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Objectives Around 30% of patients with RA have an inadequate response to MTX. We aimed to use routine clinical and biological data to build machine learning models predicting EULAR inadequate response to MTX and to identify simple predictive biomarkers. Methods Models were trained on RA patients fulfilling the 2010 ACR/EULAR criteria from the ESPOIR and Leiden EAC cohorts to predict the EULAR response at 9 months (± 6 months). Several models were compared on the training set using the AUROC. The best model was evaluated on an external validation cohort (tREACH). The model's predictions were explained using Shapley values to extract a biomarker of inadequate response. Results We included 493 therapeutic sequences from ESPOIR, 239 from EAC and 138 from tREACH. The model selected DAS28, Lymphocytes, Creatininemia, Leucocytes, AST, ALT, swollen joint count and corticosteroid co-treatment as predictors. The model reached an AUROC of 0.72 [95% CI (0.63, 0.80)] on the external validation set, where 70% of patients were responders to MTX. Patients predicted as inadequate responders had only 38% [95% CI (20%, 58%)] chance to respond and using the algorithm to decide to initiate MTX would decrease inadequate-response rate from 30% to 23% [95% CI: (17%, 29%)]. A biomarker was identified in patients with moderate or high activity (DAS28 > 3.2): patients with a lymphocyte count superior to 2000 cells/mm3 are significantly less likely to respond. Conclusion Our study highlights the usefulness of machine learning in unveiling subgroups of inadequate responders to MTX to guide new therapeutic strategies. Further work is needed to validate this approach.

Right ventricular (RV) failure has a significant adverse impact on pulmonary hypertension (PH) prognosis. None of the currently used parameters directly assess whether RV fails to provide enough energy output to propel the blood through diseased pulmonary vascular system. Furthermore, most of the current parameters are affected by the volume status of the patient. We aimed to explore whether RV energy failure has a predictive power for mortality on top of the established prognostic risk parameters in patients with PH. We screened 723 cases from our database. A total of 3 sets of binary regression analyses were executed to determine the hazard ratios (HRs) of RV energy failure for 5-year mortality in clinical, echocardiographic, and hemodynamic context, using adjustment variables chosen according to previous studies. The final study population encompassed 549 cases. A total of 77 patients died during the 5-year follow-up (14%). RV energy failure was observed in 146 of 549 patients (26.6%). In the univariate model, RV energy failure strongly associated with increased long-term mortality (HR 4.25, 95% confidence interval [CI] 2.58 to 7.00, p

Research leading to this article was funded by the Wellcome Trust [grant ID 217988/Z/19/Z] for the project “The Global War Against the Rat and the Epistemic Emergence of Zoonosis.” I trace the development of the concept of sylvatic plague – the first sylvatic disease – examining its invention by Ricardo Jorge to describe a global phenomenon of plague reservoirs among wild rodents, and its circulation. The concept implied a space where plague was enzootic, and relied on a division between inhabited and uninhabited spaces and between domestic rats and wild rodents. Some of the characteristics of this space varied, but it always referred to places imagined as empty of humans and rats. In 1927, it designated ambiguously deserts, in 1935, uninhabited regions in general, and in Brazil, it referred to the jungle. O artigo retraça o desenvolvimento do conceito de peste selvática, a primeira doença selvática, da utilização por Ricardo Jorge para descrever um fenômeno global de reservatórios de peste entre roedores selvagens, até sua circulação nos anos 1930 e 40. O conceito inventou um espaço onde a peste se mantinha enzoótica, dividindo entre lugares habitados e inabitados, e roedores domésticos e selvagens. Algumas características desse espaço mudaram com o tempo, mas sempre mantendo a ideia de lugares imaginados como vazios de humanos e ratos. Em 1927, o conceito designava ambiguamente desertos, em 1935, regiōes desabitadas em geral, e no Brasil, ele se referia à selva. Publisher PDF

Previous evidence shows that better insurance coverage increases medical expenditure. However, formal studies on the effect of spending on health outcomes, and especially mental health, are lacking. To fill this gap, we reanalyze data from the Rand Health Insurance Experiment and estimate a joint non-linear model of spending and mental health. We address the endogeneity of spending in a flexible copula regression model with Bernoulli and Tweedie margins and discuss its implementation in the freely available GJRM R package. Results confirm the importance of accounting for endogeneity: in the joint model, a $1000 spending in mental care is estimated to reduce the probability of low mental health by 1.3 percentage points, but this effect is not statistically significant. Ignoring endogeneity leads to a spurious (upwardly biased) estimate.

Funding: Review conducted under the Global Challenges Research Fund (GCRF) PhD scholarship at the University of St-Andrews. The increasing burden of chronic diseases, and shortage of health care workers especially in Low and Middle Income countries (LMICs) requires greater collaborative working between health professions. There is a growing body of evidence that interprofessional education (IPE) and interprofessional continuous education (IPCE) can improve collaborative practice thus strengthening health care delivery in low resource settings. The World Health Organization (WHO) promotes this educational strategy in these regions as part of wider programs to improve health care. The purpose of this systematic review was to summarize IPE and IPCE activities in sub-Saharan Africa (SSA) and its outcomes; including practice, service and patient outcomes. Standard guidelines for conducting and reporting systematic reviews were followed. The online databases searched included MEDLINE, Embase, Education Resources Information Centre (ERIC), the Cumulative Index of Nursing and Allied Health Literature (CINAHL) and Science Direct. The Kirkpatrick model was used to classify IPE outcomes reported from literature. Following full text screening, 41 articles were selected for data extraction. It was found that IPE/IPCE is still a relatively new concept in SSA with 93% of studies published after 2012. Furthermore, IPE is concentrated predominantly in undergraduate institutions and mainly implemented to improve collaborative practice and address important public health concerns. Positive reaction and outcomes of IPE/IPCE were reported in terms of change of attitude and perception toward collaborative practice as well as knowledge and skills acquisition. Few studies in SSA sought to understand and measure the outcomes of IPE/IPCE relating to health care practice. More work in this important potential outcome of IPE/IPCE is recommended. Publisher PDF

The perinatal period is a time when provision of responsive care offers a life course opportunity for positive change to improve health outcomes for mothers, infants and families. Australian perinatal systems carry the legacy of settler-colonialism, manifesting in racist events and interactions that First Nations parents encounter daily. The dominance of a western risk lens, and conscious and unconscious bias in the child protection workforce, sustains disproportionately high numbers of First Nations infants being removed from their parents' care. Cascading medical interventions compound existing stressors and magnify health inequities for First Nations women. Critical discourse was informed by Indigenous ways of knowing, being and doing via targeted dialogue with a group of First Nations and non-Indigenous experts in Australian perinatal care who are co-authors on this paper. Dynamic discussion evolved from a series of yarning circles, supplemented by written exchanges and individual yarns as themes were consolidated. First Nations maternity services prioritise self-determination, partnership, strengths and communication and have demonstrated positive outcomes with, and high satisfaction from First Nations women. Mainstream perinatal settings could be significantly enhanced by embracing similar principles and models of care. The Australian Anti-racism in Perinatal Practice (AAPP) Alliance calls for urgent transformations to Australian perinatal models of care whereby non-Indigenous health policy makers, managers and clinicians take a proactive role in identifying and redressing ethnocentrism, judgemental and culturally blind practices, reframing the risk narrative, embedding strength-based approaches and intentionally prioritising engagement and connectedness within service delivery. [Abstract copyright: Copyright © 2022 The Authors. Published by Elsevier Ltd.. All rights reserved.]

Considering the concerted investments in anti-female genital mutilation/cutting (FGM/C) campaigns championed by the Nigerian government and non-governmental organizations, research findings suggest that reduction in intergenerational (mother-to-daughter) prevalence of FGM/C in Nigeria has been very slow. What can we learn from the 2018 Nigerian Demographic and Health Survey (2018 NDHS) about the roles of the key drivers of mother-to-daughter FGM/C prevalence in Nigeria? Here, drawing upon the 2018 NDHS dataset, we provided a context-specific study on the geographical patterns and the enabling factors of intergenerational trends in FGM/C among Nigerian women aged 15 – 49 years and their daughters aged 0 – 14 years. Using Bayesian semi-parametric geo-additive regression model, we simultaneously controlled for the effects of individual-level, community-level and unobserved geographical factors. We learnt that although there has been an overall decline in mother-to-daughter prevalence of FGM/C, the practice persists in Nigeria largely due to geographical location and social norm related factors – risk was high among daughters of circumcised women and daughters of women who supported the continuation of FGM/C. We identified Kano, Kaduna, Imo and Bauchi states as the hotspots and there was an increased risk of FGM/C among daughters of women who lived in the neigbouring states of Jigawa and Yobe. Daughters of circumcised women were about 2.7 times more likely to be cut. We recommend the development of tailored community-level interventions targeting circumcised women in the hotspot states and their neighbours to ensure a total eradication of female circumcision in Nigeria by the year 2030.

The Covid-19 pandemic led to a global food crisis. Like previous food crises how the debate is framed by food policy actors can have a bearing on policy outcomes. This study researches how the policy responses to migrant horticultural labour shortages, due to the pandemic, were framed in the Italian print media and how this relates to longer-term food policy making. Data were gathered from the six highest-circulation Italian daily newspapers. The coverage was dominated by left-leaning outlets and peaked in relation to Covid-19 recovery policies and political processes. Farmer industry bodies were the most quoted group, and the legalisation of undocumented migrant workers was the most frequently discussed policy response. A frames analysis was conducted and identified three principal frames: food security, worker exploitation and immigration. The worker exploitation and immigration frames were most frequently used by left-leaning newspapers, while centre-right papers used the food security frame the most often. The results suggest that media framing could contribute to both policy change, helping to open policy windows, as well as policy lock-ins, side-lining certain debates, actors and policy solutions. The research aims to contribute to growing empirical work which seeks to understand the impact of Covid-19 on migrant agricultural workers and food policy.

Funding information: Grant funding for this analysis was provided by the: (1) Centre for Surveillance and Research, Public Health Agency of Canada (6D016-123071/001/SS); 2) Canadian Institutes of Health Research (Project Grant PJT 162237); 3) Polish National Science Centre (2013/09/B/HS6/03438). Corresponding author, Valerie F. Pagnotta, is supported by a CIHR Frederick Banting and Charles Best Canada Graduate Scholarship. Background Strong variations in injury rates have been documented cross-nationally. Historically, these have been attributed to contextual determinants, both social and physical. We explored an alternative, yet understudied, explanation for variations in adolescent injury reporting-that varying access to medical care is, in part, responsible for cross-national differences. Methods Age-specific and gender-specific rates of medically treated injury (any, serious, by type) were estimated by country using the 2013/2014 Health Behaviour in School-aged Children study (n=209 223). Available indicators of access to medical care included: (1) the Healthcare Access and Quality Index (HAQ; 39 countries); (2) the Universal Health Service Coverage Index (UHC; 37 countries) and (3) hospitals per 100 000 (30 countries) then physicians per 100 000 (36 countries). Ecological analyses were used to relate injury rates and indicators of access to medical care, and the proportion of between-country variation in reported injuries attributable to each indicator. Results Adolescent injury risks were substantial and varied by country and sociodemographically. There was little correlation observed between national level injury rates and the HAQ and UHC indices, but modest associations between serious injury and physicians and hospitals per 100 000. Individual indicators explained up to 9.1% of the total intercountry variation in medically treated injuries and 24.6% of the variation in serious injuries. Conclusions Cross-national variations in reported adolescent serious injury may, in part, be attributable to national differences in access to healthcare services. Interpretation of cross-national patterns of injury and their potential aetiology should therefore consider access to medical care as a plausible explanation. Postprint

Oral and Maxillofacial research has utilised predominantly quantitative research approaches and qualitative methodologies have been applied with very narrow scope. Although qualitative surgical research is increasing in popularity there is a lack of patient voice within extant research and important aspects of patients’ experiences including preparation, perceptions of well-being and functional outcomes are potentially overlooked. This provides researchers with significant opportunities to devise approaches that expand our understanding of the social contexts surrounding surgical interventions and associated outcomes and to develop better-informed approaches to research and practice. Reflecting on a novel research project involving OMFS patients this paper seeks to outline some distinct advantages of qualitative research based on researcher reflections. Firstly, we contend that understanding patients as collaborators within the research process helps to establish a research design that reflects the context and complexities of the phenomenon under investigation and in-creases the precision of the concepts being addressed. Secondly, interactive group-based data col-lection approaches create a space in which patients are able to explore aspects relating to OMFS. Thirdly, we suggest that patient interaction optimizes the quality of data by providing participants with the opportunity to engage in conversation with those who understand the treatment processes. The final advantage concerns the intentional involvement of patients within the data analysis phase. We contend that interactive approaches to data collection and analysis where data are collected, analysed, compared and refined as new data are acquired helps to develop a conceptual explanation for the phenomenon in question that is both significant and relevant to the setting being studied. We conclude with recommendations for future research.

Objectives To investigate the association between vaccination against coronavirus disease 2019 (COVID-19) and autoimmune rheumatic disease (AIRD) flare. Material and methods Patients with AIRDs vaccinated against COVID-19 who consulted for disease flare between 1 December 2020 and 31 December 2021 were ascertained in Clinical Practice Research Datalink (Aurum). AIRD flare was defined as consultation for AIRD with CS prescription on the same day or the next day. Vaccination was defined using date of vaccination and product code. The observation period was partitioned into vaccine-exposed (21 days after vaccination), pre-vaccination (7 days before vaccination) and remaining vaccine-unexposed periods. Participants contributed data with multiple vaccinations and outcomes. Season adjusted incidence rate ratios (aIRR) and 95% CI were calculated using self-controlled case series analysis. Results Data for 3554 AIRD cases, 72% female, mean age 65 years and 68.3% with RA, were included. COVID-19 vaccination was associated with significantly fewer AIRD flares in the 21-day vaccine-exposed period when all vaccinations were considered [aIRR (95% CI) 0.89 (0.80, 0.98)]. Using dose-stratified analyses there was a statistically significant negative association in the 21 days after first COVID-19 vaccination but no association after the second or third COVID-19 vaccinations [aIRR (95% CI) 0.76 (0.66, 0.89), 0.94 (0.79, 1.11) and 1.01 (0.85, 1.20), respectively]. On AIRD-type stratified analyses, vaccination was not associated with disease flares. Vaccination without or after severe acute respiratory syndrome coronavirus 2 infection, and with vectored DNA or mRNA vaccines, associated with comparable reduced risk of AIRD flares in the vaccine-exposed period after first COVID-19 vaccination. Conclusions Vaccination against COVID-19 was not associated with increased AIRD flares regardless of prior COVID-19, AIRD type, and whether mRNA or DNA vaccination technology were used.

In the early stages of the pandemic, Saudi Arabia and other countries in the Arab Gulf region relied on non-pharmaceutical therapies to limit the effect of the pandemic, much like other nations across the world. In comparison to other nations in the area or globally, these interventions were successful at lowering the healthcare burden. This was accomplished via the deterioration of the economy, education, and a variety of other societal activities. By the end of 2020, the promise of effective vaccinations against SARS-CoV-2 have been realized, and vaccination programs have begun in developed countries, followed by the rest of the world. Despite this, there is still a long way to go in the fight against the disease. In order to explore disease transmission, vaccine rollout and prioritisation, as well as behavioural dynamics, we relied on an age-structured compartmental model. We examine how individual and social behaviour changes in response to the initiation of vaccination campaigns and the relaxation of non-pharmacological treatments. Overall, vaccination remains the most effective method of containing the disease and resuming normal life. Additionally, we evaluate several vaccination prioritisation schemes based on age group, behavioural responses, vaccine effectiveness, and vaccination rollout speed. We applied our model to four Arab Gulf nations (Saudi Arabia, Bahrain, the United Arab Emirates, and Oman), which were chosen for their low mortality rate compared to other countries in the region or worldwide, as well as their demographic and economic settings. We fitted the model using actual pandemic data in these countries. Our results suggest that vaccinations focused on the elderly and rapid vaccine distribution are critical for reducing disease resurgence. Our result also reinforces the cautious note that early relaxation of safety measures may compromise the vaccine's short-term advantages.

Background A series of 31 radiographs is recommended by the Royal College of Radiologists (RCR) when investigating suspected physical abuse (SPA). Objective To determine the radiation dose delivered for skeletal surveys performed for SPA in Victorian radiology departments based on their local protocols. Materials and methods A 5-year-old paediatric bone fracture phantom was radiographed at five radiology sites using both the RCR recommended protocol and, where applicable, the local departmental SPA protocol. The radiation doses were measured and recorded. These were scaled down to estimate the effective radiation doses for a 2-year-old child at each site and the associated radiation risks estimated. Results The median effective dose for all radiographic projections in the RCR skeletal survey radiographic series was 0.09 mSv. The estimated risk of radiation-induced cancer and radiation-induced death from cancer for 2-year-old children is classified as “very low,” with girls having a higher risk than boys. Conclusion The median effective radiation dose for the RCR skeletal survey for imaging in SPA was 0.09 mSv resulting in a “very low” additional risk of radiation-induced cancer. The authors will now aim to ascertain whether whole-body CT skeletal survey can replace the radiographic series for imaging in SPA while maintaining a comparable radiation dose.

AISI 1045 can be machined well in all machining operations, namely drilling, milling, turning, broaching and grinding. It has many applications, such as crankshafts, rollers, spindles, shafts, and gears. Wiper geometry has a great influence on cutting forces (Fr, Ff, Fc and R), temperature, material removal rate (MRR) and surface roughness (Ra). Wiper inserts are used to achieve good surface quality and avoid the need to buy a grinding machine. In this paper, an optimization-based investigation into previously reported results for Taguchi’s based L27 orthogonal array experimentations was conducted to further examine effect of the edge geometry on the turning performance of AISI 1045 steel in dry conditions. Three input parameters used in current research include the cutting speed (Vc), feed (f) and depth of cut (ap), while performance measures in this research were Ra, Fr, Ff, Fc, R, temperature (temp) and MRR. The Vise Kriterijumska Optimizacija Kompromisno Resenje (VIKOR) method was used to normalize and convert all the performance measures to a single response known as the VIKOR-based performance index (Vi). The machine learning (ML) approach was used for the prediction and optimization of the input variables. A correlation plot is developed between the input variable and Vi using the ML approach. The optimized setting suggested by Vi-ML is Vc: 160 m/min; ap: 1 mm and f: 0.135 mm/rev, and the corresponding value of Vi was 0.2883, while the predicted values of Ra, Fr, Ff, Fc, R, temp and MRR were 2.111 µm, 43.85 N, 159.33 N, 288.13 N, 332,16 N, 554.4 °C and 21,600 mm3/min, respectively.

Objective The aim of this study was to investigate the effect of treat-to-target combination therapy with intensification at 13 weeks in early RA. Methods Early RA patients were classified as being at high or low risk of worsening RA based on disease activity and prognostic factors. High-risk patients received COBRA-light (prednisolone 30 mg/day tapered to 7.5 mg/day, MTX increasing to 25 mg/week), and low-risk patients received MTX monotherapy increasing to 25 mg/week. The primary outcome (target) was DAS44 Results In the high-risk group (n = 150), 110 patients (73%) reached the target at 13 weeks, and 9 dropped out. Non-responders were randomized to intensification (n = 15) or continuation (n = 16), and after 26 weeks, 12 (80%) vs 7 (44%) of these, respectively, reached the target [difference: 36%, (95% CI 2%, 71%); P = 0.04]. In the low-risk group (n = 40), 17 (43%) reached the target. Non-responders were randomized to intensification (n = 8) or continuation (n = 7); 4 vs 3, respectively, reached the target. Adverse event rates were higher in the high-risk group, and higher in the intensification subgroup of that group. Serious adverse events were rare. Protocol violations were frequent and mostly led to mitigation of actual treatment intensification. Conclusion Initial combination therapy was very successful in high-risk RA, and early intensification was beneficial in patients not reaching the strict target. The low-risk group was too small for drawing conclusions. In routine practice, adherence to early intensification based on strict targets is difficult. Trial registration Netherlands Trial Register (NTR), NL4393, https://www.trialregister.nl/.

Objective: Methotrexate (MTX) is effective in controlling disease activity in rheumatoid arthritis (RA). Parenteral MTX may have benefits over oral MTX, but it is rarely used in practice. To better understand this low usage rate, it is necessary to explore the barriers and enablers of therapy from the perspective of RA patients. The objectives of this scoping review were to describe RA patients’ perspectives on the barriers and enablers in the use of parenteral MTX and to identify the research gaps in this field. Methods: The search was performed in Medline, Embase, Scopus, and Cochrane Library from inception to May 2021. Data synthesis was conducted using the Theoretical Framework of Acceptability. This scoping review included any type of study that explored the use of parenteral MTX by adult RA patients from the patients’ perspective, written in English. Results: Fifteen studies were included; findings related to the constructs “affective attitude,” “burden,” “intervention coherence,” and “self-efficacy” were explored the most, while some were rarely (“opportunity cost” and “perceived effectiveness”) or not (“ethicality”) reported. RA patients were generally satisfied with MTX injections (“affective attitude”). From the burden construct, the requirement for dexterity for administering MTX by injection was considered a barrier, whereas the lack of significant pain from MTX injection was considered an enabler. Conclusion: The findings suggested that patients generally preferred parenteral MTX formulations with attributes that facilitate self-administration. However, much of the identified research focused on prefilled pen devices, and significant gaps were identified, such as a lack of qualitative research. Refereed/Peer-reviewed

Severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) infection is associated with a range of persistent symptoms impacting everyday functioning, known as post-COVID-19 condition or long COVID. We undertook a retrospective matched cohort study using a UK-based primary care database, Clinical Practice Research Datalink Aurum, to determine symptoms that are associated with confirmed SARS-CoV-2 infection beyond 12 weeks in non-hospitalized adults and the risk factors associated with developing persistent symptoms. We selected 486,149 adults with confirmed SARS-CoV-2 infection and 1,944,580 propensity score-matched adults with no recorded evidence of SARS-CoV-2 infection. Outcomes included 115 individual symptoms, as well as long COVID, defined as a composite outcome of 33 symptoms by the World Health Organization clinical case definition. Cox proportional hazards models were used to estimate adjusted hazard ratios (aHRs) for the outcomes. A total of 62 symptoms were significantly associated with SARS-CoV-2 infection after 12 weeks. The largest aHRs were for anosmia (aHR 6.49, 95% CI 5.02–8.39), hair loss (3.99, 3.63–4.39), sneezing (2.77, 1.40–5.50), ejaculation difficulty (2.63, 1.61–4.28) and reduced libido (2.36, 1.61–3.47). Among the cohort of patients infected with SARS-CoV-2, risk factors for long COVID included female sex, belonging to an ethnic minority, socioeconomic deprivation, smoking, obesity and a wide range of comorbidities. The risk of developing long COVID was also found to be increased along a gradient of decreasing age. SARS-CoV-2 infection is associated with a plethora of symptoms that are associated with a range of sociodemographic and clinical risk factors.

Autistic Children and young people (CYP) experience higher rates of mental health problems, including anxiety and depression, than their neurotypical peers. Yet, often mental health assessment and support is lacking for autistic CYP as assessment tools and evidence-based interventions have typically been developed with neurotypical population needs in mind. Following a narrative matters style, this article outlines the lack of recognition given in mental health services towards autistic CYP attempting to access support, highlighting some future priorities in service delivery. Issues relating to health professionals misinterpreting and mis-labelling autistic CYP experiences, the impact that this has upon those attempting to gain mental health support and possible changes that can be implemented at minimal cost both financially and to service delivery design and implementation are highlighted.

Objective To examine the effects of shoe-stiffening inserts on lower limb kinematics in individuals with first metatarsophalangeal (MTP) joint osteoarthritis (OA). Methods Forty-eight individuals with radiographically confirmed first MTP joint OA (24 males and 24 females; mean age 57.8 years, standard deviation 10.5) were randomized to receive either shoe-stiffening inserts or sham inserts, and underwent gait analysis during level walking using a 10-camera infrared Vicon motion analysis system. Sagittal plane kinematics of the first MTP, ankle, knee, and hip joints were compared between the shoe only (control) and insert conditions in both groups (within-groups) and between both insert conditions (between-groups). Results Compared to the shoe only condition, the sham insert reduced knee flexion and total excursion, and the shoe-stiffening insert reduced first MTP joint maximum dorsiflexion and ankle joint maximum plantarflexion, and increased maximum knee flexion and total excursion. Between-group comparisons indicated that the shoe-stiffening inserts significantly decreased first MTP joint maximum dorsiflexion, ankle joint maximum plantarflexion and total excursion, and increased knee joint maximum flexion and total excursion compared to the sham inserts. Conclusion Carbon fibre shoe-stiffening inserts significantly alter sagittal plane lower limb joint kinematics during walking, particularly first MTP joint maximum dorsiflexion. These findings provide insights into the mechanisms that may be responsible for their clinical effectiveness in the treatment of first MTP joint OA, and potentially explain changes in symptoms in other lower limb joints.

Je dobře známo, že neúplná bainitická transformace během austemperace je způsobena především přesycením austenitu uhlíkem. Takto přesycený austenit se stává stabilnějším a k další stabilizaci vede legování křemíkem. Stabilní austenit se nepřeměňuje a zůstává ve struktuře jako tzv. zbytkový austenit. Proto nemohou vznikat karbidy, které jsou v konvenční bainitické struktuře žádoucí, a vzniká bainit bez karbidů. Pozitivní vliv křemíku a uhlíku na stabilizaci austenitu v CFB strukturách byl již prokázán a popsán. Chrom je však dalším prvkem, který má zásadní význam při neúplné bainitické transformaci. Vliv chromu na vývoj mikrostruktury v nekonvenčních AHS ocelích při austemperaci je podrobně diskutován v experimentu v tomto článku. It is well known that incomplete bainitic transformation during austempering treatment is mainly caused by the supersaturation of austenite with carbon. Such supersaturated austenite becomes more stable and further stabilization is led by silicon alloying. Stable austenite does not transform and re-mains in the structure as socalled residual austenite. Therefore, carbides, which are desirable in a conventional bainitic structure, cannot be formed and carbide free bainite is formed. The positive effect of silicon and carbon on austenite stabilization in CFB structures has already been demonstrated and described. But chromium is another element that is crucial in the incomplete bainitic trans-formation. The influence of chromium on the development of microstructure in unconventional AHS steels during austempering is discussed in detail in the experiment in this paper.

Widely shared traumas have the potential to both improve and impair our relationships with others. During COVID-19 anxiety has been seen as a major individual vulnerability associated with relationship change, as have the wider economic, situational factors facing families and communities. In this national sample of 997 Japanese respondents we assessed perceived relationship changes in couple relations, neighbourhood relations, and wider relations with Japanese nationals, alongside anxiety, exposure to previous mass traumas, household economics, education, and vulnerability to COVID-19. Whilst most respondents reported little change in their relationships during this year there was a small overall improvement in couple relationships and a decline in relations with wider communities. Participant's economic resources were positively associated with an improvement in couple relationships, while anxiety was associated with a decline in relations with both the neighbourhood and the wider society. While neither prior experience of mass trauma, nor education or health vulnerability to COVID-19, were associated with relationship change, having time to talk, and younger age, was positively associated with improvement in couple relations. Findings suggest that anxiety can function to distance relationships during a time of stress, but perceived changes in relationships are little effected by experience of previous trauma. Relationship growth is likely to be greatest in those with better economic conditions. Practitioners need to be mindful of the impact of enhanced anxiety during the pandemic on interpersonal relations, and a potential threat to the relationships of older couples during this time of pandemic threat.

Background: Experimental and epidemiological studies indicate an association between exposure to particulate matter (PM) air pollution and increased risk of type 2 diabetes. In view of the high and increasing prevalence of diabetes, we aimed to quantify the burden of type 2 diabetes attributable to PM2·5 originating from ambient and household air pollution.Methods: We systematically compiled all relevant cohort and case-control studies assessing the effect of exposure to household and ambient fine particulate matter (PM2·5) air pollution on type 2 diabetes incidence and mortality. We derived an exposure–response curve from the extracted relative risk estimates using the MR-BRT (meta-regression—Bayesian, regularised, trimmed) tool. The estimated curve was linked to ambient and household PM2·5 exposures from the Global Burden of Diseases, Injuries, and Risk Factors Study 2019, and estimates of the attributable burden (population attributable fractions and rates per 100 000 population of deaths and disability-adjusted life-years) for 204 countries from 1990 to 2019 were calculated. We also assessed the role of changes in exposure, population size, age, and type 2 diabetes incidence in the observed trend in PM2·5-attributable type 2 diabetes burden. All estimates are presented with 95% uncertainty intervals.Findings: In 2019, approximately a fifth of the global burden of type 2 diabetes was attributable to PM2·5 exposure, with an estimated 3·78 (95% uncertainty interval 2·68–4·83) deaths per 100 000 population and 167 (117–223) disability-adjusted life-years (DALYs) per 100 000 population. Approximately 13·4% (9·49–17·5) of deaths and 13·6% (9·73–17·9) of DALYs due to type 2 diabetes were contributed by ambient PM2·5, and 6·50% (4·22–9·53) of deaths and 5·92% (3·81–8·64) of DALYs by household air pollution. High burdens, in terms of numbers as well as rates, were estimated in Asia, sub-Saharan Africa, and South America. Since 1990, the attributable burden has increased by 50%, driven largely by population growth and ageing. Globally, the impact of reductions in household air pollution was largely offset by increased ambient PM2·5.Interpretation: Air pollution is a major risk factor for diabetes. We estimated that about a fifth of the global burden of type 2 diabetes is attributable PM2·5 pollution. Air pollution mitigation therefore might have an essential role in reducing the global disease burden resulting from type 2 diabetes.Funding: Bill & Melinda Gates Foundation.

Background:\ud Diets in the Lake Victoria region of Kenya have been described as monotonous, consisting chiefly of starchy staple foods, accompanied by green vegetables and oil. To promote healthy eating in the region, 11 food-based dietary guidelines (FBDGs) were proposed.\ud \ud Objective:\ud This study was designed to assess perception of the proposed FBDGs amongst consumers in Lake Victoria region.\ud \ud Design and setting:\ud A qualitative, descriptive cross-sectional design was used to collect data from 36 focus-group discussions (FGD) among adult males (18) and females (18) in Kisumu and Homa Bay Counties.\ud \ud Subjects:\ud A total of 207 adult males (26–74 years) and 211 females (18–71 years) participated in this study.\ud \ud Data collection and analysis:\ud Proposed FBDGs were printed on posters and presented to FGD participants. Proceedings were audio-taped, transcribed, translated and analysed based on themes.\ud \ud Results:\ud The proposed FBDGs were perceived as promoting the consumption of a balanced diet. As a concept, a balanced diet was misrepresented as composed of only three nutrients: carbohydrates, proteins and vitamins. There was no mention of fats/oils and minerals as other significant nutrient constituents of a balanced diet. Other concepts, which included ‘three regular meals’, ‘snacks’, ‘food variety’, ‘healthy and physically active lifestyle’, were polysemous.\ud \ud Conclusion:\ud The findings provide insight to guide the adaptation of the national FBDGs. The findings also provide a basis for nutrition advocacy programmes and a rationale for the revision of nutrition education materials, including the school curriculum, to align content with current evidence-based information.

Purpose The purpose of this paper is to present findings from a mixed-methods study on the impact that COVID-19 has had on adult safeguarding. The research sought to explore the challenges and opportunities presented by COVID-19 to both frontline and non-frontline professionals working in adult safeguarding. Design/methodology/approach A mixed-methods project was undertaken comprising a literature review, survey, semi-structured interviews and a small number of freedom of information requests. This paper presents the findings predominantly from the survey and interviews. Findings Unsurprisingly, COVID-19 has presented a variety of challenges for professionals working in adult safeguarding. The themes that occurred most often were the day-to-day changes and challenges, relationships across sectors, information and navigating the ethical questions in safeguarding. Originality/value To the best of the authors’ knowledge, the findings represent the first focused qualitative mixed-method study aimed at understanding more about the impact the pandemic has had on adult safeguarding through the eyes of those professionals working in that field.

Objective: Mothers play a significant role in decision making about human papillomavirus (HPV) vaccination for their daughters and about cervical screening attendance for themselves. This study had three objectives, to explore: 1) mothers’ knowledge and attitudes about HPV and HPV vaccination, 2) their knowledge and attitudes about cervical cancer and screening, and 3) whether their daughter’s HPV vaccination invitation was an opportunity to nudge mothers to attend screening. \ud \ud Design: 138 women from North Staffordshire completed a cross-sectional survey and 15 took part in follow-up focus groups. \ud \ud Results: Despite high self-reported engagement with both the cervical screening and HPV vaccination programmes, relatively low levels of knowledge and some uncertainty were evident. There was mixed opinion about the potential of using the vaccination invite as an opportunity to nudge mothers to attend cervical screening. \ud \ud Conclusion: Even amongst women who do engage positively with the programmes, knowledge is not as complete and certain as it could be. Further research is needed with women who are less likely to accept the vaccination for their daughters. Women need to be better informed, which may go some way to reversing the decline in screening and maintaining high levels of vaccination.

Objective To elicit what information and clinical decision-making processes physiotherapists use in the assessment and management of paediatric shoulder instability.\ud \ud Design Qualitative study. A modified nominal focus group technique, involving three clinical vignettes, was used to elicit physiotherapists' decision-making processes.\ud \ud Setting Physiotherapy departments from across four separate clinical sites.\ud \ud Subjects Twenty-five physiotherapists, (18F:7M), ranging from two to 29 years post qualification.\ud \ud Outcomes measures Thematic analysis. The initial round of coding was used to draw up a quantitative assessment of the diagnoses and map information used for clinical decision-making against the International Classification of Functioning (ICF) framework.\ud \ud Results The themes identified related to 'Differences in diagnoses, classification and diagnostic processes', 'Diagnostic process occurs over a long period of time', 'Management and prognosis are influenced by a number of factors' and 'Diagnostic test choices and prognosis influenced by factors beyond the patient injury' .\ud \ud Conclusion Current methods of assessment are prone to bias and error and may lead to inconsistent or delayed provision of essential care. Further work is needed to develop methods of measurement and frameworks which can accurately identify relevant physiological mechanisms and personal factors associated with shoulder instability as a part of the assessment/diagnostic process. (C) 2022 Chartered Society of Physiotherapy. Published by Elsevier Ltd. All rights reserved.

Older forensic mental health patients have complex needs and requirements; service provision is required to address mental health, offending risk and issues associated with aging (geriatric care). This study aimed to identify the systems and processes that enable valued progress (in terms of quality of life, health, wellbeing, recovery and reduced risk) for older forensic mental health patients. Interviews were conducted with 48 members of staff working with these patients in secure hospitals or the community. Thematic analysis was used to analyse the data. Four overarching themes were identified regarding what facilitated or acted as a barrier in relation to quality of life, health, wellbeing and recovery. Multidisciplinary input, an individualised approach and implementing holistic and needs-led care was found to facilitate progress. However, lack of resources, excluding the patients in care planning, gaps in expertise and knowledge, and a lack of specialised units that could address mental health, forensic and elderly needs were found to be barriers. Extensive, multilevel and wide-ranging support is required specifically for older forensic mental health patients. Joint working is required between older adult and forensic mental health services incorporating geriatric medicine expertise in order to implement co-produced care and treatment plans.

Background: Women’s magazines provide a space in which gendered norms around alcohol-related practice are (re)-produced. They act as important points of reference for women to draw upon in their own understandings of alcohol use within their identity making. Studying the alcohol-related messages women’s magazines disseminate is therefore an important line of inquiry.\ud Methods: An analysis of textual and visual alcohol depictions, including alcohol advertising, in 70 editions of 20 printed magazines targeted at and read by women, published between August 2020 and January 2021, was conducted using quantitative content and qualitative thematic analysis.\ud Results: Women’s magazines have the potential to disseminate public health messages about the physical and mental health impacts of alcohol use, alcohol’s role in gender inequalities and the risk of harm from alcohol use by men. However, they do so in ways that reproduce harmful gender norms and expectations, and overlook the structural causes of alcohol-related harms. Associations between alcohol use and violence against women were simplified, in ways that ignored the root causes, produced victim-blaming narratives and deflected responsibility from the perpetrator to the effects of alcohol. Narratives around drinking and sobriety were underpinned by concerns over appearance, which reinforced social expectations of the ideal feminine body. Health narratives were in conflict with the presence of pro-alcohol messages such as consumption suggestions and alcohol advertising, which promoted alcohol use as a normalised aspect of women’s day to day lives.\ud Conclusions: Women receive a number of mixed and contradictory messages on alcohol use through their magazine readership, which places limits on magazines as educational sources of public health messaging.

Background/Objective To explore acceptability by patients and health care professionals of a new surveillance pathway for people with previously treated and stable diabetic macular oedema (DMO) and/or proliferative diabetic retinopathy (PDR). Subject/Methods Structured discussions in 10 focus groups with patients; two with ophthalmic photographers/graders, and one with ophthalmologists, held across the UK as part of a large diagnostic accuracy study (EMERALD). Results The most prominent issues raised by patients concerned (i) expertise of the various professionals within clinic, (ii) quality of interactions with clinic professionals, especially the flow of information from professionals to patients, and (iii) wish to be treated holistically. Ophthalmologists suggested such issues could be best dealt with via a programme of patient education and tended to overlook deeper implications of patient concerns for the organisation of services. Conclusion For patients, the clinical service should not only include the identification and treatment of disease but also exchange of information, reassurance, and mitigation of anxiety. Alterations in the standard care pathway need to take account of such concerns and their implications, in addition to any assessments of ‘efficiency’ that may flow from changes in diagnostic technology, or the division of professional labour.

Objective We aimed to systematically review the literature to retrieve evidence on the diagnostic and prognostic value of musculoskeletal ultrasound for a treat to target (T2T) approach in RA. Methods Eight research questions were developed addressing the role of ultrasound (including different ultrasound scores and elementary lesions) for diagnosis, monitoring and prognosis of RA. PubMed and EMBASE were searched (2005–2020). Articles on RA and reporting data on musculoskeletal ultrasound were included and extracted according to the underlying questions, and risk of bias assessed according to the study design. Results Out of 4632 records, 60 articles were included. Due to clinical heterogeneity, meta-analysis was not possible. Ultrasound better predicted disease relapses with respect to clinical examination in patients in remission, while both methods performed similarly in predicting response to therapy, achievement of remission and radiographic progression. Ultrasound was superior to clinical examination in diagnosing joint involvement using another imaging modality, such as magnetic resonance imaging, as reference. Limited ultrasound scores performed like more extensive evaluations for the detection of joint inflammation and for outcome prediction. Higher ultrasound scores of synovitis were linked to poor outcomes at all disease stages, but a specific cut-off distinguishing between low- and high-risk groups did not emerge. Conclusions These data confirm the pivotal role of ultrasound when evaluating synovial inflammation and when identifying RA patients at higher risk of relapse. Further research is needed to better define the role of ultrasound in a T2T management strategy in moderately-to-highly active RA.

The separation of nomadic pastoralist settlements from settled communities is a well-known challenge to the health system. Difficulties reaching these groups contribute to inequities in their health and impact the spread or control of several diseases. COVID-19 has led to the suspension of many public health interventions in Cameroon, while preventive measures including behavior change communication have been ongoing since the onset of the pandemic. The reach and utility of these campaigns in semi-nomadic population remain unclear. This exploratory qualitative study was conducted in September to October 2020 using semi-structured interviews and focus group discussions with nomadic camp heads, and their wives to explore their interactions with communication campaigns, awareness, understanding, and acceptance of behavior change messages. The study revealed a general awareness of COVID-19 and its preventive measures and a prevailing belief that they were less at risk because their camps are isolated from the main communities, and the fact that they had never met a COVID-19 case. They perceived that the women were at lower risk because of their limited interaction outside the camps. There was a common concern regarding the transmission of COVID-19 to their cattle. Routes of communication were markets and mosques frequented by men, making access to information limited to or dependent on men. Financial constraints and lack of water were the main barriers affecting the access to and use of COVID-19 prevention measures. There is need for adaptive communication strategies especially tailored to the culture of nomadic pastoralists addressing gender dynamics of this subgroup.

Purpose The service configuration with distinct child and adolescent mental health services (CAMHS) and adult mental health services (AMHS) may be a barrier to continuity of care. Because of a lack of transition policy, CAMHS clinicians have to decide whether and when a young person should transition to AMHS. This study describes which characteristics are associated with the clinicians’ advice to continue treatment at AMHS. Methods Demographic, family, clinical, treatment, and service-use characteristics of the MILESTONE cohort of 763 young people from 39 CAMHS in Europe were assessed using multi-informant and standardized assessment tools. Logistic mixed models were fitted to assess the relationship between these characteristics and clinicians’ transition recommendations. Results Young people with higher clinician-rated severity of psychopathology scores, with self- and parent-reported need for ongoing treatment, with lower everyday functional skills and without self-reported psychotic experiences were more likely to be recommended to continue treatment. Among those who had been recommended to continue treatment, young people who used psychotropic medication, who had been in CAMHS for more than a year, and for whom appropriate AMHS were available were more likely to be recommended to continue treatment at AMHS. Young people whose parents indicated a need for ongoing treatment were more likely to be recommended to stay in CAMHS. Conclusion Although the decision regarding continuity of treatment was mostly determined by a small set of clinical characteristics, the recommendation to continue treatment at AMHS was mostly affected by service-use related characteristics, such as the availability of appropriate services.

Objectives To investigate the association between patient–physician discordance in the assessment of disease activity and residual US synovitis/tenosynovitis in a cohort of patients with RA in clinical remission. Methods A post hoc analysis of the STARTER study, promoted by the Musculoskeletal-US (MSUS) Study Group of the Italian Society for Rheumatology, was performed using data from 361 consecutive patients with RA in clinical remission. The global assessment of disease activity by each patient (PGA) and evaluator/physician (EGA) was recorded on a 100-mm visual analogue scale. The PGA-EGA discordance was classified as positive (PGA>EGA) or negative (PGA Results The mean (s.d.) PGA and EGA scores were 6.1 (7.1) and 8.8 (12) mm, respectively, with a median (IQR) absolute difference of 4 (0–10) mm. Positive and negative discordances were recorded in 39 (10.8%) and 65(18.0%) patients, respectively. The GS-S (adjOR 1.099) and PD-S (adjOR 1.167) scores were associated with positive discordance (P Conclusions Patient–physician discordance is associated with the lack of US remission in patients with RA and may represent a further indication for MSUS.

During the Covid-19 Pandemic, the usage of social media networks increased exponentially. People engage in education, business, shopping, and other social activities (i.e., Twitter, Facebook, WhatsApp, Instagram, YouTube). As social networking expands rapidly, its positive and negative impacts affect human health. All this leads to social crimes and illegal activities like phishing, hacking, ransomware, password attacks, spyware, blackmailing, Middle-man-attack. This research extensively discusses the social networking threats, challenges, online surveys, and future effects. We conduct an online survey using the google forms platform to collect the responses of social networking sites (SNS) users within Pakistan to show how SNS affects health positively and negatively. According to the collected response, we analyzed that 50% of the users use SNS for education purposes, 17.5% use it for shopping purposes, 58.2% use it for entertainment, 37.1% use it for communication, and 9.8% use it for other purposes. According to the response, the excessive use of SNS affects the health that 9.8% users face the physical threat, 42.8% user faces mental health issues due to excessive or inappropriate use of SN, and 50.5% users feel moral threat using Social sites. Finally, we conclude our paper by discussing the open challenges, conclusions, and future directions.

Whole genome sequencing (WGS) is being considered as a tool to deliver newborn screening (NBS) internationally. Its use would dramatically increase the number of genetic variants identified, presenting a host of ethical, social, and practical considerations. A scoping review was conducted to examine the acceptability of WGS-NBS among parents, the public, and health professionals. Parent/public groups were enthusiastic about WGS-NBS, holding panoramic views of current/future benefits, incorporating family and wider society. While actionable early-onset findings were prioritised, non-actionable and uncertain results were still viewed as empowering. Conversely, professionals preferred selective results disclosure, prioritised by clinical need. They emphasised the need for meaningful consent and protection of the child’s autonomy. All groups outlined the importance of properly considered implementation (e.g. resources, governance) to minimise harms and prevent a reduction in NBS participation. As genomic medicine integrates into healthcare, divergent conceptualisations of ‘harms’ and ‘benefits’ across social groups must be considered.

The public and patients can be powerful sensors for shaping and powering healthcare research. They are joining research teams as investigators and collaborators to co-produce evidence for the practical use of interventions in clinical practice. While clinicians and researchers are encouraged by funders and policymakers to involve the public and patients as partners in research, knowledge on what involvement consists of is limited, and the continuum between consultation, collaboration and co-production are not clearly defined. In this article, we explore Patient and Public Involvement (PPI) and introduce greater involvement through research co-production. Co-production describes ways that research partnership can work through public and patient involvement and we outline the similarities of co-production to "The Commons", a strategy utilized by economists to increase effective use of resources. We share examples of how public and patient involvement have used co-production, to demonstrate financial and health benefits. We then outline practical challenges at system, social and cultural levels and consider how others have worked to resolve them. [Abstract copyright: Copyright © 2021 Elsevier B.V. All rights reserved.]

BackgroundOwing to poor continuity of care between child and adult mental health services, young people are often discharged to their GP when they reach the upper boundary of child and adolescent mental health services (CAMHS). This handover is poorly managed, and GPs can struggle to support young people without input from specialist services. Little is known about young people’s experiences of accessing mental health support from their GP after leaving CAMHS.AimTo explore the experiences and perspectives of young people and the parents/carers of young people receiving primary care support after CAMHS and to identify barriers and facilitators to accessing primary care.Design and settingQualitative study with young people and parents in two English counties: London and West Midlands.MethodNarrative interviews were conducted with 14 young people and 13 parents who had experienced poor continuity of care after reaching CAMHS transition boundary. Data were analysed using reflexive thematic analysis.ResultsThree themes were identified: unmet mental health needs, disjointed care, and taking responsibility for the young person’s mental health care. Barriers included the perception that GPs couldn’t prescribe certain medication, anxiety caused by the general practice environment, and having to move to a new practice at university. Young people’s positive experiences were more likely to include having a long-term relationship with their GP and finding that their GP made time to understand their needs and experiences.ConclusionGPs could help to meet the unmet needs of young people unable to access specialist mental health services after leaving CAMHS. There is a need for comprehensive handover of care from CAMHS to GPs, which could include a joint meeting with the young person and a member of the CAMHS team. Future research should focus on interventions which improve continuity of care for young people after leaving CAMHS, and collaborative working across community mental health services.

Pathogen deep-sequencing is an increasingly routinely used technology in infectious disease surveillance. We present a semi-parametric Bayesian Poisson model to exploit these emerging data for inferring infectious disease transmission flows and the sources of infection at the population level. The framework is computationally scalable in high-dimensional flow spaces thanks to Hilbert Space Gaussian process approximations, allows for sampling bias adjustments, and estimation of gender- and age-specific transmission flows at finer resolution than previously possible. We apply the approach to densely sampled, population-based HIV deep-sequence data from Rakai, Uganda, and find substantive evidence that adolescent and young women were predominantly infected through age-disparate relationships in the study period 2009–2015.

Background It is unclear whether seven interventions recommended by Public Health England for preventing and managing common musculoskeletal conditions reduce or widen health inequalities in adults with musculoskeletal conditions. Methods We used citation searches of Web of Science (date of ‘parent publication’ for each intervention to April 2021) to identify original research articles reporting subgroup or moderator analyses of intervention effects by social stratifiers defined using the PROGRESS-Plus frameworks. Randomized controlled trials, controlled before-after studies, interrupted time series, systematic reviews presenting subgroup/stratified analyses or meta-regressions, individual participant data meta-analyses and modelling studies were eligible. Two reviewers independently assessed the credibility of effect moderation claims using Instrument to assess the Credibility of Effect Moderation Analyses. A narrative approach to synthesis was used (PROSPERO registration number: CRD42019140018). Results Of 1480 potentially relevant studies, seven eligible analyses of single trials and five meta-analyses were included. Among these, we found eight claims of potential differential effectiveness according to social characteristics, but none that were judged to have high credibility. Conclusions In the absence of highly credible evidence of differential effectiveness in different social groups, and given ongoing national implementation, equity concerns may be best served by investing in monitoring and action aimed at ensuring fair access to these interventions.

Smart wearables provide an opportunity to monitor health in daily life and are emerging as potential tools for detecting cardiovascular disease (CVD). Wearables such as fitness bands and smartwatches routinely monitor the photoplethysmogram signal, an optical measure of the arterial pulse wave that is strongly influenced by the heart and blood vessels. In this survey, we summarize the fundamentals of wearable photoplethysmography and its analysis, identify its potential clinical applications, and outline pressing directions for future research in order to realize its full potential for tackling CVD., This work was supported by British Heart Foundation grants [PG/15/104/31913] and [FS/20/20/34626], the University of Cambridge EPSRC Impact Acceleration Account, the Wellcome EPSRC Centre for Medical Engineering at King’s College London [WT 203148/Z/16/Z], the European COST ACTION-Network for Research in Vascular Ageing CA18216 supported by COST (European Cooperation in Science and Technology), and the European Regional Development Fund (project No. 01.2.2-LMTK- 718-01-0030) under a grant agreement with the Research Council of Lithuania (LMTLT). The authors acknowledge: financial support from the Department of Health through the National Institute for Health Research Cardiovascular MedTech Co-operative at Guy’s and St Thomas’ NHS Foundation Trust.

COVID-19 pandemic has disrupted the political, economic and healthcare systems of most, if not all countries across the globe. As such, the COVID-19 pandemic represents another global health catastrophe similar to the Spanish influenza (1918–1920), H1N1 swine influenza (2009–2010) and West African Ebola (2014–2016) with high mortalities. Current public health measures aimed at subduing the spread of COVID-19 virus seem to be working but are not extensive enough to prevent ongoing infections and death.1 There is a need for leadership at the systems level, necessary because COVID-19 represents a complex problem, of a type commonly characterised as (volatile, uncertain, complex ambiguous (VUCA) unlikely to be effectively addressed by a single agency or person.2 In the context of COVID-19, leadership of the system encompasses politicians, scientific experts, civil servants and front-line practitioners, where leadership is shaped by the system in which it is enacted, and its historical, political and national characteristics.3 4 We discuss systems level leadership to address the COVID-19 outbreak,5–7 with concern for recovering from COVID-19. As our first aim, we outline three themes related to how systems level leadership might influence recovery from the COVID-19 pandemic. Second, we provide comparative international descriptors that we critically evaluate against these three systems level leadership themes. We draw on observations of the way systems level leadership is enacted across England, Australia, India and in the Caribbean (Aruba), thus drawing on lessons from both OECD nations and low-income and middle-income countries (LMICs), and small as well as large countries, in our analysis. Following which, in our conclusion, we set out prescriptions for systems level leadership in the context of considerable VUCA.2 As our first theme, to understand prospects for recovery, we need to examine preparation precrisis. In the preparation phase, while organisations and their leaders are faced …

Background Increasing physical activity among girls is a public health priority. Peers play a central role in influencing adolescent behaviour. Peer-led interventions may increase physical activity in adolescent girls, and a feasibility trial had shown that PLAN-A (Peer-led physical Activity iNtervention for Adolescent girls) had evidence of promise to increase physical activity in adolescent girls. Objective The objective was to test whether or not PLAN-A can increase adolescent girls’ physical activity, relative to usual practice, and be cost-effective. Design This was a two-arm, cluster-randomised controlled trial, including an economic evaluation and a process evaluation. Participants State-funded secondary schools in the UK with girls in Year 9 (aged 13–14 years) participated in the trial. All Year 9 girls in participating schools were eligible. Randomisation Schools were the unit of allocation. They were randomised by an independent statistician, who was blinded to school identities, to the control or intervention arm, stratified by region and the England Index of Multiple Deprivation score. Intervention The intervention comprised peer nomination (i.e. identification of influential girls), train the trainers (i.e. training the instructors who delivered the intervention), peer supporter training (i.e. training the peer-nominated girls in techniques and strategies underpinned by motivational theory to support peer physical activity increases) and a 10-week diffusion period. Outcomes The primary outcome was accelerometer-assessed mean weekday minutes of moderate to vigorous physical activity among Year 9 girls. The follow-up measures were conducted 5–6 months after the 10-week intervention, when the girls were in Year 10 (which was also 12 months after the baseline measures). Analysis used a multivariable, mixed-effects, linear regression model on an intention-to-treat basis. Secondary outcomes included weekend moderate to vigorous physical activity, and weekday and weekend sedentary time. Intervention delivery costs were calculated for the economic evaluation. Results A total of 33 schools were approached; 20 schools and 1558 pupils consented. Pupils in the intervention arm had higher Index of Multiple Deprivation scores than pupils in the control arm. The numbers randomised were as follows: 10 schools (n = 758 pupils) were randomised to the intervention arm and 10 schools (n = 800 pupils) were randomised to the control arm. For analysis, a total of 1219 pupils provided valid weekday accelerometer data at both time points (intervention, n = 602; control, n = 617). The mean weekday moderate to vigorous physical activity was similar between groups at follow-up. The central estimate of time spent engaging in moderate to vigorous physical activity was 2.84 minutes lower in the intervention arm than in the control arm, after adjustment for baseline mean weekday moderate to vigorous physical activity, the number of valid days of data and the stratification variables; however, this difference was not statistically significant (95% confidence interval –5.94 to 0.25; p = 0.071). There were no between-arm differences in the secondary outcomes. The intervention costs ranged from £20.85 to £48.86 per pupil, with an average cost of £31.16. Harms None. Limitations The trial was limited to south-west England. Conclusions There was no evidence that PLAN-A increased physical activity in Year 9 girls compared with usual practice and, consequently, it was not cost-effective. Future work Future work should evaluate the utility of whole-school approaches to promote physical activity in schools. Trial registration This trial is registered as ISRCTN14539759. Funding This project was funded by the National Institute for Health Research (NIHR) Public Health Research programme and will be published in full in Public Health Research; Vol. 10, No. 6. See the NIHR Journals Library website for further project information. This trial was designed and delivered in collaboration with the Bristol Randomised Trials Collaboration (BRTC), a United Kingdom Clinical Research Commission (UKCRC)-registered Clinical Trials Unit that, as part of the Bristol Trials Centre, is in receipt of NIHR Clinical Trials Unit support funding. The sponsor of this trial was University of Bristol, Research and Enterprise Development www.bristol.ac.uk/red/. The costs of delivering the intervention were funded by Sport England.

Rheumatoid arthritis (RA) is an inflammation-involved disorder and features the disruption of CD4+ T lymphocytes. Herein, we describe that microRNA-10b-5p (miR-10b) promotes RA progression by disrupting the balance between subsets of CD4+ T cells. MiR-10b-deficient mice protected against collagen antibody-induced arthritis (CAIA) model. RNA sequencing results indicated that disordered genes in miR-10b−/− CAIA model are closely associated with CD4+ T cells differentiation. Moreover, miR-10b mimics promoted Th1/Th17 and suppressed Th2/Treg cells differentiation, whereas miR-10b inhibitor induced contrary effects. In addition, GATA3 and PTEN was confirmed as two targets of miR-10b, and GATA3 siRNA could increase Th1 and reduce Th2 cells meanwhile PTEN siRNA could increase Th17 and decrease Treg cells. Furthermore, miR-10b inhibitor significantly ameliorated collagen-induced arthritis (CIA) development by attenuating the dysfunctional CD4+ T cell subpopulations. The present findings suggest that miR-10b could disrupt the balance of CD4+ T subsets, while suppressed miR-10b could attenuate the severity of experimental arthritis, which provided us a novel mechanistic and therapeutic insight into the RA.

PurposeThe study examines alcohol and drug related accidental dwelling fire injuries during 2006–2016 in Merseyside in England.Design/methodology/approachThe study carries out an examination of alcohol and drug related fire injuries from 2006 to 2016 in Merseyside, including analysis of injuries by age group, gender, level of deprivation and housing type.FindingsDeprivation was a significant factor in alcohol and drug related fire injuries over the period studied, with 70% of such injuries occurring in areas with the highest level of deprivation. Males appeared roughly twice as likely to be injured in an alcohol and drug related fire incident than females. The majority of those injured were in the age range 35–59.Research limitations/implicationsThere were limitations on the generalizability of the research findings to other fire and rescue services, as Merseyside has some of the highest levels of alcohol consumption and deprivation in UK.Practical implicationsAn understanding of those vulnerable to alcohol and drug related fire risks can support more targeted fire prevention strategies and aid referrals to partner health agencies to help to reduce underlying alcohol and drug misuse issues.Originality/valueThe study provides a detailed analysis of the circumstances associated with alcohol and drug related fire injuries over a ten-year period covered by a UK fire and rescue service, in particular, in terms alcohol and drug related fire injury risk differences between different groups.

Purpose Trichotillomania (TTM) is characterised by the recurrent pulling out of one’s own hair, resulting in hair loss. It is a poorly understood disorder with no consensus on aetiology or epidemiology. Nested within a larger qualitative study exploring a wide range of TTM topics, the aim of this paper is to report and consider participant views on the acceptability and feasibility of the asynchronous email interview method. Method Cross-cultural qualitative research on TTM is sparse; therefore, an international qualitative study with a geographically diverse sample was conducted using an asynchronous email interview method. Results Participant perspectives highlighted three themes related to the study method: the value in creating personal connections, cathartic reflections, and perceived strengths and weaknesses. This paper highlights the potential of the asynchronous email interview method for sustaining remote research across multiple locations, using a sample of 20 adults with TTM (18–55 years) from 15 different countries. Conclusions This was an acceptable and feasible method for data collection, facilitating remote access while yielding rich data from an often hidden and hard-to-reach population.

Introduction\ud Scholarship is a key activity in health professions education (HPE). When disseminating scholarly work, how one selects the journal to which they submit is often argued to be a key determinant of subsequent success. To draw more evidence-based recommendations in this regard, we surveyed successful scholars working in HPE regarding their perspectives and experiences with journal selection.\ud \ud Methods\ud We conducted an international survey of HPE scholars, investigating their decisions regarding journal choice. Corresponding authors were identified from a sample of 4000 papers published in 2019 and 2020. They were invited via email with up to four reminders. We describe their experience and use principle component and regression analyses to identify factors associated with successful acceptance.\ud \ud Results\ud In total, 863 responses were received (24.7% response rate), 691 of which were included in our analyses. Two thirds of respondents had their manuscripts accepted at their first-choice journal with revisions required in 98% of cases. We identified six priority factors when choosing journals. In descending order of importance, they were: fit, impact, editorial reputation, speed of dissemination, breadth of dissemination, and guidance from others. Authors who prioritised fit higher and who selected a journal earlier were more likely to have their manuscripts accepted at their first-choice journal.\ud \ud Discussion\ud Based on our results we make three recommendations for authors when writing manuscripts: do not be disheartened by a revise decision, consider journal choice early in the research process, and use the fit between your manuscript and the journal as the main factor driving journal choice.

Background:\ud Controversy exists over the use of bone cement in hip fractures treated with hemiarthroplasty. Only limited data on quality of life after cemented as compared with modern uncemented hemiarthroplasties are available.\ud \ud Methods:\ud We conducted a multicenter, randomized, controlled trial comparing cemented with uncemented hemiarthroplasty in patients 60 years of age or older with an intracapsular hip fracture. The primary outcome was health-related quality of life measured with the use of utility scores on the EuroQol Group 5-Dimension (EQ-5D) questionnaire at 4 months after randomization (range of scores, −0.594 to 1, with higher scores indicating better quality of life; range for minimal clinically important difference, 0.050 to 0.075).\ud \ud Results:\ud A total of 610 patients were assigned to undergo cemented hemiarthroplasty and 615 to undergo modern uncemented hemiarthroplasty; follow-up data were available for 71.6% of the patients at 4 months. The mean EQ-5D utility score was 0.371 in patients assigned to the cemented group and 0.315 in those assigned to the uncemented group (adjusted difference, 0.055; 95% confidence interval [CI], 0.009 to 0.101; P=0.02). The between-group difference at 1 month was similar to that at 4 months, but the difference at 12 months was smaller than that at 4 months. Mortality at 12 months was 23.9% in the cemented group and 27.8% in the uncemented group (odds ratio for death, 0.80; 95% CI, 0.62 to 1.05). Periprosthetic fractures occurred in 0.5% and 2.1% of the patients in the respective groups (odds ratio [uncemented vs. cemented], 4.37; 95% CI, 1.19 to 24.00). The incidences of other complications were similar in the two groups.\ud \ud Conclusions:\ud Among patients 60 years of age or older with an intracapsular hip fracture, cemented hemiarthroplasty resulted in a modestly but significantly better quality of life and a lower risk of periprosthetic fracture than uncemented hemiarthroplasty. (Funded by the National Institute for Health Research; WHiTE 5 ISRCTN number, ISRCTN18393176. opens in new tab.)

Aims:\ud The COVID-19 pandemic forced the rapid move of mental health services to being delivered online. This included the delivery of a psychosocial recovery program (PRP) delivered in youth mental health services in Melbourne, Australia which consists of groups that address functional recovery. At the time, there was limited evidence about how this switch in service provision would be received by service users or what impact the pandemic was having on their mental health.\ud \ud Methods:\ud Young people engaged with the PRP between March and May 2020 were sent a link to complete an online survey that was co-developed by young people and clinicians. Attendance data at groups were extracted as a proximal measure of feasibility and acceptability.\ud \ud Results:\ud A total of 44 young people undertook the survey with the domains of wellbeing most impacted by lockdown being work/study, motivation and social connection. Groups provided online were generally well attended during lockdown, particularly those that had a focus on therapeutic content. Young people indicated little preference for continuing to attend groups run purely online when restrictions eased, with many expressing a preference for these to be offered face-to-face or in a combined format.\ud \ud Conclusions:\ud These findings suggest that implementation of online psychosocial groups during periods of lockdown is both feasible and acceptable. Whilst young people found accessing groups online to be of benefit at the time, they felt that continued substitution of face-to-face groups would not necessarily be preferable and clinical services should consider these preferences in their long-term service delivery.

Objectives To develop and validate in real-world patients a conversion algorithm from the Multidimensionel Health Assessment Questionnaire physical function scale (MDHAQ) to the Stanford Health Assessment Questionnaire disability index physical function scale (HAQ) score. Methods From the DANBIO registry, 13 391 patients with RA (n = 8983), PsA (n = 2649) and axial spondyloarthritis (axSpA, n = 1759) with longitudinal data on HAQ and MDHAQ were included, stratified by diagnosis, and randomized 1:1 into development and validation cohorts. Conversion algorithms were developed by linear regression and applied in validation cohorts. From MDHAQ, the HAQ was calculated (cHAQ) and validated against the observed HAQ for criterion, correlational and construct validity. Results For RA, we developed the conversion algorithm cHAQ = 0.15+MDHAQ*1.08, and validated it in the RA validation cohort. Criterion validity: HAQ and cHAQ had comparable discriminative power to distinguish between high and low patient global scores (standardized mean difference: HAQ:–1.29, cHAQ:–1.35). Kappa value between HAQ and cHAQ functional states indicated good agreement (0.83). Correlational validity: baseline HAQ and cHAQ, respectively, correlated well with patient global scores (r = 0.65/0.67). Bland–Altman plots showed good agreement across all functional states. Construct validity: HAQ and cHAQ discriminated equally well between patients reporting symptom state as acceptable vs not, and across responses to an external anchor. Aiming for a common algorithm, the RA conversion algorithm was validated for PsA and axSpA with similar results. Conclusion This study suggests that in observational datasets with only the MDHAQ available, a simple algorithm allows valid conversion to HAQ on the group level in RA, PsA and axSpA.