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Summary Statement: Otherwise known as debriefing the debrief, meta-debriefing describes the practice of debriefing simulation facilitators after they have facilitated, or observed, a debriefing. It is a vital component of enhancing debriefing skills, irrespective of where debriefers may be in terms of their professional development journey from novice to expert. We present the following 4 fundamental pillars, which underpin the creation of an impactful meta-debriefing strategy: theoretically driven, psychologically safe, context dependent, and formative in function. Furthermore, we describe various strategies that, underpinned by these 4 key pillars, contribute to a toolbox of techniques that enable meta-debriefers to develop proficiency and flexibility in their practice. We have synthesized and critically reviewed the current evidence base, derived mostly from the debriefing literature, and highlighted gaps to address in meta-debriefing contexts. We hope this article stimulates discussion among simulation practitioners, progresses the science and art of meta-debriefing, and prompts further research so that meta-debriefing can become an integral evidence-based component of our faculty development processes., Competing Interests: The authors declare no conflict of interest., (Copyright © 2024 The Author(s). Published by Wolters Kluwer Health, Inc. on behalf of the Society for Simulation in Healthcare.)

Background: Optimal use of lithium involves adjustment of the dose, to keep the plasma level within the narrow, recommended range. Brand-specific prescribing has long been considered critical to achieving this aim, but this is a convention based on very limited data., Objectives: To explore the effect of selected demographic and clinical factors on the relationship between lithium dose and plasma level and determine whether there is an independent effect of lithium brand., Design: Analysis of clinical audit data collected in 2023 as part of a quality improvement programme addressing the use of lithium, conducted by the Prescribing Observatory for Mental Health., Methods: Data were collected from clinical records using a bespoke proforma, submitted online and analysed using SPSS., Results: Data were submitted for 4405 patients who had been prescribed solid-dosage formulations of lithium for more than a year. Priadel ® was prescribed for 3722 (84%) of these patients, Camcolit ® for 112 (2.5%) and the prescription was written generically for 554 (12.5%). Compared with Priadel, where Camcolit was prescribed, the mean daily dose was 10% higher and the mean plasma lithium level was 11% higher. A multivariable analysis was conducted to explore the relationship between selected clinical variables and maintenance lithium dose. This found that in 4213 patients whose most recent plasma lithium level was between 0.3 and 1.19 mmol/L, the variables age, sex, ethnicity, psychiatric diagnosis and the severity of chronic kidney disease were independently associated with dose while the brand of lithium prescribed was not., Conclusion: Our findings replicate those of previous studies with respect to the demographic and clinical variables that can be expected to influence lithium dosage in routine clinical practice. This reinforces the need to titrate the dosage for each individual patient, to achieve and maintain the target plasma level. However, the findings suggest that the Priadel and Camcolit brands of lithium are essentially interchangeable., (© The Author(s), 2024.)

Background: Medications with anticholinergic properties are associated with a range of adverse effects that tend to be worse in older people., Aims: To investigate medication regimens with high anticholinergic burden, prescribed for older adults under the care of mental health services., Method: Clinical audit of prescribing practice, using a standardised data collection tool., Results: Fifty-seven trusts/healthcare organisations submitted data on medicines prescribed for 7915 patients: two-thirds (66%) were prescribed medication with anticholinergic properties, while just under a quarter (23%) had a medication regimen with high anticholinergic burden (total score ≥3 on the anticholinergic effect on cognition (AEC) scale). Some 16% of patients with a diagnosis of dementia or mild cognitive impairment were prescribed medication regimens with a high anticholinergic burden, compared with 35% of those without such diagnoses. A high anticholinergic burden was mostly because of combinations of commonly prescribed psychotropic medications, principally antidepressant and antipsychotic medications with individual AEC scores of 1 or 2., Conclusions: Adults under the care of older people's mental health services are commonly prescribed multiple medications for psychiatric and physical disorders; these medication regimens can have a high anticholinergic burden, often an inadvertent consequence of the co-prescription of medications with modest anticholinergic activity. Prescribers for older adults should assess the anticholinergic burden of medication regimens, assiduously check for adverse anticholinergic effects and consider alternative medications with less anticholinergic effect where indicated. The use of a scale, such as the AEC, which identifies the level of central anticholinergic activity of relevant medications, can be a helpful clinical guide.

In classical cerebellar learning, Purkinje cells (PkCs) associate climbing fiber (CF) error signals with predictive granule cells (GrCs) that were active just prior (∼150 ms). The cerebellum also contributes to behaviors characterized by longer timescales. To investigate how GrC-CF-PkC circuits might learn seconds-long predictions, we imaged simultaneous GrC-CF activity over days of forelimb operant conditioning for delayed water reward. As mice learned reward timing, numerous GrCs developed anticipatory activity ramping at different rates until reward delivery, followed by widespread time-locked CF spiking. Relearning longer delays further lengthened GrC activations. We computed CF-dependent GrC→PkC plasticity rules, demonstrating that reward-evoked CF spikes sufficed to grade many GrC synapses by anticipatory timing. We predicted and confirmed that PkCs could thereby continuously ramp across seconds-long intervals from movement to reward. Learning thus leads to new GrC temporal bases linking predictors to remote CF reward signals-a strategy well suited for learning to track the long intervals common in cognitive domains., Competing Interests: Declaration of interests The authors declare no competing interests., (Published by Elsevier Inc.)

Introduction: Digital Health Technologies (DHTs) have been shown to have variable usability as measured by efficiency, effectiveness and user satisfaction despite large-scale government projects to regulate and standardise user interface (UI) design. We hypothesised that Human-Computer Interaction (HCI) modelling could improve the methodology for DHT design and regulation, and support the creation of future evidence-based UI standards and guidelines for DHTs., Methodology: Using a Design Science Research (DSR) framework, we developed novel UI components that adhered to existing standards and guidelines (combining the NHS Common User Interface (CUI) standard and the NHS Design System). We firstly evaluated the Patient Banner UI component for compliance with the two guidelines and then used HCI-modelling to evaluate the "Add New Patient" workflow to measure time to task completion and cognitive load., Results: Combining the two guidelines to produce new UI elements is technically feasible for the Patient Banner and the Patient Name Input components. There are some inconsistencies between the NHS Design System and the NHS CUI when implementing the Patient Banner. HCI-modelling successfully quantified challenges adhering to the NHS CUI and the NHS Design system for the "Add New Patient" workflow., Discussion: We successfully developed new design artefacts combing two major design guidelines for DHTs. By quantifying usability issues using HCI-modelling, we have demonstrated the feasibility of a methodology that combines HCI-modelling into a human-centred design (HCD) process could enable the development of standardised UI elements for DHTs that is more scientifically robust than HCD alone., Conclusion: Combining HCI-modelling and Human-Centred Design could improve scientific progress towards developing safer and more user-friendly DHTs., Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2024 The Author(s). Published by Elsevier Inc. All rights reserved.)

Background: Each year an estimated 2.3 million newborns die in the first 28 days of life. Most of these deaths are preventable, and high-quality neonatal care is fundamental for surviving and thriving. Service readiness is used to assess the capacity of hospitals to provide care, but current health facility assessment (HFA) tools do not fully evaluate inpatient small and sick newborn care (SSNC)., Methods: Health systems ingredients for SSNC were identified from international guidelines, notably World Health Organization (WHO), and other standards for SSNC. Existing global and national service readiness tools were identified and mapped against this ingredients list. A novel HFA tool was co-designed according to a priori considerations determined by policymakers from four African governments, including that the HFA be completed in one day and assess readiness across the health system. The tool was reviewed by > 150 global experts, and refined and operationalised in 64 hospitals in Kenya, Malawi, Nigeria, and Tanzania between September 2019 and March 2021., Results: Eight hundred and sixty-six key health systems ingredients for service readiness for inpatient SSNC were identified and mapped against four global and eight national tools measuring SSNC service readiness. Tools revealed major content gaps particularly for devices and consumables, care guidelines, and facility infrastructure, with a mean of 13.2% (n = 866, range 2.2-34.4%) of ingredients included. Two tools covered 32.7% and 34.4% (n = 866) of ingredients and were used as inputs for the new HFA tool, which included ten modules organised by adapted WHO health system building blocks, including: infrastructure, pharmacy and laboratory, medical devices and supplies, biomedical technician workshop, human resources, information systems, leadership and governance, family-centred care, and infection prevention and control. This HFA tool can be conducted at a hospital by seven assessors in one day and has been used in 64 hospitals in Kenya, Malawi, Nigeria, and Tanzania., Conclusion: This HFA tool is available open-access to adapt for use to comprehensively measure service readiness for level-2 SSNC, including respiratory support. The resulting facility-level data enable comparable tracking for Every Newborn Action Plan coverage target four within and between countries, identifying facility and national-level health systems gaps for action., (© 2024. The Author(s).)

In this case series, we demonstrate how open-source software has been widely adopted as the primary health information system in many low- and middle-income countries, and for government-developed applications in high-income settings. We discuss the concept of Digital Global Goods and how the general approach of releasing software developed through public funding under open-source licences could improve the delivery of healthcare in all settings through increased transparency and collaboration as well as financial efficiency.

Background: Melatonin is commonly used to treat sleep disturbance in children and adolescents, although uncertainties about its optimal use remain., Objective: To determine to what extent prescribing of melatonin complies with evidence-based clinical practice standards., Methods: As part of a quality improvement programme, the Prescribing Observatory for Mental Health conducted a retrospective clinical audit in UK services for children and adolescents., Findings: Data were submitted for 4151 children and adolescents up to 18 years of age, treated with melatonin: 3053 (74%) had a diagnosis of neurodevelopmental disorder. In 2655 (73%) of the 3651 patients prescribed melatonin to be taken regularly, the main reason was to reduce sleep latency (time taken to fall asleep). In 409 patients recently starting melatonin, a non-pharmacological intervention had already been tried in 279 (68%). The therapeutic response of patients early in treatment (n=899) and on long-term treatment (n=2353) had been assessed and quantified in 36% and 31%, respectively, while for review of side effects, the respective proportions were 46% and 43%. Planned treatment breaks were documented in 317 (13%) of those on long-term treatment., Conclusions: Melatonin was predominantly prescribed for evidence-based clinical indications, but the clinical review and monitoring of this treatment fell short of best practice., Clinical Implications: With limited methodical review of melatonin use in their patients, clinicians will fail to garner reliable information on its risks and benefits for individual patients. The lack of such practice-based evidence may increase the risk of melatonin being inappropriately targeted or continued despite being ineffective or no longer indicated., Competing Interests: Competing interests: CP, OR, AR, GB and TREB have no interests to declare. PG was CI on the NIHR investigator-led Mends RCT melatonin trial and the Neurim industry-led international RCT for Slenyto melatonin; reports participation in advisory panels for AGB, Flynn Pharma and Alturix; but reports no shares or ongoing work with any of the above. AL reports speaking and travel honoraria from Takeda and Flynn Pharma., (© Author(s) (or their employer(s)) 2024. Re-use permitted under CC BY-NC. Published by BMJ.)

The neurotoxic effects of ozone exposure are related to neuroinflammation and increases in reactive oxygen species (ROS). This study aimed to assess inflammation, Brain-Derived Neurotrophic Factor (BDNF), and cognition in healthy male cyclists following polyphenol supplementation and exercise in an ozone-polluted environment. Ten male cyclists initially completed a maximal incremental test and maximal effort 4 km time trial in ambient air. Cyclists then completed two trials in an ozone-polluted environment (0.25 ppm) following 7 days of supplementation with either polyphenol (POLY) or placebo (PL). Experimental trials consisted of a three-stage submaximal test followed by a 4 km time trial. Blood samples were drawn pre- and post-exercise, and analyzed for BDNF, interleukin 6 (IL-6), interleukin 10 (IL-10) and tumor necrosis factor (TNF-α). The Stroop test and serial subtraction task were performed before ozone exposure and again after the 4 km TT. Serum BDNF increased post-exercise ( p < 0.0001), and positive differences were observed post-exercise in the ozone POLY group relative to PL ( p = 0.013). Plasma IL-6 increased post-exercise ( p = 0.0015), and TNF-α increased post-ozone exposure ( p = 0.0018). There were no differences in Stroop or serial subtraction tasks pre- or post-exercise. Exercise increases BDNF in ozone.

Introduction: Neonatal mortality remains significant in low-income and middle-income countries (LMICs) with in-hospital mortality rates similar to those following discharge from healthcare facilities. Care continuity interventions have been suggested as a way of reducing postdischarge mortality by better linking care between facilities and communities. This scoping review aims to map and describe interventions used in LMICs to improve care continuity for newborns after discharge and examine assumptions underpinning the design and delivery of continuity., Methods: We searched seven databases (MEDLINE, CINAHL, Scopus, Web of Science, EMBASE, Cochrane library and (Ovid) Global health). Publications with primary data on interventions focused on continuity of care for newborns in LMICs were included. Extracted data included year of publication, study location, study design and type of intervention. Drawing on relevant theoretical frameworks and classifications, we assessed the extent to which interventions adopted participatory methods and how they attempted to establish continuity., Results: A total of 65 papers were included in this review; 28 core articles with rich descriptions were prioritised for more in-depth analysis. Most articles adopted quantitative designs. Interventions focused on improving continuity and flow of information via education sessions led by community health workers during home visits. Extending previous frameworks, our findings highlight the importance of interpersonal continuity in LMICs where communication and relationships between family members, healthcare workers and members of the wider community play a vital role in creating support systems for postdischarge care. Only a small proportion of studies focused on high-risk babies. Some studies used participatory methods, although often without meaningful engagement in problem definition and intervention implementation., Conclusion: Efforts to reduce neonatal mortality and morbidity should draw across multiple continuity logics (informational, relational, interpersonal and managerial) to strengthen care after hospital discharge in LMIC settings and further focus on high-risk neonates, as they often have the worst outcomes., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2024. Re-use permitted under CC BY. Published by BMJ.)

Astrocytes play crucial roles in regulating neural circuit function by forming a dense network of synapse-associated membrane specializations, but signaling pathways regulating astrocyte morphogenesis remain poorly defined. Here, we show the Drosophila lipid-binding G protein-coupled receptor (GPCR) Tre1 is required for astrocytes to establish their intricate morphology in vivo. The lipid phosphate phosphatases Wunen/Wunen2 also regulate astrocyte morphology and, via Tre1, mediate astrocyte-astrocyte competition for growth-promoting lipids. Loss of s1pr1, the functional analog of Tre1 in zebrafish, disrupts astrocyte process elaboration, and live imaging and pharmacology demonstrate that S1pr1 balances proper astrocyte process extension/retraction dynamics during growth. Loss of Tre1 in flies or S1pr1 in zebrafish results in defects in simple assays of motor behavior. Tre1 and S1pr1 are thus potent evolutionarily conserved regulators of the elaboration of astrocyte morphological complexity and, ultimately, astrocyte control of behavior., Competing Interests: Declaration of interests The authors declare no competing interests., (Copyright © 2023 Elsevier Inc. All rights reserved.)

LEOMO™ is a commercial inertial measurement unit system that provides cycling-specific motion performance indicators (MPIs) and offers a mobile solution for monitoring cyclists. We aimed to validate the LEOMO sensors during sprint cycling using gold-standard marker-based three-dimensional (3D) motion technology (Qualisys, AB). Our secondary aim was to explore the relationship between peak power during sprints and MPIs. Seventeen elite track cyclists performed 3 × 15s seated start maximum efforts on a cycle ergometer. Based on intraclass correlation coefficient (ICC 3,1 ), the MPIs derived from 3D and LEOMO showed moderate agreement (0.50 < 0.75) for the right foot angular range (FAR); left foot angular range first quadrant (FARQ1); right leg angular range (LAR); and mean angle of the pelvis in the sagittal plane. Agreement was poor (ICC < 0.50) between MPIs derived from 3D and LEOMO for the left FAR, right FARQ1, left LAR, and mean range of motion of the pelvis in the frontal and transverse planes. Only one LEOMO-derived (pelvic rotation) and two 3D-derived (right FARQ1 and FAR) MPIs showed large positive significant correlations with peak power. Caution is advised regarding use of the LEOMO for short maximal cycling efforts and derived MPIs to inform peak sprint cycling power production.