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Purpose: There is a dearth of information on cultural perceptions of children's language development for ethnic minorities in New Zealand to guide service provision. The current study explored differences across ethnicities in mothers' report of language concern and child language scores within a complex cultural, social, educational, and political context., Method: Data from the antenatal and 54-month waves of Growing Up in New Zealand were utilized. At the 54-month wave interviews, 5,053 mothers were asked if language concerns had been raised and to rate their child's main language proficiency along with other measures., Results: Logistic regression models (including influencing variables) indicated Chinese, Indian, and other Asian mothers were less likely to report language concern, whereas Māori, Pacific, other Asian, and Middle Eastern, Latin American, and African children were more likely to score low on the language measure. Higher maternal education was associated with higher child main language scores, but not with language concerns. Child multilingualism was not associated with low language scores, and these mothers were less likely to raise concern., Conclusions: This study demonstrated differences by ethnicity in mothers' language concern and child main language scores, which are likely to affect access to speech-language pathology services, as these typically rely on parent concern being expressed. Cultural bias in the language measure may also be present. Further research is needed to ask ethnic communities their views on culturally appropriate ways to identify children with communication needs and to develop culturally safe services.

Inertial measurement units (IMUs) provide benefits over the traditional optoelectronic motion capture (OMC) systems in measuring kinematics for the low back pain population. The reliability and validity of IMUs to quantify three-dimensional motion for multiple hip/spine segments have not been systematically evaluated. The purpose of this study was to determine the repeated-measures reliability and concurrent validity of an IMU system for measuring the three-dimensional spine/hip kinematics in six common movement assessments. Seventeen participants (32.3 (14.7) years; 11 female) performed two trials each of six range-of-motion assessments while fitted with four IMUs (T1/T2, T12/L1, L5/S1, and femur). The IMUs showed good-excellent reliability for most of the movements in the primary plane and poor-moderate reliability in the non-primary planes. The IMU and OMC systems showed generally good-excellent agreement in the primary plane and RMSE values between 3.03° and 15.75°. The removal of outliers based on the Bland-Altman analysis resulted in RMSE values between 2.44° and 10.30°. The system agreement in the non-primary planes was generally poor-moderate, and the RMSE values ranged from 2.19° to 45.88°. Anomalies in the proprietary sensor fusion algorithm or calibration may have contributed to the large RMSE values, highlighting the importance of assessing data for physiological relevance. The results suggest that these IMUs may be best suited for population-based studies measuring movement in the primary plane and point toward the need for the development of more robust approaches for broader implementation.

Background: Tackling poor mental health in university students has been identified as a priority in higher education. However, there are few evidence-based prevention initiatives designed for students. Repetitive Negative Thought (RNT, e.g. worry, rumination) is elevated in university students and is a well-established vulnerability factor for anxiety and depression. Furthermore, there are now evidence-based cognitive-behavioural interventions to tackle RNT. A mobile self-help cognitive-behavioural app targeting RNT, adapted for students may therefore be an effective, scalable, and acceptable way to improve prevention in students., Methods: An online single blind, two-arm parallel-group Randomised Controlled Trial (RCT) to examine the incidence of major depression and symptoms of anxiety and depression across 12 months in university students aged over 16 who screen into the study with self-reported high levels of worry and/or rumination and no current diagnosis of major depression. Eligible participants will be randomised to the active intervention arm (usual practice plus using a self-guided mobile app targeting RNT) or to the control arm (usual practice). In total, 648 participants aged over 16, with no current major depression, bipolar disorder or psychosis will be recruited from UK universities. Assessments will take place at baseline (pre-randomisation), 3 months and 12 months post- randomisation. Primary endpoint and outcome is incidence of major depression as determined by self-reported diagnostic criteria at 12-month follow-up. Depressive symptoms, anxiety, well-being, health-related quality of life, functioning and academic outcomes are secondary outcomes. Compliance, adverse events, and potentially mediating variables will be carefully monitored., Discussion: The trial aims to provide a better understanding of the causal role of tackling RNT (worry, rumination) using a self-help mobile app with respect to preventing depression in university students. This knowledge will be used to develop and disseminate innovative evidence-based, feasible, and effective mobile-health public health strategies for preventing common mental health problems., Trial Registration: https://www.isrctn.com/ISRCTN86795807 Date of registration: 27 October 2022., (© 2024. The Author(s).)

Background: Irritable bowel syndrome, characterised by abdominal pain and a change in stool form or frequency, is most often managed in primary care. When first-line therapies are ineffective, National Institute for Health and Care Excellence guidelines suggest considering low-dose tricyclic antidepressants as second-line treatment, but their effectiveness in primary care is unknown and they are infrequently prescribed by general practitioners., Objective: To evaluate the clinical and cost-effectiveness of low-dose titrated amitriptyline as a second-line treatment for irritable bowel syndrome in primary care., Design: A pragmatic, randomised, multicentre, two-arm, double-blind, placebo-controlled trial. A nested, qualitative study explored participant and general practitioner experiences of treatments and trial participation, and implications for wider use of amitriptyline for irritable bowel syndrome in primary care. Participants, clinicians, investigators and analysts were masked to allocation., Setting: Fifty-five general practices in three regions in England (Wessex, West of England, West Yorkshire)., Participants: Patients aged ≥ 18 years meeting Rome IV criteria for irritable bowel syndrome with ongoing symptoms after trying first-line treatments and no contraindications to TCAs., Intervention: Amitriptyline 10 mg once-daily, self-titrated by participants to a maximum of 30 mg once-daily or matched placebo for 6 months. Participants randomised 1 : 1 with most having the option to continue blinded treatment for a further 6 months., Main Outcome Measures: The primary participant-reported outcome was the effect of amitriptyline on global irritable bowel syndrome symptoms at 6 months, measured using the irritable bowel syndrome Severity Scoring System, with a 35-point between-group difference defined as the minimum clinically important difference. The key secondary outcome was the proportion of participants reporting subjective global assessment of relief at 6 months, defined as somewhat, considerable, or complete relief of symptoms. Other secondary outcomes included: effect on global symptoms, via the irritable bowel syndrome Severity Scoring System, and subjective global assessment of relief of irritable bowel syndrome symptoms at 3 and 12 months; effect on somatic symptom-reporting at 6 months; anxiety an-d depression scores; ability to work and participate in other activities at 3, 6 and 12 months; acceptability, tolerability and adherence to trial medication., Results: Four hundred and sixty-three participants were randomised to amitriptyline (232) or placebo (231). An intention-to-treat analysis of the primary outcome showed a significant difference in favour of amitriptyline for irritable bowel syndrome Severity Scoring System score between arms at 6 months [-27.0, 95% confidence interval (CI) -46.9 to -7.10; p = 0.008]. For the key secondary outcome of subjective global assessment of relief of irritable bowel syndrome symptoms, amitriptyline was superior to placebo at 6 months (odds ratio 1.78, 95% CI 1.19 to 2.66; p = 0.005). Amitriptyline was superior to placebo across a range of other irritable bowel syndrome symptom measures but had no impact on somatoform symptom-reporting, anxiety, depression, or work and social adjustment scores. Adverse event trial withdrawals were more common with amitriptyline (12.9% vs. 8.7% for placebo) but most adverse events were mild. The qualitative study thematically analysed 77 semistructured interviews with 42 participants and 16 GPs. Most participants found the self-titration process acceptable and empowering., Conclusions: General practitioners should offer low-dose amitriptyline to patients with irritable bowel syndrome whose symptoms do not improve with first-line therapies. Guidance and resources should support GP-patient communication to distinguish amitriptyline for irritable bowel syndrome from use as an antidepressant and to support patients managing their own dose titration., Study Registration: This trial is registered as ISRCTN48075063., Funding: This award was funded by the National Institute for Health and Care Research (NIHR) Health Technology Assessment programme (NIHR award ref: 16/162/01) and is published in full in Health Technology Assessment Vol. 28, No. 66. See the NIHR Funding and Awards website for further award information.

Introduction: Breast cancer is the most common malignancy among women in the United Kingdom. Surgical management commonly comprises mastectomy and reconstruction, of which implant-based breast reconstruction (IBBR) is the most prevalent. Acellular dermal matrices (ADM) are widely used in pre-pectoral IBBR; however, there is limited high-quality evidence supporting their efficacy. This study aimed to establish an equipoise via an expert consensus survey., Methods: An online survey was designed with a steering group of experts. Questions covered participant information, opinions regarding surgical outcomes with ADM use in pre-pectoral IBBR and opinions regarding the available scientific evidence on the topic. The survey was advertised via national and international professional organisations. Quantitative and qualitative analyses were performed., Results: Thirty-two participants from the UK, Italy and Australia completed the survey. Key findings of this study included disagreement among participants regarding the surgical outcomes associated with ADM use. Participants who believed that ADM reduced the risk of short-term complications and implant failure/explantation comprised a minority (21.9%). Participants who felt that ADM use improved cosmetic outcomes and reduced long-term complications were a relative majority at 43.8% and 40.6%, respectively. Furthermore, 56.3% of the participants felt that there was scarce scientific evidence on the topic., Conclusions: This study provides insights from international surgeons, establishing a lack of consensus on surgical outcomes, efficacy and evidence-base supporting the use of ADMs in pre-pectoral IBBR. Given this clinical equipoise, alongside the growing burden of breast cancer associated morbidity and need for reconstruction, the implications of this study are that large-scale, prospective, randomised-controlled data are needed to establish whether ADM use in pre-pectoral breast reconstruction improves the outcomes., (Copyright © 2024 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.)

Diagnostic error is a significant category within preventable patient harm, and it takes many years of effort to develop proficiency in diagnostic reasoning. One of the key challenges medical schools must address is preparing students for the complexity, uncertainty and clinical responsibility in going from student to doctor. Recognising the importance of both cognitive and systems-related factors in diagnostic accuracy, we designed the QUID Prompt (Questions to Use for Improving Diagnosis) for students to refer to at the bedside. This set of questions prompts careful consideration, analysis, and signposting of decision-making processes, to assist students in transitioning from medical school to the real-world of work and achieving diagnostic excellence in clinical settings.

Objective. To investigate the potential of 3D-printable thermoplastics as tissue-equivalent materials to be used in multimodal radiotherapy end-to-end quality assurance (QA) devices. Approach. Six thermoplastics were investigated: Polylactic Acid (PLA), Acrylonitrile Butadiene Styrene (ABS), Polyethylene Terephthalate Glycol (PETG), Polymethyl Methacrylate (PMMA), High Impact Polystyrene (HIPS) and StoneFil. Measurements of mass density (ρ), Relative Electron Density (RED), in a nominal 6 MV photon beam, and Relative Stopping Power (RSP), in a 210 MeV proton pencil-beam, were performed. Average Hounsfield Units (HU) were derived from CTs acquired with two independent scanners. The calibration curves of both scanners were used to predict averageρ,RED and RSP values and compared against the experimental data. Finally, measured data ofρ,RED and RSP was compared against theoretical values estimated for the thermoplastic materials and biological tissues. Main results. Overall, goodρand RSP CT predictions were made; only PMMA and PETG showed differences >5%. The differences between experimental and CT predicted RED values were also <5% for PLA, ABS, PETG and PMMA; for HIPS and StoneFil higher differences were found (6.94% and 9.42/15.34%, respectively). Small HU variations were obtained in the CTs for all materials indicating good uniform density distribution in the samples production. ABS, PLA, PETG and PMMA showed potential equivalency for a variety of soft tissues (adipose tissue, skeletal muscle, brain and lung tissues, differences within 0.19%-8.35% for all properties). StoneFil was the closest substitute to bone, but differences were >10%. Theoretical calculations of all properties agreed with experimental values within 5% difference for most thermoplastics. Significance. Several 3D-printed thermoplastics were promising tissue-equivalent materials to be used in devices for end-to-end multimodal radiotherapy QA and may not require corrections in treatment planning systems' dose calculations. Theoretical calculations showed promise in identifying thermoplastics matching target biological tissues before experiments are performed., (Creative Commons Attribution license.)

Background: Irritable bowel syndrome (IBS) can cause troublesome symptoms impacting patients' quality of life and incur considerable health service resource use. Guidelines suggest low-dose amitriptyline for IBS as second line treatment, but this is rarely prescribed in primary care., Aim: To explore patients' and general practitioners' (GPs) views and experiences of using low-dose amitriptyline for IBS., Design and Setting: Qualitative interview study with patients and GPs in England, nested within the ATLANTIS trial of low-dose amitriptyline versus placebo (ISRCTN48075063)., Methods: Semi-structured telephone interviews with 42 patients at 6-months post-randomisation, 19 patients again at 12-months post-randomisation, and 16 GPs. Reflexive thematic analysis was used to analyse patient and GP data separately, then together, to identify unique and cross-cutting themes., Results: We found concerns about amitriptyline being an antidepressant, medicalising IBS, and side-effects. Perceived benefits included the low and flexible dose, ease of treatment, familiarity of amitriptyline and its potential to offer benefits beyond IBS symptom relief. These concerns and perceived benefits were expressed in the context of desire for a novel approach to IBS: GPs were keen to offer more options for IBS and patients sought a cure for their symptoms., Conclusions: Patients and GPs felt the potential benefits from trying low-dose amitriptyline for IBS outweighed their concerns. When offering low-dose amitriptyline for IBS, GPs could address patient concerns about taking an antidepressant for IBS, highlighting the low and flexible dosage and other potential benefits of amitriptyline such as improved sleep., (Copyright © 2024, The Authors.)

Background: A high proportion of patients do not regain outdoor mobility after hip fracture. Rehabilitation explicitly targeting outdoor mobility is needed to enable these older adults to recover activities which they value most. The overarching aim of this study is to determine the feasibility of a randomised controlled trial which aims to assess the clinical- and cost-effectiveness of an intervention designed to enable recovery of outdoor mobility among older adults after hip fracture (the OUTDOOR intervention)., Methods: This is a protocol for a multi-centre pragmatic parallel group (allocation ratio 1:1) randomised controlled assessor-blinded feasibility trial. Adults aged 60 years or more, admitted to hospital from- and planned discharge to- home, with self-reported outdoor mobility in the three-months pre-fracture, surgically treated for hip fracture, and who are able to consent and participate, are eligible. Individuals who require two or more people to support mobility on discharge will be excluded. Screening and consent (or consent to contact) will take place in hospital. Baseline assessment and randomisation will follow discharge from hospital. Participants will then receive usual care (delivered by physiotherapy, occupational therapy, or therapy assistants), or usual care plus the OUTDOOR intervention. The OUTDOOR intervention includes a goal-orientated outdoor mobility programme (supported by up to six in-person visits), therapist-led motivational dialogue (supported by up to four telephone calls), supported by a past-patient led video where recovery experiences are shared, and support to transition to independent ongoing recovery. Therapists delivering the OUTDOOR intervention (distinct from those supporting usual care) will receive training in motivational interviewing and behaviour change techniques. Baseline demographics will be collected. Patient reported outcome measures including health related quality of life, activities of daily living, pain, community mobility, falls related self-efficacy, resource use, readmissions, and mortality will be collected at baseline, 6-weeks, 12-weeks, and 6-months (for those enrolled early in the trial) post-randomisation. Exercise adherence (6- and 12- weeks) and intervention acceptability (12-weeks) will be collected. A subset of 20 participants will also support accelerometery data collection for 10 days at each time point., Dissemination: The trial findings will be disseminated to patients and the public, health professionals and researchers through publications, presentations and social media channels., Trial Registration: The trial has been registered at ISRCTN16147125., Protocol Version: 3.0., Competing Interests: The authors have received grants from the National Institutes of Health Research (NIHR) and The Royal Osteoporosis Society related to this work. This funding provides salary support for DB, and partial salary support for SC, CH, SL, CS, EG and KS. KS receives funding from UKRI for hip fracture health services research. KS is Chair of the Scientific and Publications Committee at the Falls and Fragility Fracture National Audit programme and the Chair-elect of the Scientific Committee of the Fragility Fracture Network. CS, TS, SC receive funding from the National Institutes of Health Research for research not related to the current study. SC is partially supported by the National Institute for Health Research Applied Research Collaboration South West Peninsula. DS, SG, SP, FM declare no additional conflicts of interest. This does not alter our adherence to PLOS ONE policies on sharing data and materials., (Copyright: © 2024 Sheehan et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.)

Objective: Currently, CT pulmonary angiogram (CTPA) for evaluating acute pulmonary embolism (PE) in emergency departments (EDs) is overused and with low yields. The goal of this study is to assess the impact of an evidence-based clinical decision support (CDS) tool, aimed at optimizing appropriate use of CTPA for evaluating PE., Methods: The study was performed at EDs in a large health care system and included nine academic and community hospitals. The primary outcome was the percent difference in utilization (number of CTPAs performed per number of ED visits) and secondary outcome was yield (percentage of CTPAs positive for acute PE), comparing 12 months before (June 1, 2021, to May 31, 2022) versus 12 months after (June 1, 2022, to May 31, 2023) a systemwide implementation of the CDS. Univariate and multivariable analyses using logistic regression were performed to assess factors associated with diagnosis of acute PE. Statistical process control charts were used to assess monthly trends in utilization and yield., Results: Among 931,677 visits to EDs, 28,101 CTPAs were performed on 24,675 patients. In all, 14,825 CTPAs were performed among 455,038 visits (3.26%) pre-intervention and 13,276 among 476,639 visits (2.79%) postintervention, a 14.51% relative decrease in CTPA utilization (χ 2 , P < .001). CTPA yield remained unchanged (1,371 of 14,825 = 9.25% pre- versus 1,184 of 13,276 = 8.92% postintervention; χ 2 , P = .34). Patients with coronavirus disease of 2019 diagnosis before CTPA had higher probability of acute PE. Statistical process control charts demonstrated seasonal variation in utilization (Friedman test, P = .047)., Discussion: Implementing a CDS based on validated decision rules was associated with a significant reduction in CTPA utilization. The change was immediate and sustained for 12 months postintervention., (Copyright © 2024 American College of Radiology. Published by Elsevier Inc. All rights reserved.)

Background Individuals with opioid dependence often experience poor oral health, including dental decay, periodontal disease and mucosal infection, frequently exacerbated by factors such as smoking, alcohol consumption, inadequate oral hygiene and low utilisation of oral health services. This study aimed to assess oral health status and oral health-related quality of life (OHRQoL) among opioid-dependent individuals and explore their potential associations. Methods Participants enrolled in an opioid treatment program (OTP) at three Australian urban clinics were assessed using the validated Oral Health Assessment Tool (OHAT) and Oral Health Impact Profile (OHIP-14). Results The average age of the 75 participants was 44.7years, with 45% receiving opioid treatment for over 5years. Dental decay and inadequate oral hygiene were prevalent. Mean OHAT and OHIP-14 scores were 6.93 and 20.95 respectively, indicating moderate oral health severity and poor OHRQoL. Physical pain and psychological discomfort significantly impacted participants' quality of life, with the effects being particularly pronounced for those aged 30 and above. An exploratory analysis revealed a strong correlation between OHAT and OHIP-14 severity scores, with a one-point increase in OHAT associated with 1.85times higher odds of a lower OHRQoL (odds ratio=1.85, 95% confidence interval: 1.38-2.49, P = Conclusions These findings underscore the multifaceted impact of oral health on the well-being of OTP clients. Routine dental check-ups, education on oral hygiene practices and timely treatment for oral health problems are crucial recommendations based on this study. Such measures hold the potential to enhance the quality of life for individuals attending OTPs.

We realise an intrinsic optically pumped magnetic gradiometer based on non-linear magneto-optical rotation. We show that our sensor can reach a gradiometric sensitivity of 18 fT cm - 1 Hz - 1 and can reject common mode homogeneous magnetic field noise with up to 30 dB attenuation. We demonstrate that our magnetic field gradiometer is sufficiently sensitive and resilient to be employed in biomagnetic applications. In particular, we are able to record the auditory evoked response of the human brain, and to perform real-time magnetocardiography in the presence of external magnetic field disturbances. Our gradiometer provides complementary capabilities in human biomagnetic sensing to optically pumped magnetometers, and opens new avenues in the detection of human biomagnetism., (© 2024 IOP Publishing Ltd.)

Osteoarthritis (OA) is the most common degenerative joint disease, presented as wearing down of articular cartilage and resulting in pain and limited mobility for 1 in 10 adults in the UK [Osteoarthr. Cartil.28(6), 792 (2020)10.1016/j.joca.2020.03.004]. There is an unmet need for patient friendly paradigms for clinical assessment that do not use ionizing radiation (CT), exogenous contrast enhancing dyes (MRI), and biopsy. Hence, techniques that use non-destructive, near- and shortwave infrared light (NIR, SWIR) may be ideal for providing label-free, deep tissue interrogation. This study demonstrates multimodal "spectromics", low-level abstraction data fusion of non-destructive NIR Raman scattering spectroscopy and NIR-SWIR absorption spectroscopy, providing an enhanced, interpretable "fingerprint" for diagnosis of OA in human cartilage. This is proposed as method level innovation applicable to both arthro- or endoscopic (minimally invasive) or potential exoscopic (non-invasive) optical approaches. Samples were excised from femoral heads post hip arthroplasty from OA patients (n = 13) and age-matched control (osteoporosis) patients (n = 14). Under multivariate statistical analysis and supervised machine learning, tissue was classified to high precision: 100% segregation of tissue classes (using 10 principal components), and a classification accuracy of 95% (control) and 80% (OA), using the combined vibrational data. There was a marked performance improvement (5 to 6-fold for multivariate analysis) using the spectromics fingerprint compared to results obtained from solely Raman or NIR-SWIR data. Furthermore, clinically relevant tissue components were identified through discriminatory spectral features - spectromics biomarkers - allowing interpretable feedback from the enhanced fingerprint. In summary, spectromics provides comprehensive information for early OA detection and disease stratification, imperative for effective intervention in treating the degenerative onset disease for an aging demographic. This novel and elegant approach for data fusion is compatible with various NIR-SWIR optical devices that will allow deep non-destructive penetration., Competing Interests: The authors declare no conflicts of interest., (© 2024 The Author(s).)

Background: Breast cancer is the most common malignancy among women in the UK. Following mastectomy, reconstruction is now integral to the surgical management of breast cancer, of which implant-based reconstruction (IBBR) is the most common type. IBBR initially evolved from pre-pectoral to post-pectoral due to complications, but with developments in oncoplastic techniques and new implant technology, interest in pre-pectoral IBBR has increased. Many surgeons use acellular dermal matrices (ADM); however, there is little evidence in literature as to whether this improves surgical outcomes in terms of complications, failure and patient satisfaction. This review aims to assess the available evidence as to whether there is a difference in surgical outcomes for breast reconstructions using ADM versus non-use of ADM., Methods: A database search will be performed using Ovid MEDLINE, Embase, Cochrane Central Register of Controlled Trials, Cochrane Database of Systematic Reviews and Clinicaltrials.org. The search timeframe will be 10 years. Studies will be screened using inclusion and exclusion criteria and data extracted into a standardised spreadsheet. Risk of bias will be assessed. Screening, extraction and risk-of-bias assessments will be performed independently by two reviewers and discrepancies discussed and rectified. Data analysis and meta-analysis will be performed using Microsoft Excel and R software. Forest plots will be used for two-arm studies to calculate heterogeneity and p-value for overall effect., Discussion: With the renaissance of pre-pectoral IBBR, it is important that surgeons have adequate evidence available to assist operative decision-making. Assessing evidence in literature is important to help surgeons determine whether using ADM for IBBR is beneficial compared to non-use of ADM. This has potential impacts for patient complications, satisfaction and cost to healthcare trusts., Systematic Review Registration: PROSPERO 2023 CRD42023389072., (© 2024. Crown.)

Aim: To evaluate the impact of usual care plus a fundamental nursing care guideline compared to usual care only for patients in hospital with COVID-19 on patient experience, care quality, functional ability, treatment outcomes, nurses' moral distress, patient health-related quality of life and cost-effectiveness., Design: Parallel two-arm, cluster-level randomized controlled trial., Methods: Between 18th January and 20th December 2021, we recruited (i) adults aged 18 years and over with COVID-19, excluding those invasively ventilated, admitted for at least three days or nights in UK Hospital Trusts; (ii) nurses caring for them. We randomly assigned hospitals to use a fundamental nursing care guideline and usual care or usual care only. Our patient-reported co-primary outcomes were the Relational Aspects of Care Questionnaire and four scales from the Quality from the Patient Perspective Questionnaire. We undertook intention-to-treat analyses., Results: We randomized 15 clusters and recruited 581 patient and 418 nurse participants. Primary outcome data were available for 570-572 (98.1%-98.5%) patient participants in 14 clusters. We found no evidence of between-group differences on any patient, nurse or economic outcomes. We found between-group differences over time, in favour of the intervention, for three of our five co-primary outcomes, and a significant interaction on one primary patient outcome for ethnicity (white British vs. other) and allocated group in favour of the intervention for the 'other' ethnicity subgroup., Conclusion: We did not detect an overall difference in patient experience for a fundamental nursing care guideline compared to usual care. We have indications the guideline may have aided sustaining good practice over time and had a more positive impact on non-white British patients' experience of care., Implications for the Profession And/or Patient Care: We cannot recommend the wholescale implementation of our guideline into routine nursing practice. Further intervention development, feasibility, pilot and evaluation studies are required., Impact: Fundamental nursing care drives patient experience but is severely impacted in pandemics. Our guideline was not superior to usual care, albeit it may sustain good practice and have a positive impact on non-white British patients' experience of care., Reporting Method: CONSORT and CONSERVE., Patient or Public Contribution: Patients with experience of hospitalization with COVID-19 were involved in guideline development and writing, trial management and interpretation of findings., (© 2023 The Authors. Journal of Advanced Nursing published by John Wiley & Sons Ltd.)

Background: Peripheral nerve injuries are burdensome on healthcare systems, individuals and society as a whole. The current standard of treatment for neurotmesis is primary neurorrhaphy or nerve grafting. However, several patients do not recover their full function. There has been a suggestion that primary distal neurolysis at common entrapment sites maximises surgical outcomes; however, no guidelines exist on this practice. This scoping review aims to ascertain the existing evidence on prophylactic distal decompression of peripheral nerves following repair., Methods: A literature search was performed using Ovid Medline, PubMed, Embase and Cochrane Central Register of Controlled Trials and Cochrane Database of Systematic Reviews for studies published in the past 50 years. Studies were screened using a selection criteria and study quality was assessed using standardised tools. Furthermore, thematic content analysis was performed., Results: Six studies were eligible for inclusion after screening; all studies were retrospective and at most level 3 evidence. No studies were designed specifically to assess the efficacy of distal neurolysis following proximal repair, thus no comparative data with control cohorts are available. All studies that recommended distal decompression of proximally repaired nerves based their conclusions on cases observed by the authors in practice or from theories on nerve regeneration., Conclusions: This systematic review suggests that the evidence on the role of immediate distal neurolysis in primary neurorrhaphy is inadequate. Recommendations are limited by the lack of large-scale and generalisable data. Further research is needed with definitive objective outcomes and patient-related outcome measures., (Crown Copyright © 2024. Published by Elsevier Ltd. All rights reserved.)

Without new transcription, gene expression across the oocyte-to-embryo transition (OET) relies instead on regulation of mRNA poly(A) tails to control translation. However, how tail dynamics shape translation across the OET in mammals remains unclear. We perform long-read RNA sequencing to uncover poly(A) tail lengths across the mouse OET and, incorporating published ribosome profiling data, provide an integrated, transcriptome-wide analysis of poly(A) tails and translation across the entire transition. We uncover an extended wave of global deadenylation during fertilization in which short-tailed, oocyte-deposited mRNAs are translationally activated without polyadenylation through resistance to deadenylation. Subsequently, in the embryo, mRNAs are readenylated and translated in a surge of global polyadenylation. We further identify regulation of poly(A) tail length at the isoform level and stage-specific enrichment of mRNA sequence motifs among regulated transcripts. These data provide insight into the stage-specific mechanisms of poly(A) tail regulation that orchestrate gene expression from oocyte to embryo in mammals., Competing Interests: Declaration of interests The authors declare no competing interests., (Copyright © 2024 The Authors. Published by Elsevier Inc. All rights reserved.)

Human embryo implantation is remarkably inefficient, and implantation failure remains among the greatest obstacles in treating infertility. Gene expression data from human embryos have accumulated rapidly in recent years; however, identification of the subset of genes that determine successful implantation remains a challenge. We leverage clinical morphologic grading-known for decades to correlate with implantation potential-and transcriptome analyses of matched embryonic and abembryonic samples to identify factors and pathways enriched and depleted in human blastocysts of good and poor morphology. Unexpectedly, we discovered that the greatest difference was in the state of extraembryonic primitive endoderm (PrE) development, with relative deficiencies in poor morphology blastocysts. Our results suggest that implantation success is most strongly influenced by the embryonic compartment and that deficient PrE development is common among embryos with decreased implantation potential. Our study provides a valuable resource for those investigating the markers and mechanisms of human embryo implantation., Competing Interests: Declaration of interests The authors declare no competing interests., (Published by Elsevier Inc.)

A fit man in his 60s presented with an infected Achilles tendon (AT) following two failed repairs for a traumatic rupture. Initial debridement of necrotic tissue resulted in a large soft tissue defect requiring robust coverage. Following aggressive wound management, an anterolateral thigh flap was elevated with tensor fasciae latae (TFL) which was triple-rolled to provide soft tissue coverage and tendon reconstruction.The flap remained healthy and was monitored with a flow coupler device. Initially, the foot was placed in plantarflexion before gradually increasing the angle to neutral and a thermoplastic splint was used to offload pressure on the flap. Following 1 month of non-weight-bearing, gentle mobilisation began. Three months postoperatively, the patient could walk, had resumed indoor cycling and demonstrated a comparable heel raise with the contralateral side. MRI showed a taut TFL attached to the distal AT and ultrasound showed a smoothly gliding TFL., Competing Interests: Competing interests: None declared., (© BMJ Publishing Group Limited 2024. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: Most patients with irritable bowel syndrome (IBS) are managed in primary care. When first-line therapies for IBS are ineffective, the UK National Institute for Health and Care Excellence guideline suggests considering low- dose tricyclic antidepressants as second-line treatment, but their effectiveness in primary care is unknown, and they are infrequently prescribed in this setting., Methods: This randomised, double-blind, placebo-controlled trial (Amitriptyline at Low-Dose and Titrated for Irritable Bowel Syndrome as Second-Line Treatment [ATLANTIS]) was conducted at 55 general practices in England. Eligible participants were aged 18 years or older, with Rome IV IBS of any subtype, and ongoing symptoms (IBS Severity Scoring System [IBS-SSS] score ≥75 points) despite dietary changes and first-line therapies, a normal full blood count and C-reactive protein, negative coeliac serology, and no evidence of suicidal ideation. Participants were randomly assigned (1:1) to low-dose oral amitriptyline (10 mg once daily) or placebo for 6 months, with dose titration over 3 weeks (up to 30 mg once daily), according to symptoms and tolerability. Participants, their general practitioners, investigators, and the analysis team were all masked to allocation throughout the trial. The primary outcome was the IBS-SSS score at 6 months. Effectiveness analyses were according to intention-to-treat; safety analyses were on all participants who took at least one dose of the trial medication. This trial is registered with the ISRCTN Registry (ISRCTN48075063) and is closed to new participants., Findings: Between Oct 18, 2019, and April 11, 2022, 463 participants (mean age 48·5 years [SD 16·1], 315 [68%] female to 148 [32%] male) were randomly allocated to receive low-dose amitriptyline (232) or placebo (231). Intention-to-treat analysis of the primary outcome showed a significant difference in favour of low-dose amitriptyline in IBS-SSS score between groups at 6 months (-27·0, 95% CI -46·9 to -7·10; p=0·0079). 46 (20%) participants discontinued low-dose amitriptyline (30 [13%] due to adverse events), and 59 (26%) discontinued placebo (20 [9%] due to adverse events) before 6 months. There were five serious adverse reactions (two in the amitriptyline group and three in the placebo group), and five serious adverse events unrelated to trial medication., Interpretation: To our knowledge, this is the largest trial of a tricyclic antidepressant in IBS ever conducted. Titrated low-dose amitriptyline was superior to placebo as a second-line treatment for IBS in primary care across multiple outcomes, and was safe and well tolerated. General practitioners should offer low-dose amitriptyline to patients with IBS whose symptoms do not improve with first-line therapies, with appropriate support to guide patient-led dose titration, such as the self-titration document developed for this trial., Funding: National Institute for Health and Care Research Health Technology Assessment Programme (grant reference 16/162/01)., Competing Interests: Declaration of interests ACF, MJR, and HAE report National Institute for Health and Care Research (NIHR) grant funding paid to their institutions. AW-H reports NIHR grant funding paid to her institution, being a Data Monitoring and Ethics Committee and Trial Steering Committee member of NIHR funded and Medical Research Council funded projects, and travel reimbursement for expert Committee membership of the Yorkshire and Northeast Regional Advisory Committee for NIHR Research for Patient Benefit. SLA reports NIHR, Yorkshire Cancer Research, and Health Data Research UK grant funding paid to her institution, consulting fees from West Yorkshire Integrated Care Board paid to her institution, speaker's payments from Xytal, and being a grant funding panel member for NIHR. RF reports NIHR and Yorkshire Cancer Research grant funding paid to his institution, and being a Chair of a NICE Implementation Strategy Group. EAG reports NIHR and Leeds Hospitals Charity grant funding paid to her institution. AJF reports NIHR grant funding paid to her institution, and reports being a Data Monitoring and Ethics Committee and Trial Steering Committee member of NIHR and BHF funded projects, and an NIHR senior investigator. All other authors declare no competing interests., (Copyright © 2023 Elsevier Ltd. All rights reserved.)

Dry powder inhalers are an effective yet costly COPD medication-delivery device. Patients must possess a minimum peak inspiratory flow rate (PIFR) for inhaled medication to be properly deposited into the lungs. Hospitalized palliative-care patients with diminished lung function due to advanced COPD may not possess the minimum PIFR (30 L/min) for adequate drug delivery. This study aims to quantify PIFR values for hospitalized palliative-care patients with advanced COPD to evaluate whether these patients meet the minimum PIFR requirements. Hospitalized patients ≥18 years old with a palliative-care consultation were eligible if they had a diagnosis of advanced COPD (GOLD C or D). Patients were excluded if they lacked decision-making capacity or had a positive COVID-19 test within the previous 90 days. Three PIFR values were recorded utilizing the In-Check TM device, with the highest of the three PIFR attempts being utilized for statistical analysis. Eighteen patients were enrolled, and the mean of the highest PIFR readings was 72.5 L/min (±29 L/min). Post hoc analysis indicated 99.9% power when comparing the average best PIFR to the minimum PIFR (30 L/min) but only 51.4% power when compared to the optimal PIFR (60 L/min). This study found that palliative-care patients possess the minimum PIFR for DPI drug delivery.

Introduction: In the United Kingdom (UK), complications that arise following the administration of Botulinum Toxin are reported to the Medicines and Health Regulatory Agency (MHRA) via the Yellow Card Reporting Scheme. Over the past decade, there has been a significant increase in the number of non-surgical aesthetic procedures. Concerns have been raised that the MHRA is not fully capturing complications in terms of volume and impact on patients., Aim: This novel study explores the lived experiences of individuals who have experienced an adverse event following administration of Botulinum Toxin for aesthetic purposes. Using a combination of qualitative and quantitative methodologies, this analysis evaluates data relating to long-lasting physical, psychological, emotional, and financial sequelae of complications arising from cosmetic Botulinum Toxin injections in the UK., Methods: A mixed method, qualitative and quantitative approach was adopted to gain comprehensive insights into patients' experiences. A focus group which comprised patient representatives, psychologists, and researchers reached a consensus on a 17-question survey which was disseminated via social media channels. Deductive thematic analysis was used to analyse coded themes. Furthermore, for secondary analysis, sentiment analysis was used computationally as an innovative approach to identify and categorise free text responses associated with sentiments using natural language processing (NLP)., Results: In the study, 655 responses were received, with 287 (44%) of respondents completing all questions. The mean age of respondents was 42.6 years old. 94.1% of respondents identified as female. In the sample, 79% of respondents reported an adverse event following their procedure, with the most common event being reported as 'anxiety'. Findings revealed that 69% of respondents reported long-lasting adverse effects. From the responses, 68.4% reported not having recovered physically, 63.5% of respondents stated that they had not recovered emotionally from complications, and 61.7% said that they have not recovered psychologically. In addition, 84% of respondents stated that they do not know who regulates the aesthetics industry. Furthermore, 92% of participants reported that their clinic or practitioner did not inform them about the Yellow Card Reporting Scheme. The sentiment analysis using the AFINN Lexicon yielded adjusted scores ranging from -3 to +2, with a mean value of -1.58., Conclusion: This is the largest survey in the UK completed by patients who experienced an adverse outcome following the aesthetic administration of Botulinum Toxin. Our study highlights the extent of the challenges faced by patients who experience an adverse event from physical, emotional, psychological, and financial perspectives. The lack of awareness of MHRA reporting structures and the lack of regulation within the UK's cosmetic injectables sector represent a significant public health challenge., Competing Interests: All authors have completed the Unified Competing Interest form (available on request from the corresponding author) and declare: no support from any other organisation for the submitted work; the research presented was sponsored by QUAD A – see below, no other relationships or activities that could appear to have influenced the submitted work., (© 2023 The Authors. Skin Health and Disease published by John Wiley & Sons Ltd on behalf of British Association of Dermatologists.)

Objective: To study the clinical use of elagolix in ovarian stimulation and its effect on premature ovulation in a cohort of women undergoing oocyte donation., Design: A prospective cohort study with the use of historical controls., Setting: A private reproductive endocrinology and infertility clinic., Patients: Seventy-five oocyte donors and 75 historical donors, aged 21-30 years, who had each passed Food and Drug Administration and American Society for Reproductive Medicine-approved oocyte donor screening., Interventions: Administration of elagolix 200 mg orally every night at bedtime with development of a follicular size of ≥14 mm for ovulation suppression compared with ganirelix 250 μg every night at bedtime., Main Outcome Measures: Premature ovulation rate, total oocytes, mature oocytes, maximum estradiol, luteinizing hormone, and progesterone levels., Results: Oocytes were available in all retrievals because there were no instances of premature ovulation in either the elagolix or ganirelix groups. There were no statistically significant differences between the groups in baseline demographics. Both groups had the same amounts of gonadotropins consumed and days of stimulation. The average number of total oocytes was similar between the control group and elagolix group (30.55 vs. 30.31). Furthermore, the average number of mature oocytes was similar between the control and study groups (25.42 vs. 24.73). An analysis of the 580 fresh oocytes in the elagolix group and the 737 fresh oocytes in the ganirelix group showed similar outcomes with fertilization rates of 79.7% and 84.6%, respectively. Blastocyst development rates were also similar: 62.9% in the elagolix group and 57.3% in the ganirelix group., Conclusions: Compared with a historical control group using ganirelix, patients receiving elagolix demonstrated a similar number of oocytes and mature oocytes with on average 4.2 fewer injections per cycle and average per-cycle patient savings of $289.10., Clinical Trial Registration Number: Western IRB Pr. No.: 20191163, April 11, 2019. First enrollment June 20, 2019., (© 2023 The Author(s).)

Objective . In proton therapy there is a need for proton optimised tissue-equivalent materials as existing phantom materials can produce large uncertainties in the determination of absorbed dose and range measurements. The aim of this work is to develop and characterise optimised tissue-equivalent materials for proton therapy. Approach . A mathematical model was developed to enable the formulation of epoxy-resin based tissue-equivalent materials that are optimised for all relevant interactions of protons with matter, as well as photon interactions, which play a role in the acquisition of CT numbers. This model developed formulations for vertebra bone- and skeletal muscle-equivalent plastic materials. The tissue equivalence of these new materials and commercial bone- and muscle-equivalent plastic materials were theoretical compared against biological tissue compositions. The new materials were manufactured and characterised by their mass density, relative stopping power (RSP) measurements, and CT scans to evaluate their tissue-equivalence. Main results . Results showed that existing tissue-equivalent materials can produce large uncertainties in proton therapy dosimetry. In particular commercial bone materials showed to have a relative difference up to 8% for range. On the contrary, the best optimised formulations were shown to mimic their target human tissues within 1%-2% for the mass density and RSP. Furthermore, their CT-predicted RSP agreed within 1%-2% of the experimental RSP, confirming their suitability as clinical phantom materials. Significance . We have developed a tool for the formulation of tissue-equivalent materials optimised for proton dosimetry. Our model has enabled the development of proton optimised tissue-equivalent materials which perform better than existing tissue-equivalent materials. These new materials will enable the advancement of clinical proton phantoms for accurate proton dosimetry., (Creative Commons Attribution license.)

Abstract: Technology-enhanced rehabilitation can improve access to training activities in multiple care delivery settings and may improve patient outcomes. However, the rate at which rehabilitation technology is being developed makes it difficult for healthcare systems to keep pace with the volume of products emerging in this space. Formal processes are needed to help healthcare systems review products as they emerge and to determine whether they should be incorporated into clinical practice. Here, we describe an approach to reviewing emerging rehabilitation technologies as performed by the Center for Emerging Rehabilitation Technology at our institution. Developed using an iterative approach, the rehabilitation technology review process used by the Center for Emerging Rehabilitation Technology team classifies technologies into the following three categories: (1) for clinical deployment, (2) for innovation in product development/product-market fit testing, and (3) for research, for example, a sponsored clinical trial. We describe the processes used to evaluate, categorize, investigate, and integrate rehabilitation technology, share our experience with the review process, and make recommendations for other institutions who may wish to implement rehabilitation technology into clinical practice., Competing Interests: Financial disclosure statements have been obtained, and no conflicts of interest have been reported by the authors or by any individuals in control of the content of this article., (Copyright © 2023 Wolters Kluwer Health, Inc. All rights reserved.)

Epilepsy is a highly heterogeneous neurological disorder with variable etiology, manifestation, and response to treatment. It is imperative that new models of epileptiform brain activity account for this variability, to identify individual needs and allow clinicians to curate personalized care. Here, we use a hidden Markov model (HMM) to create a unique statistical model of interictal brain activity for 10 pediatric patients. We use magnetoencephalography (MEG) data acquired as part of standard clinical care for patients at the Children's Hospital of Philadelphia. These data are routinely analyzed using excess kurtosis mapping (EKM); however, as cases become more complex (extreme multifocal and/or polymorphic activity), they become harder to interpret with EKM. We assessed the performance of the HMM against EKM for three patient groups, with increasingly complicated presentation. The difference in localization of epileptogenic foci for the two methods was 7 ± 2 mm (mean ± SD over all 10 patients); and 94% ± 13% of EKM temporal markers were matched by an HMM state visit. The HMM localizes epileptogenic areas (in agreement with EKM) and provides additional information about the relationship between those areas. A key advantage over current methods is that the HMM is a data-driven model, so the output is tuned to each individual. Finally, the model output is intuitive, allowing a user (clinician) to review the result and manually select the HMM epileptiform state, offering multiple advantages over previous methods and allowing for broader implementation of MEG epileptiform analysis in surgical decision-making for patients with intractable epilepsy., (© 2022 The Authors. Human Brain Mapping published by Wiley Periodicals LLC.)

Higher education has increasingly adopted online and blended models of teaching. Guided by institutional policy and digital competence frameworks, the integration of digital tools and competences is perceived as essential. The pivot to emergency remote teaching (ERT) in response to the COVID-19 pandemic increased the use of digital technologies and the need to deploy and support digital competences. Researchers captured a range of remote teaching practices in higher education across this period that highlight the adaptability of teachers despite a lack of preparation for such an event. This study reviewed empirical studies of ERT from the past 2 years to derive a conceptual frame for ERT digital competence, which was then applied as a lens to analyse teaching or digital competency frameworks from Australian universities. The findings of this paper demonstrate the pre-pandemic teaching and digital competency frameworks captured digital competencies relevant to ERT in varied ways. Practically, the findings provide a starting point for understanding digital competences needed for ERT to ensure future preparedness in responding to a crisis that disrupts educational provision. We also suggest universities can better support the development of teachers' digital competence through practical operationalisations that connect technical and pedagogical knowledge, make digital possibilities across modes of delivery explicit, and acknowledge the need to protect wellbeing of educators., Competing Interests: Conflict of interestThe authors have no relevant financial or non-financial interests to disclose., (© The Author(s) 2023.)

Anterior cruciate ligament (ACL) injuries often require a lengthy duration of rehabilitation for patients to return to their prior level of function. Adherence to rehabilitation during this prolonged period can be subpar due to the treatment duration and poor adherence to home exercises. This work evaluates whether a smart instrumented knee brace system is capable of monitoring knee range of motion and velocity during a series of common knee rehabilitation exercises and an exergame. A total of 15 healthy participants completed a series of common knee rehabilitation exercises and played an exergame while wearing a smart instrumented knee brace. The range of motion (ROM) and velocity of the knee recorded by the knee brace was compared to a reference optoelectronic system. The results show good agreement between the knee brace system and the reference system for all exercises performed. Participants were able to quickly learn how to play the exergame and scored well within the game. The system investigated in this study has the potential to allow rehabilitation to occur outside of the clinic with the use of remote monitoring, and improve adherence and outcomes through the use of an exergame.

Background: Palliative care (PC) pharmacists can play an important role in optimizing medications for patients with serious illnesses by aligning patients' goals with their treatment regimens. Objectives: The objectives of this study were to (1) quantify successful pharmacist deprescribing interventions incorporated in the hospital discharge plan and (2) describe deprescribing interventions by medication class, reason for discontinuation, and perception of patient/caregiver understanding and acceptance. Methods: This pilot study included 45 inpatient PC consultations and collected data on deprescribing interventions performed by PC clinical pharmacists in Maryland and Washington, D.C., U.S. Descriptive statistics were used to analyze outcomes. Results: Eighty-two percent of recommendations were successfully implemented during hospitalization and included in the discharge plan. Medication classes recommended for discontinuation included vitamins/supplements (20%), antidiabetics (13%), antiplatelets (10%), anticoagulants (10%), statins (10%), antihypertensives (7%), proton pump inhibitors/H2 blockers (7%), antibiotics (5%), dementia medications (1%), and antidepressants (1%). Top reasons for discontinuation included pill burden, unacceptable treatment burden, and potential harm outweighs potential benefit. Conclusions: Results of this study demonstrate PC pharmacists' deprescribing recommendations have a high rate of successful implementation by the primary inpatient care team.

Nonsense-mediated RNA decay (NMD) is a highly conserved RNA turnover pathway that degrades RNAs harboring in-frame stop codons in specific contexts. Loss of NMD factors leads to embryonic lethality in organisms spanning the phylogenetic scale, but the mechanism remains unknown. Here, we report that the core NMD factor, UPF2, is required for expansion of epiblast cells within the inner cell mass of mice in vivo. We identify NMD target mRNAs in mouse blastocysts - both canonical and alternatively processed mRNAs - including those encoding cell cycle arrest and apoptosis factors, raising the possibility that NMD is essential for embryonic cell proliferation and survival. In support, the inner cell mass of Upf2-null blastocysts rapidly regresses with outgrowth and is incompetent for embryonic stem cell derivation in vitro. In addition, we uncovered concordant temporal- and lineage-specific regulation of NMD factors and mRNA targets, indicative of a shift in NMD magnitude during peri-implantation development. Together, our results reveal developmental and molecular functions of the NMD pathway in the early embryo., Competing Interests: Competing interests The authors declare no competing or financial interests., (© 2022. Published by The Company of Biologists Ltd.)

Migratory hoverflies are long-range migrants that, in the Northern Hemisphere, move seasonally to higher latitudes in the spring and lower latitudes in the autumn. The preferred migratory direction of hoverflies in the autumn has been the subject of radar and flight simulator studies, while spring migration has proved to be more difficult to characterize owing to a lack of ground observations. Consequently, the preferred migratory direction during spring has only been inferred from entomological radar studies and patterns of local abundance, and currently lacks ground confirmation. Here, during a springtime arrival of migratory insects onto the Isles of Scilly and mainland Cornwall, UK, we provide ground proof that spring hoverfly migrants have an innate northward preference. Captured migratory hoverflies displayed northward vanishing bearings when released under sunny conditions under both favourable wind and zero-wind conditions. In addition, and unlike autumn migrants, spring individuals were also able to orientate when the sun was obscured. Analysis of winds suggests an origin for insects arriving on the Isles of Scilly as being in western France. These findings of spring migration routes and preferred migration directions are likely to extend to the diverse set of insects found within the western European migratory assemblage.

Background: Initial training and ongoing post-training consultation (i.e., ongoing support following training, provided by an expert) are among the most common implementation strategies used to change clinician practice. However, extant research has not experimentally investigated the optimal dosages of consultation necessary to produce desired outcomes. Moreover, the degree to which training and consultation engage theoretical implementation mechanisms-such as provider knowledge, skills, and attitudes-is not well understood. This study examined the effects of a brief online training and varying dosages of post-training consultation (BOLT+PTC) on implementation mechanisms and outcomes for measurement-based care (MBC) practices delivered in the context of education sector mental health services., Methods: A national sample of 75 clinicians who provide mental health interventions to children and adolescents in schools were randomly assigned to BOLT+PTC or control (services as usual). Those in BOLT+PTC were further randomized to 2-, 4-, or 8-week consultation conditions. Self-reported MBC knowledge, skills, attitudes, and use (including standardized assessment, individualized assessment, and assessment-informed treatment modification) were collected for 32 weeks. Multilevel models were used to examine main effects of BOLT+PTC versus control on MBC use at the end of consultation and over time, as well as comparisons among PTC dosage conditions and theorized mechanisms (skills, attitudes, knowledge)., Results: There was a significant linear effect of BOLT+PTC over time on standardized assessment use (b = .02, p < .01), and a significant quadratic effect of BOLT+PTC over time on individualized assessment use (b = .04, p < .001), but no significant effect on treatment modification. BOLT + any level of PTC resulted in higher MBC knowledge and larger growth in MBC skill over the intervention period as compared to control. PTC dosage levels were inconsistently predictive of outcomes, providing no clear evidence for added benefit of higher PTC dosage., Conclusions: Online training and consultation in MBC had effects on standardized and individualized assessment use among clinicians as compared to services as usual with no consistent benefit detected for increased consultation dosage. Continued research investigating optimal dosages and mechanisms of these established implementation strategies is needed to ensure training and consultation resources are deployed efficiently to impact clinician practices., Trial Registration: ClinicalTrials.gov NCT05041517 . Retrospectively registered on 10 September 2021., (© 2022. The Author(s).)

Background: Irritable bowel syndrome (IBS) is a common functional bowel disorder that has a considerable impact on patient quality of life and substantial societal and health care resource costs. Current treatments are often ineffective. Tricyclic antidepressants have shown promise in secondary care populations but their effectiveness in a primary care setting remains unclear., Methods: ATLANTIS is a randomised, multi-centre, parallel-group, two-arm, double-blind, placebo-controlled trial of low-dose amitriptyline as a second-line treatment for IBS in primary care. Participants will be invited by letter, or recruited opportunistically, from general practices in three regions of England (West Yorkshire, Wessex, and West of England) and screened for eligibility. A total of 518 adult patients with IBS, who are symptomatic despite first-line therapies, will be randomised 1:1 to amitriptyline or identical placebo for 6 months. Treatment will commence at a dose of 10 mg (or one placebo tablet) daily at night, with dose titration up to a maximum of 30 mg at night, depending on side effects and response to treatment. Participant-reported assessments will be conducted at baseline and 3, 6, and 12 months post-randomisation. The primary objective is to determine the effectiveness of amitriptyline, compared with placebo, in improving participant-reported global symptoms of IBS at 6 months (using the IBS Severity Scoring System). Secondary outcomes include relief of IBS symptoms, effect on IBS-associated somatic symptoms (Patient Health Questionnaire-12), anxiety and depression (Hospital Anxiety and Depression Scale), ability to work and participate in other activities (Work and Social Adjustment Scale), acceptability and tolerability of treatment, self-reported health care use, health-related quality of life (EQ-5D-3L), and cost-effectiveness. A nested, qualitative study will explore patient and general practitioner experiences of treatments and trial participation, including acceptability, adherence, unanticipated effects, and implications for wider use of amitriptyline for IBS in primary care., Discussion: Determining the clinical and cost-effectiveness of low-dose amitriptyline as a second-line treatment for IBS in primary care will provide robust evidence to inform management decisions., Trial Registration: ISRCTN ISRCTN48075063 . Registered on 7th June 2019., (© 2022. The Author(s).)

Clinician bias has been identified as a potential contributor to persistent healthcare disparities across many medical specialties and service settings. Few studies have examined strategies to reduce clinician bias, especially in mental healthcare, despite decades of research evidencing service and outcome disparities in adult and pediatric populations. This manuscript describes an intervention development study and a pilot feasibility trial of the Virtual Implicit Bias Reduction and Neutralization Training (VIBRANT) for mental health clinicians in schools-where most youth in the U.S. access mental healthcare. Clinicians ( N = 12) in the feasibility study-a non-randomized open trial-rated VIBRANT as highly usable, appropriate, acceptable, and feasible for their school-based practice. Preliminarily, clinicians appeared to demonstrate improvements in implicit bias knowledge, use of bias-management strategies, and implicit biases (as measured by the Implicit Association Test [IAT]) post-training. Moreover, putative mediators (e.g., clinicians' VIBRANT strategies use, IAT D scores) and outcome variables (e.g., clinician-rated quality of rapport) generally demonstrated correlations in the expected directions. These pilot results suggest that brief and highly scalable online interventions such as VIBRANT are feasible and promising for addressing implicit bias among healthcare providers (e.g., mental health clinicians) and can have potential downstream impacts on minoritized youth's care experience.

Heel ulcerations are common complications seen in patients suffering from chronic conditions such as diabetes mellitus, peripheral vascular disease, and in bed ridden patients. When these systemic pathologies lead to heel ulcers, an increased risk of calcaneal osteomyelitis often significantly limits the benefits of conventional therapeutic interventions and increases risk of major lower extremity amputation. The Vertical Contour Calcanectomy (VCC) is a novel surgical procedure specific for the surgical management of these complex and often recalcitrant heel ulcerations. The VCC was described as a reproducible procedure in which wide excision of both the soft tissue ulceration as well as defined bone cuts of the calcaneus allows for decreased bioburden and in many cases, for primary soft tissue closure. The present study describes the outcomes related to the VCC and provides guidance based on the objective findings detailed herein. This study, at the time of publication, represents the largest collection of patients that have undergone the VCC (N = 51) and their outcomes at 1 year. Those who remained healed without recurrence, amputation, or mortality at 1-year follow-up were 31.4%. Post-VCC total limb salvage rate is 68.6% at one year, mean follow-up 663.9 ± 464.7 days. One-year all-cause mortality post-VCC was 9.8%. Post-VCC function at 1-year follow-up reflects 79.3% of patients having the same or better function that their perioperative state., (Copyright © 2021 the American College of Foot and Ankle Surgeons. Published by Elsevier Inc. All rights reserved.)

Purpose: In particle therapy, determination of range by measurement or calculation can be a significant source of uncertainty. This work investigates the development of a bespoke Range Length Phantom (RaLPh) to allow independent determination of proton range in tissue. This phantom is intended to be used as an audit device., Method: RaLPh was designed to be compact and allows different configurations of tissue substitute slabs, to facilitate measurement of range using radiochromic film. Fourteen RaLPh configurations were tested, using two types of proton fluence optimised water substitutes, two types of bone substitute, and one lung substitute slabs. These were designed to mimic different complex tissue interfaces. Experiments were performed using a 115 MeV mono-energetic scanning proton beam to investigate the proton range for each configuration. Validation of the measured film ranges was performed via Monte Carlo simulations and ionisation chamber measurements. The phantom was then assessed as an audit device, by comparing film measurements with Treatment Planning System (TPS) predicted ranges., Results: Varying the phantom slab configurations allowed for measurable range differences, and the best combinations of heterogeneous material gave agreement between film and Monte Carlo on average within 0.2% and on average within 0.3% of ionisation chamber measurements. Results against the TPS suggest a material density override is currently required to enable the phantom to be an audit device., Conclusion: This study found that a heterogeneous phantom with radiochromic film can provide range verification as part of a dedicated audit for clinical proton therapy beams., (Copyright © 2021 Associazione Italiana di Fisica Medica e Sanitaria. Published by Elsevier Ltd. All rights reserved.)

Background: The General Medical Council (GMC) states that all intimate examinations should have a chaperone offered. Documentation of chaperone identity, or patient's refusal, is essential., Objective: This project aimed to improve documentation of chaperones during intimate examination of patients based in a Surgical Admissions Unit (SAU) within a large tertiary hospital in the Southwest of the UK., Methods: A Plan-Do-Study-Act (PDSA) cycle structure was used. Initial data collection and planning occurred in December 2019. Intervention implementation and analysis occurred from January 2020 to March 2021. Intervention 1 involved presenting results at a clinical governance meeting. Intervention 2 was information posters in the SAU and intervention 3 involved training sessions for nursing staff. Intervention 4 was editing the surgical clerking proforma., Results: Prior to interventions, chaperone identity or patient's refusal was correctly documented only 9.7% (N = 7 out of 72) of the time. Intervention 1 increased this to 34.6%. Following interventions 3 and 4, correct documentation was 25.0% and 28.6% respectively. After intervention 4 correct documentation was at 59.1%., Conclusions: Initial documentation of chaperones was poor. Interventions 1 to 3 were successful in educating clinicians how to document accurately, but engaging individuals in person was more successful than passive education through posters. Changing the proforma structure was the most successful intervention. This suggests a visual reminder for clinicians at the point of contact with the patient is the most effective way to encourage correct documentation of chaperones, improving patient care and clinical practice.

Background: Human trafficking is a recognized human rights violation, and a public health and global development issue. Violence is often a hallmark of human trafficking. This study aims to describe documented cases of violence amongst persons identified as victims of trafficking, examine associated factors throughout the trafficking cycle and explore prevalence of abuse in different labour sectors., Methods and Findings: The IOM Victim of Trafficking Database (VoTD) is the largest database on human trafficking worldwide. This database is actively used across all IOM regional and country missions as a standardized anti-trafficking case-management tool. This analysis utilized the cases of 10,369 trafficked victims in the VoTD who had information on violence., Results: The prevalence of reported violence during human trafficking included: 54% physical and/or sexual violence; 50% physical violence; and 15% sexual violence, with 25% of women reporting sexual violence. Experiences of physical and sexual violence amongst trafficked victims were significantly higher amongst women and girls (AOR 2.48 (CI: 2.01,3.06)), individuals in sexual exploitation (AOR 2.08 (CI: 1.22,3.54)) and those experiencing other forms of abuse and deprivation, such as threats (AOR 2.89 (CI: 2.10,3.98)) and forced use of alcohol and drugs (AOR 2.37 (CI: 1.08,5.21)). Abuse was significantly lower amongst individuals trafficked internationally (AOR 0.36 (CI: 0.19,0.68)) and those using forged documents (AOR 0.64 (CI: 0.44,0.93)). Violence was frequently associated with trafficking into manufacturing, agriculture and begging (> 55%)., Conclusions: An analysis of the world's largest data set on trafficking victims indicates that violence is indeed prevalent and gendered. While these results show that trafficking-related violence is common, findings suggest there are patterns of violence, which highlights that post-trafficking services must address the specific support needs of different survivors., Competing Interests: The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (© 2021 The Author(s). Published by Elsevier Ltd.)

Releasing sterile or incompatible male insects is a proven method of population management in agricultural systems with the potential to revolutionize mosquito control. Through a collaborative venture with the "Debug" Verily Life Sciences team, we assessed the incompatible insect technique (IIT) with the mosquito vector Aedes aegypti in northern Australia in a replicated treatment control field trial. Backcrossing a US strain of Ae. aegypti carrying Wolbachia w AlbB from Aedes albopictus with a local strain, we generated a w AlbB2-F4 strain incompatible with both the wild-type (no Wolbachia ) and w Mel- Wolbachia Ae. aegypti now extant in North Queensland. The w AlbB2-F4 strain was manually mass reared with males separated from females using Verily sex-sorting technologies to obtain no detectable female contamination in the field. With community consent, we delivered a total of three million IIT males into three isolated landscapes of over 200 houses each, releasing ∼50 males per house three times a week over 20 wk. Detecting initial overflooding ratios of between 5:1 and 10:1, strong population declines well beyond 80% were detected across all treatment landscapes when compared to controls. Monitoring through the following season to observe the ongoing effect saw one treatment landscape devoid of adult Ae. aegypti early in the season. A second landscape showed reduced adults, and the third recovered fully. These encouraging results in suppressing both wild-type and w Mel- Ae. aegypti confirms the utility of bidirectional incompatibility in the field setting, show the IIT to be robust, and indicate that the removal of this arbovirus vector from human-occupied landscapes may be achievable., Competing Interests: Competing interest statement: Verily Life Sciences assisted with project funding., (Copyright © 2021 the Author(s). Published by PNAS.)

Green space is important for health, yet, objective research on children's use of green space is sparse. This study aimed to objectively assess children's use of green space in both public and private settings during their summer leisure time, using wearable cameras. Images from cameras worn by 74 children were analysed for green space use over 4 days. Children spent an average of ∼1/10 h of leisure time in green space in the summer months, were physically active 68%, and with others 85%, of the time. Green spaces are important places for children's health because they are places they frequent and places where they are physically active and socialize. Wearable cameras provide an effective method for objective assessment of green space use., (© The Author(s) 2020. Published by Oxford University Press. All rights reserved. For permissions, please email: journals.permissions@oup.com.)

Purpose: This study aimed to assess the incidence of intimate partner violence (IPV) in women with isolated ulnar fractures and compare the injury characteristics in victims of IPV with those who sustained the same fractures due to other causes., Methods: Electronic health records from three level I trauma centers were queried to identify a cohort of women, aged 18 to 50, sustaining isolated ulnar fractures from 2005 to 2019. Radiographs were reviewed for fracture location, comminution, and displacement. Demographic data, number of visits to the emergency department, and documentation of IPV were also collected. Patients were stratified into four groups based on clinical chart review: confirmed IPV, possible IPV, not suspected for IPV, and not IPV. Historical imaging analysis for IPV prediction was also performed., Results: There were 62 patients, with a mean age of 31 years (IPV: 12 confirmed, 8 possible, 8 suspected not IPV, 34 confirmed not IPV). Comparative analysis with and without suspected cases demonstrated IPV to be associated with nondisplaced fractures (95% versus 43%; P < .001 and 91% versus 44%; P = .012). Confirmed cases were also associated with homelessness (46% versus 0%; P < .001), and the number of documented emergency department visits (median 7.0; interquartile range 2.0-12.8 versus 1.0; interquartile range 1.0-2.0; P < .001). Formal documentation of IPV evaluation was completed in only 14 of 62 (22.5%) patients. Historical imaging analysis predicted IPV in 8 of 12 (75%) confirmed IPV cases., Conclusion: Up to one-third of adult women sustaining isolated ulnar fractures may be the victims of IPV. Lack of displacement on radiographs, frequent emergency department visits, and homelessness would favor IPV etiology., (Copyright © 2021 American College of Radiology. Published by Elsevier Inc. All rights reserved.)

A comprehensive pain assessment is the first step in safe, effective pain management. Few studies have explored variations of strategies and measures for multidimensional pain assessment education in both verbal and nonverbal patients. In this retrospective cohort study, interprofessional health care students enrolled in a palliative care curriculum completed a pain assessment training, which taught the PQRSTA ("palliating factors, precipitating factors, previous treatments, quality, region, radiation, severity, temporal factors and associated symptoms") mnemonic as a strategy for assessing pain in verbal patients and the Pain Assessment in Advance Dementia and Checklist of Nonverbal Pain Indicators measures for nonverbal patients. The purpose of this study was to compare the change in attitudes, self-perceived skills, and knowledge regarding pain assessment before and after the training. Attitudes and self-perceived skills were assessed in the pretraining and posttraining survey, which was analyzed using χ2 test or Fisher exact test. Students' knowledge responses were analyzed using Wilcoxon signed rank test to assess accuracy of responses compared with the expert defined score. One hundred eighty-two students were included. Results showed a statistically significant improvement in attitudes related to applicability of pain measures and self-perceived skills. Overall, data did not support an increase in knowledge using the PQRSTA mnemonic, or Pain Assessment in Advance Dementia and Checklist of Nonverbal Pain Indicators measures. Future pain trainings should consider training on only 1 nonverbal pain measure, incorporating bedside assessments, and integrating real-time feedback., Competing Interests: The authors have no conflicts of interest to disclose., (Copyright © 2021 by The Hospice and Palliative Nurses Association. All rights reserved.)

This study evaluates if the Kiddie Children and Teachers on the Move physical activity (PA) program improves the proportion of days meeting the Institute of Medicine (IOM) PA guideline, and whether meeting the guideline is correlated with improvement in school readiness. Thirteen Head Start-affiliated pre-kindergarten classrooms participated in this study. Minutes per hour of moderate-to-vigorous physical activity (MVPA) and proportion of days meeting the IOM PA guideline were examined across three types of intervention days: days during a non-intervention period, non-program days during the intervention period, and program days during the intervention period. Children displayed increasingly more MVPA and a greater proportion of days meeting the IOM guideline from non-intervention days to non-program days, and from non-program days to program days. Proportion of days meeting the guideline significantly predicted improvement in school readiness in five of six domains. Examination of program fidelity indicated the program was run with high fidelity.