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ABSTRACTAs research on disasters in the tourism context matures, a more holistic understanding of how businesses and communities can recover is needed. Using the disorientation and reorientation framework, this study explores recovery as a place-based process. The perceptions and memories of key stakeholders of Binna Burra Lodge, which was affected by the 2019–2020 bushfires in Australia, are investigated and the analysis reveals two themes of disorientation and four of reorientation. It is proposed that various reorientation mechanisms can be deliberately activated to foster a smoother recovery process. Furthermore, this study shows that tourism-enabled social capital can assist disaster recovery in communities and that, through embracing traditional heritage, communities can not only deal with the loss but also prepare for future disasters.

Systemic sclerosis is an autoimmune disease characterized by fibrosis and small vessel vasculopathy, which affects various organ systems, such as the heart. Takotsubo cardiomyopathy is a transient cardiomyopathy in reaction to an emotional or physical trigger. There may be clinical and pathogenetic overlap between Takotsubo cardiomyopathy and primary systemic sclerosis heart disease, and some patients with systemic sclerosis have been diagnosed with recurrent Takotsubo cardiomyopathy. Our large systemic sclerosis clinical cohort was reviewed to identify cases diagnosed with Takotsubo cardiomyopathy. The clinical features, laboratory and imaging results were reviewed and evaluated to perform a comparison between cases. We identified five patients with systemic sclerosis, all female (age 68.6 ± 5.7 years), who were diagnosed with Takotsubo cardiomyopathy. Two of these patients had recurrent episodes: one case with a history of multiple episodes and the other with one recurrence. Typical features included repolarization abnormalities on the electrocardiogram and transient left ventricular dysfunction observed using echocardiography or cardiac magnetic resonance imaging. Our findings build upon previous reports and observations that systemic sclerosis may cause Takotsubo cardiomyopathy. To our knowledge, this is the largest case series of Takotsubo syndrome in patients with systemic sclerosis. This association may provide novel insights into the aetiopathogenesis of Takotsubo cardiomyopathy as part of primary systemic sclerosis heart involvement.

This investigation discusses how Percy Ludgate’s paper from 1909, which details his design for a mechanical computer called the “Analytical Machine,” was utilized by a German patent attorney in 1960 to prevent the approval of Konrad Zuse’s computer patent, just in time, as the patent (first applied for on 16th June 1941) was about to be granted. This narrative is then followed by analyses of, and discovery of proof of, the role of IBM in preventing Zuse from getting what would have been the premier patent on the concept of a programmable computer, and then by an exploration of how information about Ludgate’s 1909 paper was found by (or for) the opposing German patent attorney.

Queen Elizabeth II spent her life in uniform. This article examines what that uniform looked like, what its significance and function was, and how her uniform acted as a discursive textual reference for the institution of the British monarchy. By contextualizing Elizabeth II’s various public uniform before, her early childhood dressed as a twin with Princess Margaret, and the influence of early designers Norman Hartnell and Hardy Aimes, and her later, streamlined wardrobe she co-designed with Angela Kelly, this article provides a framework within which to understand how the fashion of Elizabeth II contributed to public understanding of her, but more so, of the institution of the British monarchy as represented by mediated images of her and her reign.

IMPORTANCE: Patients with advanced chronic kidney disease (CKD) have the best chance for a longer and healthier life if they receive a kidney transplant. However, many barriers prevent patients from receiving a transplant. OBJECTIVES: To evaluate the effect of a multicomponent intervention designed to target several barriers that prevent eligible patients from completing key steps toward receiving a kidney transplant. DESIGN, SETTING, AND PARTICIPANTS: This pragmatic, 2-arm, parallel-group, open-label, registry-based, superiority, cluster randomized clinical trial included all 26 CKD programs in Ontario, Canada, from November 1, 2017, to December 31, 2021. These programs provide care for patients with advanced CKD (patients approaching the need for dialysis or receiving maintenance dialysis). INTERVENTIONS: Using stratified, covariate-constrained randomization, allocation of the CKD programs at a 1:1 ratio was used to compare the multicomponent intervention vs usual care for 4.2 years. The intervention had 4 main components, (1) administrative support to establish local quality improvement teams; (2) transplant educational resources; (3) an initiative for transplant recipients and living donors to share stories and experiences; and (4) program-level performance reports and oversight by administrative leaders. MAIN OUTCOMES AND MEASURES: The primary outcome was the rate of steps completed toward receiving a kidney transplant. Each patient could complete up to 4 steps: step 1, referred to a transplant center for evaluation; step 2, had a potential living donor contact a transplant center for evaluation; step 3, added to the deceased donor waitlist; and step 4, received a transplant from a living or deceased donor. RESULTS: The 26 CKD programs (13 intervention, 13 usual care) during the trial period included 20 375 potentially transplant-eligible patients with advanced CKD (intervention group [n = 9780 patients], usual-care group [n = 10 595 patients]). Despite evidence of intervention uptake, the step completion rate did not significantly differ between the intervention vs usual-care groups: 5334 vs 5638 steps; 24.8 vs 24.1 steps per 100 patient-years; adjusted hazard ratio, 1.00 (95% CI, 0.87-1.15). CONCLUSIONS AND RELEVANCE: This novel multicomponent intervention did not significantly increase the rate of completed steps toward receiving a kidney transplant. Improving access to transplantation remains a global priority that requires substantial effort. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT03329521

This is my first market report for 2024. It still continues to be difficult to prepare quarterly forestry reports which promote any confidence regarding current and future log markets. Unfortunately, any bad news related to forestry, such as the current market downturn rarely gets the media coverage which other agriculture sectors do. The current downturn has come in quickly and was unexpected, and definitely unwanted considering the volatility experienced throughout 2023. [ABSTRACT FROM AUTHOR]

This article considers how national swimsuits are more than team garments worn at international events such as the Olympics. In their development and construction as well as the public contexts within which they are worn, swimsuits have a long history of transforming and controlling swimmers’ bodies and when the swimsuit fails to control or transform, the swimmer rather than the swimsuit is blamed for any transgressions. This article follows the development of the competitive swimsuit from the Victorian era, which required swimmers to fully cover their body, through to the mid-twentieth century when swimsuits revealed more and more of the body, before returning to full body racing swimsuits in the late twentieth century. For women, swimsuits have had a history of regulating their public bodies. For female competitive swimmers, national swimsuits have been particularly problematic because the design radically changed how their bodies looked when competing. Similarly, swimsuits for transgendered competitive swimmers overly focus on body image. In transforming and controlling the competitive swimmers’ bodies, and in punishing transgressions, it is argued that this impacts on the wearer’s identity and well-being.

The aim of this study was to investigate the role of a completely synthetic dermal matrix (Biodegradable Temporizing Matrix [BTM]) for staged reconstruction of complex wounds. The authors defined complex wounds as wounds not amenable to reconstruction with skin grafting alone due to an inherent avascularity such as the presence of bare bone, tendinous, or neural structures. A retrospective review of a prospectively maintained database of complex wounds as defined above was carried out. Fifty-five patients were identified who underwent staged BTM and autologous skin graft reconstruction for complex wounds affecting a wide variety of patient demographics, treatment indications, and body sites. Wound etiology included burn injury and nonburn-related trauma such as degloving injury or infective complications. Caveats relating to the successful application of staged dermal matrix reconstruction, techniques, tips, prevention, and management of complications are outlined. This large consecutive case series demonstrates the integral role dermal substitutes play in providing biological wound cover for avascular wound beds which may otherwise require complex distant flap or free tissue transfer for reconstruction. Staged synthetic dermal matrix reconstruction has proven robustness in the face of unfavorable wounds compared with nonsynthetic dermal matrices, physiologically covering avascular structures, allowing for early graft take, expediting rehabilitation, and mobilization with good scar cosmesis and limited contracture formation.

The article discusses the challenges and uncertainties in the log market, particularly for private first rotation forests in New Zealand. The author highlights the lack of positive news and feedback from industry members, as well as the absence of emerging markets. The future demand for raw logs is expected to decrease, and adjustments in harvest levels will be necessary. The article also includes a graph and table showing log prices and returns. The author emphasizes the need for forward planning and maximizing returns in a volatile market. [Extracted from the article]

An estimated 100,000 patients each year in the United States suffer severe disability from bone defects that fail to heal, a condition where bone-regenerative therapies could provide substantial clinical benefits. Although recombinant human bone morphogenetic protein-2 (rhBMP2) is an osteogenic growth factor that is clinically approved for this purpose, it is only effective when used at exceedingly high doses that incur substantial costs, induce severe inflammation, produce adverse side effects, and form morphologically abnormal bone. Using a validated rat femoral segmental defect model, we show that bone formed in response to clinically relevant doses of rhBMP2 is accompanied by elevated expression of interleukin-1 (IL-1). Local delivery of cDNA encoding the IL-1 receptor antagonist (IL-1Ra) achieved bridging of segmental, critical size defects in bone with a 90% lower dose of rhBMP2. Unlike use of high-dose rhBMP2, bone formation in the presence of IL-1Ra occurred via the native process of endochondral ossification, resulting in improved quality without sacrificing the mechanical properties of the regenerated bone. Our results demonstrate that local immunomodulation may permit effective use of growth factors at lower doses to recapitulate more precisely the native biology of healing, leading to higher-quality tissue regeneration.

Cardiovascular disease is a leading cause of morbidity and mortality in individuals with Down syndrome. Congenital heart disease is the most common cardiovascular condition in this group, present in up to 50% of people with Down syndrome and contributing to poor outcomes. Additional factors contributing to cardiovascular outcomes include pulmonary hypertension; coexistent pulmonary, endocrine, and metabolic diseases; and risk factors for atherosclerotic disease. Moreover, disparities in the cardiovascular care of people with Down syndrome compared with the general population, which vary across different geographies and health care systems, further contribute to cardiovascular mortality; this issue is often overlooked by the wider medical community. This review focuses on the diagnosis, prevalence, and management of cardiovascular disease encountered in people with Down syndrome and summarizes available evidence in 10 key areas relating to Down syndrome and cardiac disease, from prenatal diagnosis to disparities in care in areas of differing resource availability. All specialists and nonspecialist clinicians providing care for people with Down syndrome should be aware of best clinical practice in all aspects of care of this distinct population.

Chronic thromboembolic pulmonary hypertension occurs in a proportion of patients with prior acute pulmonary embolism and is characterised by breathlessness, persistently raised pulmonary pressures and right heart failure. Surgical pulmonary endarterectomy (PEA) offers significant prognostic and symptomatic benefits for patients with proximal disease distribution. For those with inoperable disease, management options include balloon pulmonary angioplasty (BPA) and medical therapy. Current clinical practice relies on the evaluation of pulmonary haemodynamics to assess disease severity, timing of and response to treatment. However, pulmonary haemodynamics correlate poorly with patient symptoms, which are influenced by right ventricular tolerance of the increased afterload. How best to manage symptomatic patients with chronic thromboembolic pulmonary disease (CTEPD) in the absence of pulmonary hypertension is not resolved.Right ventricular–pulmonary artery coupling (RV-PAC) describes the energy transfer within the whole cardiopulmonary unit. Thus, it can identify the earliest signs of decompensation even before pulmonary hypertension is overt. Invasive measurement of coupling using pressure volume loop technology is well established in research settings. The development of efficient and less invasive measurement methods has revived interest in coupling as a viable clinical tool. Significant improvement in RV-PAC has been demonstrated after both PEA and BPA. Further studies are required to understand its clinical utility and prognostic value, in particular, its potential to guide management in patients with CTEPD. Finally, given the reported differences in coupling between sexes in pulmonary arterial hypertension, further work is required to understand the applicability of proposed thresholds for decoupling in therapeutic decision making.

To protect their membership rights to social resources, services and benefits, Australian citizens constantly renegotiate and reconceptualize sociocultural and political parameters around who belongs as a rights-worthy member of their society. Popular culture has the potential to shape the social, cultural and political attitudes that underpin these considerations. Popular culture mediums such as film and television are visual and narrative devices that posit binaries such as good/bad, men/women, citizen/non-citizen and so on. In particular, the binary of good/bad acts as a discourse through which audiences develop an understanding of what actions and behaviours are considered socially and culturally acceptable, and what actions and behaviours are not. This article seeks to broaden understandings of popular culture’s potential to influence how a society construes its social strictures around who is a member of the hegemonic group and who is the ‘other’. It examines depictions of poor, vulnerable and homeless women characters in film that frame them as the monstrous ‘other’ and argues that these representations negatively impact the visibility of real women who are poor, vulnerable and homeless in Australia, within spaces of sociopolitical discourse. The ongoing repercussions of which, it is contended, are that the needs of this cohort are less visible to the governments and policymakers who are tasked with protecting them.

Welcome to this ‘Masculinities on Film’ Special Issue. This volume examines how costume is used to construct masculinity across the world. Despite the differing national contexts, the researchers this volume demonstrate how the dressed male body can come to represent both the state and the social expectations within it.

The costuming of actors plays a significant role in how their characters and their actions are understood by audiences. This article examines how male transgression is encoded in fictional royal television via costuming. Costumes for royal characters sit at the intersection between dramatic convention and popular expectations of royal behaviour. Little work has been done to date to examine how costume works in this space, even less on fictional male royal costuming. This article demonstrates, via a discussion of the four kings of the television drama The Royals(2015–18), how costuming both engages in narrative expectations and reveals transgressions.

Background: In the EDITA trial, patients with systemic sclerosis (SSc) and mild pulmonary vascular disease (PVD) treated with ambrisentan had a significant decline of pulmonary vascular resistance (PVR) but not of mean pulmonary arterial pressure (mPAP) vs. placebo after six months. The EDITA-ON study aimed to assess long-term effects of open label therapy with ambrisentan vs. no pulmonary arterial hypertension (PAH) therapy. Methods: Patients who participated in the EDITA study and received regular follow-up were included in EDITA-ON. Clinical, echocardiographic, laboratory, exercise and hemodynamic parameters during follow-up were analysed. The primary endpoint was to assess whether continued treatment with ambrisentan vs. no treatment prevented the development of PAH according to the new definition. Results: Of 38 SSc patients included in the EDITA study four were lost to follow-up. Of the 34 remaining patients (age 55 ± 11 years, 82.1% female subjects), 19 received ambrisentan after termination of the blinded phase, 15 received no PAH medication. The mean follow-up time was 2.59 ± 1.47 years, during which 29 patients underwent right heart catheterization. There was a significant improvement of mPAP in catheterised patients receiving ambrisentan vs. no PAH treatment (-1.53 ± 2.53 vs. 1.91 ± 2.98 mmHg, p= 0.003). In patients without PAH treatment 6/12 patients had PAH vs. 1/17 of patients receiving ambrisentan (p< 0.0001). Conclusion: In SSc patients with early PVD, the development of PAH and/or deterioration was less frequent among patients receiving ambrisentan, indicating that early treatment and close follow-up could be beneficial in this high-risk group. Future trials in this field are needed to confirm these results.

Ivermectin, an effective treatment for scabies, is not licensed for children weighing <15 kg. Pharmacokinetic modelling has shown a 3 mg dose in young children (2–4 years, weighing 10–14 kg) achieves comparable drug exposure to a 200 μg/kg dose in children aged ≥5 years. This trial evaluated a 3 mg dose in young children.

Healthcare-associated infections (HAI) and antimicrobial use (AMU) are drivers for antimicrobial resistance, and robust data are required to inform interventions and track changes. We aimed to estimate the prevalence of HAI and AMU at Port Moresby General Hospital (PMGH), the largest hospital in Papua New Guinea.

Volatile substance misuse, particularly the inhalation of hydrocarbons, is a growing issue globally. Consequences of volatile substance misuse, both acute and chronic cause cardiovascular, respiratory, renal, metabolic, and central nervous system damage. Whilst the effects of hydrocarbon abuse have been reported, the combination of intoxication with hydrocarbon and burns sustained has not yet been presented. A retrospective case series of patients who presented in the last 5 years to the Royal Adelaide Hospital with hydrocarbon-related burns in the context of illicit use was undertaken. Our aims are to present to the wider scientific community the high morbidity and mortality of hydrocarbon burn injuries and why this tertiary Burns Unit feel it most appropriate to medically stabilize these patients prior to definitive surgery for their burn. All patients that presented with acute hydrocarbon intoxication and sustained concomitant burns had significant psychiatric disorder and substance abuse history and three of five had either not eaten in several days resulting in acute malnourishment, refeeding syndrome or had evidence of chronic malnourishment with deranged electrolytes and hypoalbuminemia. Their definitive burns surgery was delayed where appropriate in order to facilitate medical stabilization as they were too high risk of cardiac membrane instability, electrolyte derangement, and/or respiratory compromise to undergo safe general anesthetic and burns debridement. We propose a multidisciplinary team approach, utilizing not only our Burns Unit care model of physiotherapists, psychologists, social work, and burns trained nurses and surgeons but also Intensive Care, Toxicology, Addiction medicine and General Medical physicians in the management of these patients.

BackgroundThe General and Adolescent Paediatric Research Network in the UK and Ireland (GAPRUKI) was established in 2016. The aims of GAPRUKI are to unite general paediatricians around the UK and Ireland, to develop research ideas and protocols, and facilitate delivery of multicentre research.ObjectivesTo undertake a research prioritisation exercise among UK and Ireland general paediatricians.MethodsThis was a four-phase study using a modified Delphi survey. The first phase asked for suggested research priorities. The second phase developed ideas and ranked them in priority. In the third phase, priorities were refined; and the final stage used the Hanlon Prioritisation Process to agree on the highest priorities.ResultsIn phase one, there were 250 questions submitted by 61 GAPRUKI members (66% of the whole membership). For phase two, 92 priorities were scored by 62 members and the mean Likert scale (1–7) scores ranged from 3.13 to 5.77. In a face-to-face meeting (phases three and four), 17 research questions were identified and ultimately 14 priorities were identified and ranked. The four priorities with the highest ranking focused on these three respiratory conditions: asthma, bronchiolitis and acute wheeze. Other priorities were in the diagnosis or management of constipation, urinary tract infection, fever, gastro-oesophageal reflux and also new models of care for scheduled general paediatric clinics.ConclusionResearch priorities for child health in the UK and Ireland have been identified using a robust methodology. The next steps are for studies to be designed and funded to address these priorities.

Doctors routinely refuse donation offers from prospective living kidney donors with certain comorbidities such as diabetes or obesity out of concern for donor wellbeing. This refusal occurs despite the ongoing shortage of kidney transplants and the superior performance of living donor kidney transplants compared to those from deceased donors. In this paper, we argue that this paternalistic refusal by doctors is unjustified and that, within limits, there should be greater acceptance of such donations. We begin by describing possible weak and strong paternalistic justifications of current conservative donor acceptance guidelines and practices. We then justify our position by outlining the frequently under-recognised benefits and the routinely overestimated harms of such donation, before discussing the need to respect the autonomy of willing donors with certain comorbidities. Finally, we respond to a number of possible objections to our proposal for more liberal kidney donor acceptance criteria. We use the situation in Australia as our case study, but our argument is applicable to comparable situations around the world.

This case report details our experience using a two-stage Biodegradable Temporizing Matrix (NovoSorb®PolyNovo Ltd) and autograft for acute reconstruction of a complex perineal burn wound in an elderly comorbid patient. A 77-year-old man sustained 42% full-thickness burns extending circumferentially from bilateral thighs and buttocks, across the entire perineal and genital regions up to his mid-trunk, following self-immolation using an accelerant. Early total burn wound excision was carried out with acute application of Biodegradable Temporizing Matrix to all affected sites. Excellent integration and vascularization of Biodegradable Temporizing Matrix took place despite the challenge of intermittent fecal contamination affecting the perineal and buttock burn sites and matrix colonization with multidrug-resistant organisms. Delamination and serial split-thickness skin autografting were carried out 42 days after the first matrix application with complete and robust graft take. Perineal burns present a reconstructive challenge due to the proximity of specialized structures such as the genitalia, urethral, and anal orifices. Restoration of complex anatomy and function may be required after debridement with increased risks of infection, contracture formation, and mortality compared with burns affecting other anatomical sites. Two-stage Biodegradable Temporizing Matrix represents a reliable reconstruction option for complex extensive perineal wounds in frail elderly patients, despite an unfavorable local microbial environment.

Riociguat and phosphodiesterase-5 inhibitors (PDE5i), approved for the treatment of pulmonary arterial hypertension (PAH), act on the same pathway via different mechanisms. Riociguat might be an alternative option for patients with PAH who do not respond sufficiently to treatment with PDE5i, but comparisons of the potential benefits of riociguat and PDE5i in these patients are needed. The aim of this trial was to assess the effects of switching to riociguat from PDE5i therapy versus continued PDE5i therapy in patients with PAH at intermediate risk of 1-year mortality.

Although veterinarians encounter ethical challenges in their everyday practice, few studies have examined how they make sense of and respond to them. This research used semi-structured interviews and a qualitative methodology (phenomenological and constructivist/interpretivist approaches) to explore ethical challenges experienced by seven small animal city veterinarians and their ethical decision-making strategies. Thematic analysis of the interview transcripts identified four broad ethical issues: The first concerned disagreements about the best interests of the animal; the second centered on clinical uncertainty about the most appropriate treatment for the animal; the third involved factors influencing ethical reasoning and decision making; and the fourth concerned how ethics education might prepare veterinary students for future ethical decision making. An overarching theme identified in the analysis was one of enormous personal distress. Furthermore, a sense of veterinarians being interested in how others might think and feel about ethical challenges came through in the data. The results give insight into how veterinarians experience and respond to ethical challenges. The research also provides empirical information about everyday practice to inform future education in ethics and ethical decision making for veterinary students.

COVID-19 is a new disease. Most research into the disease has focused on prevention of viral spread and treatment, but little is known about how patients recover. Nurses, whether in hospital, the community or in primary care, have a key role in supporting recovery from COVID-19. In this article, direct evidence from studies of COVID-19, and indirect evidence from studies of infections caused by other coronaviruses (eg SARS, MERS) and of the ICU experience are explored to identify the potential course of recovery and areas where nurses can help. Most people will have an uncomplicated recovery. However, it appears that a more complicated recovery is likely to be associated with severe disease. A minority, possibly those needing hospitalisation, and/or with pre-existing physical or psychological comorbidities, may experience long-term physical effects, fatigue and mental health difficulties. The support that nurses, as part of a multidisciplinary team, can provide to facilitate recovery is discussed.

Introduction:Data suggest a potential role for vitamin D in autism spectrum disorder (ASD) prevention and treatment. It is likely that the serum response to vitamin D supplementation contributes to its effectiveness. Multiple factors affect serum vitamin D 25(OH)D response to supplementation.Methods:We conducted post-hoc analysis of two double-blind, randomized, placebo-controlled trials (RCT) of vitamin D3supplementation, one RCT involving children with ASD and another involving children with asthma. Both trials were conducted in the same geographic location (Dublin, Ireland, 53°N), conducted over Winter season and utilized the same vitamin D3dose (2000 IU/day).Results:We included 18 children with ASD and 17 children with asthma. There was no significant difference in 25(OH)D or age at baseline, however, BMI was significantly lower in ASD (P= 0.03). Compliance with vitamin D supplementation was high in both trials. Despite a significantly longer intervention period (20w vs. 15w; P < 0.0001), ASD children had a significantly lower absolute increase (+26 vs. +45 nmol/l) in 25(OH)D (P = 0.04).Conclusions:Despite similar demographics, children with ASD had a lower increase in 25(OH)D levels with supplementation. Potential mechanisms include altered absorption/metabolism as well as well genetic factors. Clinical and research work relating to vitamin D is ASD should measure 25(OHO)D response to supplementation to assess therapeutic doses.

Treatment of pulmonary arterial hypertension (PAH) has evolved substantially over the past two decades and varies according to etiology, functional class (FC), hemodynamic parameters, and other clinical factors. Current guidelines do not provide definitive recommendations regarding the use of oral prostacyclin pathway agents (PPAs) in PAH. To provide guidance on the use of these agents, an expert panel was convened to develop consensus statements for the initiation of oral PPAs in adults with PAH.

With the growing adoption of IT in tourism, mobile games are becoming an attractive interpretive tool, particularly in heritage contexts where a deeper appreciation for the heritage attraction may serve to safeguard it into the future. This study adopts a user-centred approach to systematically explore the process of developing a serious game as an interpretive tool for the Great Barrier Reef, Australia. The study uses a gaming conceptual framework, the Design-Play-Experience (DPE) model and data were collected in situ, on reef tours, by observing respondents’ interactions with the game, video recording and reviewing their gameplay and through pre and post interviews with respondents until data saturation was reached (n = 34). The findings illustrate how games can be designed to represent a complex and threatened ecosystem and elicit positive emotions among tourists, particularly curiosity and delight. The study illustrates the usefulness of the DPE framework to move beyond a simple description of games to a systematic, user-centred analysis of the process of creating a serious game to solve a particular interpretive problem. The study also confirms that designing a bespoke game for a tourist attraction is a costly and difficult process, requiring iterations of the game design, that is arguably outside the scope of many nature-based/heritage tourism businesses.

Background and goals: Missed adenomas are likely to be located in the proximal colon and failure to detect these lesions might explain the occurrence of a certain percentage of interval carcinomas. Though studies have demonstrated increased detection of significant neoplastic lesions in colonoscopic examinations where the withdrawal time is 6 min or more, there are no recommendations on how much time to spend in each colonic segment. The aim of the trial was to find ways to reduce the number of lesions missed in the proximal segments of the colon assessing the difference in adenoma detection rate (ADR) between two colonoscopic withdrawal timed techniques. Study: This was a randomized trial in a university hospital. Population was composed of patients referred for screening colonoscopy. The Main Outcome measurements was ADRs for patients subjected to a timed colonoscopy with specific withdrawal times, with special interest in the proximal colon, and implying a minimum of 2-min withdrawal delay in the cecum and right colon, a 1-min delay time in the transverse colon, and a minimum additional 3-min delay time in the left colon, as compared to a standard timed colonoscopy with free withdrawal delay time of at least 6 min. Results: A total of 1160 patients were included. Eleven were initially excluded due to incomplete colonoscopies. Of the remaining 1149 patients, 573 were randomized to the group with fixed withdrawal times (Group A) and 576 to conventional withdrawal (Group B). Median age was 57 years (SD 6), a total of 634 (55.2%) were male patients and the mean withdrawal time was 7:05 min (SD 1 min). Seven hundred and eighty-one adenomas/serrated lesions were found in 470 patients (1.66 per patient), with 28 advanced lesions and 3 adenocarcinomas. Global ADR was 41% with no significant statistical differences between the two groups (42.1% vs 39.8%, p0.43), respectively. A multivariate analysis showed clear relation between the finding of adenomas and higher BBPS ratings (Adjusted Odds Ratio [aOR] 0.92, p0.05), age (aOR 1.03, p0.01), male sex (aOR 1.51, p0.001), and time of withdrawal (aOR 1.17, p0.001), while no association was observed with either withdrawal technique (aOR 0.89, IC 95% 0.70–1.03, p0.32). There was no statistical significant difference between the two groups concerning the finding of proximal lesions (cOR 0.93, CI 95% 0.71–1.20, p0.56) (aOR 0.89, CI 95% 0.69–1.17, p0.41) or serrated polyps (cOR 0.81, CI 95% 0.51–1.27, p0.35) (aOR 0.81, IC 95% 0.51–1.28, p0.36). Conclusions: Fixed withdrawal times did not prove to lead to an increase in the number of detected adenomas. Nevertheless, our study supports previous reports stating that longer withdrawal times are indeed associated with better proximal and distal adenoma detection.

BackgroundHumanitarian crises and emergencies, events often marked by high mortality, have until recently excluded palliative care—a specialty focusing on supporting people with serious or terminal illness or those nearing death. In the COVID-19 pandemic, palliative care has received unprecedented levels of societal attention. Unfortunately, this has not been enough to prevent patients dying alone, relatives not being able to say goodbye and palliative care being used instead of intensive care due to resource limitations. Yet global guidance was available. In 2018, the WHO released a guide on ‘Integrating palliative care and symptom relief into the response to humanitarian emergencies and crises’—the first guidance on the topic by an international body.AimsThis paper argues that while a landmark document, the WHO guide took a narrowly clinical bioethics perspective and missed crucial moral dilemmas. We argue for adding a population-level bioethics lens, which draws forth complex moral dilemmas arising from the fact that groups having differential innate and acquired resources in the context of social and historical determinants of health. We discuss dilemmas concerning: limitations of material and human resources; patient prioritisation; euthanasia; and legacy inequalities, discrimination and power imbalances.ImplicationsIn parts of the world where opportunity for preparation still exists, and as countries emerge from COVID-19, planners must consider care for the dying. Immediate steps to support better resolutions to ethical dilemmas of the provision of palliative care in humanitarian and emergency contexts will require honest debate; concerted research effort; and international, national and local ethical guidance.

Chronic thromboembolic pulmonary hypertension (CTEPH) is an uncommon complication of acute pulmonary emboli necessitating lifelong anticoagulation. Despite this, few data exist on the safety and efficacy of vitamin K antagonists (VKAs) in CTEPH and none for direct oral anticoagulants (DOACs).

Objectives: The objectives were to explore rheumatologists’ current clinical screening practices of pulmonary arterial hypertension in patients with systemic sclerosis in the United Kingdom and to identify barriers to screening and consider potential solutions.Methods: A survey of 31 questions was developed and included six sections: clinician demographics, the importance of screening, screening practices, barriers to screening, treatment and patient education. The survey was disseminated among rheumatologists working in the United Kingdom.Results: Forty-four rheumatologists working in the United Kingdom participated in the study, and the majority completed all the questions. Around one-third (37.0%) worked in specialised systemic sclerosis units (university or general hospitals (54.5% and 45.4%, respectively)). The majority recognised that systemic sclerosis-pulmonary arterial hypertension is a major cause of morbidity and mortality. Over half (60.0%) reported using the DETECT algorithm to screen for systemic sclerosis-pulmonary arterial hypertension, although other algorithms were also sometimes used. All of the respondents utilised transthoracic echocardiogram, and almost all (95.0%) performed pulmonary function tests for screening purposes. Various challenges and barriers were identified relating to systemic sclerosis-pulmonary arterial hypertension screening, with the difficulty in interpreting results from other hospitals and extended wait times for diagnostic tests being the most reported (76.0% and 74.0%, respectively). Most respondents agreed that access to key investigations (87.0%), ongoing clinician education (82.0%), multidisciplinary meetings (79.5%) and a better understanding of proposed screening algorithms (79.5%) could be potential solutions.Conclusion: Screening patients with systemic sclerosis for pulmonary arterial hypertension is crucial to improve survival, but variable practices exist among UK rheumatologists. Solutions include educating healthcare professionals on guidelines, sharing information between centres and integrating care services.

The article discusses an unexpected fall in log prices in New Zealand in April 2023. The market had shown confidence in the first quarter, but prices dropped in April, posing challenges for the industry and smaller private forest owners. The decline in prices is attributed to factors such as weakening demand from China and increasing shipping rates. The article provides average log prices for different grades and highlights the difficulty in forecasting prices due to various variables in the supply chain. Forest owners are advised to plan their harvests carefully to maximize returns. [Extracted from the article]