psychiatrists deal with deviations from mental health in addition to mental disorder. Child psychiatric disorders must be viewed in the context of normal development (a process of change and increasing complexity). Many disorders are identified as failure to reach developmental milestones. Students need to be aware of the stages of normal development from an appropriate source (only a brief introduction is presented in the following section). Child psychiatric disorders must also be viewed in the context of the family, social and cultural setting. Environmental factors are important in adult psychiatry; but as children are dependent, lack certain capacities and perspectives and are vulnerable, these factors assume even greater importance. In child psychiatry (in contrast to adult psychiatry) it is rare for the “patient” to initiate contact with the psychiatric service; first contact is usually made by a parent or an educational or welfare authority. It is usually important to speak at length with the referrer and the family. Not only do family members provide much of the history, the family is the medium in which the child exists and will continue to grow (and hopefully, recover). The manner in which the family operates and the place/role of the child within the family must be understood. The manner in which the family functions may be part of the problem, and aspects of family functioning may need to be modified. Thus, the family may be a significant therapeutic modality, and must be involved and kept “on side” (wherever possible). Normal development We begin life with little awareness. We grow into fully functioning adults: walking, standing on wave-catapulted surfboards, learning and reading the newspaper, negotiating, forming relationships and providing love and guidance for our own babies. The rate of change (physical growth, skill acquisition, intellectual and emotional development) is greatest during childhood and adolescence. The basics of physical and social development of the child include: 0-6 months: rolls over, smiles and laughs, passes objects hand to hand, places objects in the mouth, vocalises syllables. Middle childhood: schooling, peer group activities, developing autonomy.

Finally generic procyclidine 5mg amex, therapist-led services generic procyclidine 5mg without a prescription, operating without referral from a paediatrician purchase procyclidine 5 mg online, were reported discount procyclidine 5mg online. Often 5mg procyclidine amex, multiple factors were driving, or informing, the development of alternative service models. Certainly, resource constraints played a part, but the responses to these constraints were informed by new thinking about therapy interventions, particularly family-centred and goals-focused approaches. Professionals taking part in the study reported that this was not uncommon, and this was certainly borne out in the experiences of parents recruited to the study. Overall approaches to therapy and schools of thought In Chapter 4, we presented a model by which therapy interventions can be understood. It was argued that specific techniques, procedures, activities, practices and equipment need to be understood in the broader context. This issue may be freely reproduced for the purposes of private research and study and extracts (or indeed, the full report) may be included in professional journals 91 provided that suitable acknowledgement is made and the reproduction is not associated with any form of advertising. Applications for commercial reproduction should be addressed to: NIHR Journals Library, National Institute for Health Research, Evaluation, Trials and Studies Coordinating Centre, Alpha House, University of Southampton Science Park, Southampton SO16 7NS, UK. DISCUSSION to the management of a case, and, second, whether the therapist adhered to, or was influenced by, particular schools of thought. Chapter 4 also described how, a few decades ago, certain schools of thought dominated the approaches taken by therapists. It was clear that some of these traditional schools of thought were no longer regarded, by some at least, as having any credibility. Other schools of thought – drawn from other disciplines or professions – were, however, reported to be influencing current therapy practice. These included cognitive–behavioural, problem-solving approaches; family-centred practice; and evidence-based practice. Importantly, the notion of early intervention continues to strongly guide the management of children with neurodisability. Here we described and illustrated the key constructs that define these interventions, namely professional autonomy, responsive practice, managing prognostic uncertainty, protocols and pathways, working out of a tool box and mode of delivery. Throughout much of this account, the notion of therapies as, typically, highly individualised interventions has emerged strongly. In Chapter 4 we referred readers to Appendix 6, which sets out the procedures, techniques and activities that interviewees reported using, or having come across, in NHS settings. This serves to portray the great diversity of practice, but we would stress that this list is, to no extent, comprehensive. Importantly, as Chapter 4 demonstrated, knowing the names of techniques or procedures is not the same as knowing how a therapist is using or implementing them. In terms of new and emerging techniques, procedures or equipment that appear promising, this was not generally a topic interviewees regarded as important or relevant, as they believed that the priority should be research into existing practices and ways of organising and delivering therapy interventions. However, there was strong support for research that evaluated new and emerging approaches to service organisation and delivery (e. We return to the topic of research priorities later in this chapter. These are not newly identified issues; they have been reported by previous studies and, indeed, have stimulated policy responses. Parental dissatisfaction with the amount of therapy partly reflects the reality of significantly constrained resources for therapies within the NHS, but may also indicate a mismatch in understanding of appropriate levels of intensity in terms of contact with therapists. Included in the stories they relayed were themes of guilt, conflict, exhaustion and a sense of working in isolation, all of which have been reported in 48 52, previous studies. Here parents focused on sharing experiences of negative reactions, which were attributed to pain, frustration and a desire to be doing something else. Sometimes these reactions were difficult to manage and this was a common reason why parents desisted from carrying out interventions and using equipment. Objectives 3 and 4: factors influencing clinical decision-making Objectives 3 and 4 were: 3. Chapter 4 reported findings relevant to study objectives 3 and 4. References within these objectives to the potential influence of impairment-related characteristics on clinical decision-making could be perceived as sitting at odds with notions of goals-focused approaches to assessment and clinical decision-making. In Chapter 4 we reported that, for the majority of therapy interventions, no protocols or manuals exist. First, children with neurodisability are highly diverse in both diagnosis and the way each diagnosis presents in terms of motor functioning and impairment. Second, the evidence base on therapy interventions is minimal. Taking these two factors into account, it is easy to see why manualised approaches and protocols are not common features of practice. Furthermore, as we discuss in the following section, very little is understood about the active ingredients of interventions. There are, therefore, significant barriers to the development of protocols or manualised interventions for this population. One exception is interventions for the management of a specific presenting need and within a specific population.

Patients An invitation to take part in a telephone interview was sent to all patients who had completed a baseline questionnaire generic procyclidine 5mg online. The invitation was included in the envelope containing their follow-up questionnaire buy procyclidine 5 mg otc. Patients wishing to take part in an interview provided their name and contact details on a form and returned this to the research team cheap procyclidine 5mg otc, together with a consent form generic procyclidine 5mg, in a prepaid envelope procyclidine 5 mg. A researcher then contacted the patient to explain the purpose of the interview in more detail and arrange a suitable time for the interview. Verbal consent was further confirmed at the start of the audio-recording of the interviews. All consenting patients were interviewed and blinded to allocation. Procedure Nurses and other practice staff were interviewed by a member of the research team who had not been involved in supporting them during the data collection phase. Interviews were conducted by telephone and were audio-recorded. The audio-recording was unsuccessful for one interview, and for this interview, written notes were used to summarise the key points made. The experience of taking part in the training, and whether or not it adequately explained the purpose of the PCAM tool and prepared staff for its implementation, was explored, along with a discussion of perceptions of using the PCAM tool. Reasons for taking part in the study, views on whether or not the PCAM was an appropriate tool for nurse-led annual reviews and how the tool was used in a typical consultation were considered. Support within the practice and any impact on patient interaction and assessment of patient needs, particularly mental well-being, were discussed, as well as perceptions and use of the resource pack. This issue may be freely reproduced for the purposes of private research and study and extracts (or indeed, the full report) may be included in professional journals 53 provided that suitable acknowledgement is made and the reproduction is not associated with any form of advertising. Applications for commercial reproduction should be addressed to: NIHR Journals Library, National Institute for Health Research, Evaluation, Trials and Studies Coordinating Centre, Alpha House, University of Southampton Science Park, Southampton SO16 7NS, UK. STUDY D: NURSE AND PATIENT PERCEPTIONS OF USING THE PATIENT CENTRED ASSESSMENT METHOD The integration of the resource pack and other PCAM-related issues with normal clinical practices were also explored. Future use of the PCAM and factors that would be needed for its widespread use were considered. Throughout the discussion, any barriers and facilitators encountered were probed. Interviews with patients considered issues that were discussed in their consultation, and whether or not they were aware that the nurse was using the PCAM tool. Patients were asked about their awareness of nurse attention to wider aspects of their overall well-being, and what their views were on this wider discussion. Patients were also asked if they had received any health promotion and lifestyle advice or had been referred or signposted to other services. Their views on any referrals or advice offered were sought. Findings Study D aimed to gather nurse and patient views on the use of the PCAM tool in their LTC reviews. Nurse participants were asked about their experience of learning how to use the PCAM tool and integrating it into their consultations. Patient participants were asked about their experience of their last review. Patient perception of the Patient Centred Assessment Method Not all patient participants in this sample noticed any overtly discernible difference in their annual review post PCAM implementation. However, some patients did report being asked more questions or finding out more about their health condition. Given that the PCAM tool is not a survey, or something administered to patients, it was not necessarily expected that the patients would notice the presence of the PCAM itself; however, patients did describe talking with their nurse about their lives and their broader concerns during reviews, and described welcoming these conversations with their nurse. Participants also described feeling listened to and feeling that the nurse was trying to address the concerns raised by the patient: And I do remember that the time before I was quite upset because it was. So she was trying hard to try and help with the problems that she thought I was having. Patient interview, participant 422 Patient participants described the consultations as being conversational in style. This confirms that the PCAM tool was implemented as intended, as a guide for conversations with patients rather than as a tick-box tool: Yeah. Patient interview, participant 449 Because the PCAM tool is delivered conversationally, participants were asked how they felt about being asked questions about the broader context of their lives within the review. Patient interview, participant 422 Participants talked about trusting that their nurse would have a reason behind the questions they asked, and that it helped to promote a good relationship with the nurse when there was an opportunity to talk more broadly about their lives.