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Success in post-secondary engineering graphics courses in technology and engineering often relies on self-efficacy, academic success, and mental rotation abilities. Using a facilitative instructor model, the Improving Undergraduate STEM Education (IUSE) team applied active learning modules as supplemental material at two post-secondary institutions in the United States of America, then used a quasi-experimental design iterative study approach to investigate impacts in an introductory engineering graphics course. Active learning modules were composed of ten units that engaged students through relatable examples and practices of foundational principles and applications of engineering graphics that are heavily applicable to the Standards for Technological and Engineering Literacy. The modules were presented to students through an online learning management system that encouraged elements of self-regulated learning. Measurements of self-efficacy, mental rotation ability, and academic success were gathered. Differences in academic and non-academic indicators were examined in combination with students at risk of non-matriculation and students not at risk of non-matriculation subgroups. Results from paired t-tests supported previous findings that there are positive impacts of supplemental materials available to students. Students at risk of non-matriculation benefited from the combination of active learning modules and supplementary video tutorials resulting in greater self-efficacy and higher final exam scores than at-risk students whose modules did not include video tutorials. Students not at risk of non-matriculation had higher levels of self-efficacy and mental rotation ability when video tutorials were not included. With this information, engineering, engineering education, and other STEM programs can model elements of active learning modules to promote early student success in both subgroups. Furthermore, the IUSE team has published the material through open access for educators and students to utilize.

Background Women’s sexual and reproductive health needs are complex and vary across the life course. They are met by a range of providers, professionals and venues. Provision is not well integrated, with inequalities in access. In some areas of the United Kingdom Women’s Health Hubs have been established to improve provision, experience and outcomes for women, and to address inequalities and reduce costs. These models were established prior to the national implementation of Women’s Health Hubs announced in the English 2022 Women’s Health Strategy. Objective To explore the ‘current state of the art’, mapping the United Kingdom landscape, and studying experiences of delivering and using Women’s Health Hubs across England, defining key features and early markers of success to inform policy and practice. Design A mixed-methods evaluation, comprising three work packages: Mapping the Women’s Health Hub landscape and context and developing a definition of Women’s Health Hubs, informed by an online national survey of Women’s Health Hub leaders, and interviews with regional stakeholders. In-depth evaluation in four hub sites, including interviews with staff and women, focus groups in local communities and documentary analysis. Interviews with national stakeholders and consolidation of findings from work packages 1 and 2. Fieldwork was undertaken from May 2022 to March 2023. The evaluation was initiated prior to the national scale-up of Women’s Health Hubs announced in the 2022 Women’s Health Strategy. Results Most areas of the United Kingdom did not have a Women’s Health Hub. Seventeen active services were identified, established between 2001 and 2022. Women’s Health Hubs were diverse, predominantly GP-led, with different perspectives of the role and definition of a hub. Women using hubs reported positive experiences, finding services caring and convenient. Implementation facilitators included committed, collaborative leaders working across boundaries, sufficient workforce capacity and a supportive policy context. Challenges included access to funding, commissioning, workforce issues, facilities and equipment, stakeholder engagement and wider system integration, priorities and pressures. Leaders were committed to addressing inequalities, but evidence of impact was still emerging. Limitations It was challenging to locate models; therefore, some may have been missed. Data availability limited assessment of impact, including inequalities. Some population groups were not represented in the data, and the evaluation was more provider-oriented. It was not possible to develop a typology of Women’s Health Hubs as planned due to heterogeneity in models. Conclusions Existing Women’s Health Hub models were providing integrated approaches to meet local needs. Many were at an early stage of development. Evidence of system-level impact and costs was still emerging. Women’s Health Hubs may widen inequalities if models are more accessible to advantaged groups. The important role of committed leaders in existing ‘bottom-up’ models may limit scalability and sustainability. Findings suggest that national scale-up will take time and requires funding and that it is necessary to design models according to local needs and resources. In 2023, the Department of Health and Social Care announced funding to establish a Women’s Health Hub in every Integrated Care System in England. Future work Future evaluation should consider system-level impact and costs, explore unintended consequences and test assumptions. Funding This award was funded by the National Institute of Health and Care Research (NIHR) Health and Social Care Delivery Research programme (NIHR award ref: NIHR135589) and is published in full in Health and Social Care Delivery Research; Vol. 12, No. 30. See the NIHR Funding and Awards website for further award information. Plain language summary In the National Health Service, care for women’s health issues such as heavy periods, menopause, contraception and abortion is provided by different services, such as GPs and hospital gynaecology and sexual health clinics. Services are not always joined up and often women find it hard to access care. To improve care, United Kingdom National Health Service teams have set up Women’s Health Hubs. Women’s Health Hubs involve a group of health professionals working together to provide more joined-up community-based services to women throughout their lives. This evaluation aimed to explore why, where and how Women’s Health Hubs have been set up and what they have achieved and to understand staff and patient experiences. The results will be shared with the government and National Health Service as new Women’s Health Hubs are set up. The evaluation included a survey of people who have set up hubs across the United Kingdom and interviews with women’s health leaders in England. In four hubs in England, we talked to local women and staff, and reviewed documents. We found 17 hubs, and most areas of the United Kingdom did not have one. Every hub was different, with different views about how hubs should work. Most were set up to improve access and experiences for women, and reduce pressure on other services. Six hubs had involved women in developing their service but most had not. Hubs offered appointments with health professionals, usually in GP or community clinics. The most common services were for coil fitting, menopause and heavy periods. The set-up of hubs was helped by passionate leaders who involved the right people, and identified funding and time. Challenges included National Health Service pressures and a lack of funding, clinic space and staff. Women who have used hubs report a good experience, with caring and convenient services. More work is needed to understand how hubs can improve care for all women, including unfair differences in care. Scientific summary Background Sexual and reproductive health covers a range of needs and conditions, including contraception, pregnancy and abortion, sexually transmitted infections (STIs), psychosexual services (e.g. counselling for sexual dysfunction), and gynaecological health (e.g. peri-menopause, menopause and menstrual problems) [All-Party Parliamentary Group on Sexual and Reproductive Health. Women’s Lives, Women’s Rights: Strengthening Access to Contraception Beyond the COVID-19 Pandemic (Internet). 2020. www.fsrh.org/documents/womens-lives-womens-rights-full-report/ (accessed 24 October 2023)]. Women’s sexual and reproductive health needs are complex and vary across the life course, and they are met by a variety of providers, venues and professionals. In England, challenges in access, workforce, funding and fragmented commissioning impact on women’s health service provision. In response to these challenges, local teams across the UK established Women’s Health Hubs (WHHs) to improve provision, experiences and outcomes. WHHs aimed to integrate women’s health services more effectively, with a more woman-centred, life-course approach. These emerging models were highlighted as best practice and wider adoption was subsequently recommended as a part of England’s Women’s Health Strategy in 2022. However, there was no agreed definition of a WHH in clinical and policy communities. Hubs were described as not necessarily a ‘place’, but a ‘concept’, and the term was being used differently across services and organisations. In response to WHHs being identified as an important policy topic, in 2022, the National Institute for Health and Care Research (NIHR) asked the BRACE Rapid Evaluation Centre to undertake a rapid evaluation of current hub evidence and practice. Objectives The aim of this evaluation was to explore the ‘current state of the art’ of WHHs, mapping the landscape, studying experiences of delivering and using hub services and defining key features and early markers of success to inform policy and practice. The evaluation explored the following questions: What are WHHs, and is there variation in how stakeholders name and define them? How many WHHs have been established or are in development across the UK, where are they and what are their characteristics, including models of structure, commissioning and delivery? Why have WHHs been implemented, and how are they intended to address health inequalities? What have WHHs achieved to date? How do WHHs achieve this? What are the experiences and perspectives of staff regarding WHH set-up, commissioning, funding, implementation and delivery? What are the experiences and perspectives of women who have used hub services? How are WHHs’ performance, outcomes and costs measured, and how might they be measured in future? Methods This was a mixed-methods evaluation, combining quantitative and qualitative data collection, with data collected at local, regional and national levels. This approach offered both breadth and depth in data collection. The evaluation comprised three work packages (WPs): Mapping the current landscape and context for WHHs, including an online survey of leads from hubs across the UK and interviews with regional stakeholders. Detailed research in four purposively selected exemplar hub sites in England, including interviews with staff and service users, focus groups in local communities and documentary analysis. Bringing together and consolidating findings from WPs 1 and 2 to generate evidence on WHH models, including interviews with national stakeholders. The mapping in WP1 was UK-wide, but the remainder of the work focused on WHHs in England. The England focus was decided collaboratively with a multidisciplinary Stakeholder Group, due to the particularly complex commissioning context in English health and social care systems. In total, interviews with 85 people were conducted: 40 WHH and wider staff, 7 regional stakeholders, 6 national stakeholders and 32 women. Four focus groups were undertaken with women in the local communities served by exemplar hubs. Ten initial scoping interviews undertaken to inform protocol design were included in the analysis. Results There were diverse approaches to implementing WHHs across England, with no standard or ‘typical’ model, and a lack of common language and terminology to describe hubs. A hub can be interpreted as a physical place, but also as a virtual platform (e.g. to triage or offer educational events for women), which can be difficult to understand for some stakeholders, including some women. In collaboration with our evaluation Stakeholder Group, and based on our findings across WPs, we developed a working definition of a WHH that represents a set of common features that were recognised within the community of practitioners as typifying a hub approach: Women’s Health Hubs are based in the community and work at the interface between primary and secondary care and/or voluntary sector and wider. Women’s Health Hubs offer more than a single service (and include the provision of both gynaecological services and contraception) or demonstrate plans to do so. Women’s Health Hubs have more than one organisation involved in the process of service delivery, including in design, commissioning and/or provision of care, beyond simply referring in. This definition should be considered alongside the need for hub design to be tailored to local contexts, needs and resources. As a result, we have not specified which model(s) should be used to implement hubs, which role(s) should lead design/delivery or other details about how the hub is established and resourced. While this offers flexibility to local areas to design a service that meets local needs, there is a risk of creating confusion for women, healthcare professionals and policy-makers regarding what a hub is and should do. This may impact on engagement by these groups and on hub implementation. The heterogeneity in hub models can also hinder evaluation, monitoring and comparison of hub impact. The working definition we have developed can be refined over time in response to evolving evidence and practice. A clear definition can support policy and decision-makers to better understand which models work best for women, including those from groups with greater needs, and which are most effective (including cost-effective). Further refinement of the definition could include standardisation of terminology, for example, to confirm the number and type of services that constitute a 'one-stop shop', and whether the ’spoke’ aspect of a ‘hub-and-spoke’ model must be a physical location or could be virtual. Clear definitions of a hub may also avoid simple rebadging of local services as hubs in response to policy initiatives, without meaningful transformation of care pathways. We identified 17 active WHHs across the UK. This means that most women did not have access to a hub at the time of data collection. Most of the hubs we identified were continuing to evolve and had plans in place to expand their offer and/or geographical reach. Hubs were introduced to meet a range of aims, primarily intending to improve healthcare access, quality and experience. Hub leaders were committed to reducing inequalities and many were implementing strategies to do so but approaches and evidence were still evolving. Hub services were often described as filling the intermediary space between standard primary care and specialist secondary care, although this boundary varied across hubs. Hubs were predominantly clinically led by GPs with a special interest in women’s health, although some were led by other professionals. Often, leadership was not well defined, with unspecified responsibilities and accountabilities, and a blurring of leadership, management and governance boundaries. While many hubs were reported as being one-stop shops, it was rare for them to offer multiple services at the same time and those that did were often opportunistic rather than a planned service offer (e.g. offering a smear test at the same time as fitting a coil). Most hubs operated from multiple venues, often in primary care or community settings. The professionals working to deliver services within hubs varied, and there was no consistent approach to staffing, with different costs associated with the roles deployed. A range of commissioning approaches were in place, often involving collaboration between multiple organisations. Given the challenges in securing funding and overcoming commissioning barriers, hub leaders had developed a range of creative approaches to accessing resources for implementation and delivery. However, these innovative local workarounds may not be suitable for long-term, sustainable scale-up and spread of WHHs. Some hubs had been unable to expand their clinical offer due to pre-existing commissioning barriers. Challenges included moving funding or activity from secondary care gynaecology to WHHs and identifying a long-term solution to enable offer of long-acting reversible contraception (LARC) for both gynaecological and contraceptive reasons in a hub. Resolving these challenges was often described as critical to successful implementation of hubs. In addition to financial resources, some hubs had secured additional expertise and capacity to support implementation, including from other areas of the health system, local authorities and pharmaceutical companies. Development of metrics and the measurement of hub outcomes was evolving and varied between hubs, making comprehensive assessment and comparison difficult. Some hubs had used local data to measure and model population need to inform hub design, and to estimate hub costs and benefits. Available data to quantify hub activity and impact so far were limited, but where reported it indicated that hubs had provided care for many hundreds of women in England. It also indicated that hubs have the potential to reduce waiting times and referral to secondary care gynaecology and increase LARC uptake. Evidence of impact on inequalities was still emerging. Women who participated in the evaluation reported having a positive experience of accessing their local hub and the care they received. However, women using the hub and other local women in the community were generally not familiar with the term ‘women’s health hub’ or did not know that they had received care from a hub, though they welcomed the hub concept. Women also described some challenges in accessing hub services, including difficulties making a GP appointment in order to be referred to the hub. A minority of hubs reported involving women in the design and development of the service. There is scope for greater involvement of women with a range of backgrounds and experiences in WHH development at both a national and local level to ensure that they meet the needs of all women and address inequalities. A number of factors facilitated the implementation and delivery of WHHs. This included leaders (both clinical and non-clinical) who were committed to the hub vision and worked collaboratively across organisational and sector boundaries to design and set up the service. Sufficient workforce capacity and wider policy and strategic support were also important. Implementation challenges included identification of funding and other resources (e.g. facilities equipment, physical space), stakeholder engagement (including allaying concerns regarding negative impacts on other parts of the system), competing priorities and pressures in the healthcare system, and IT issues. The fragmentation of English commissioning arrangements for gynaecology and contraception was a frequently reported barrier. We identified examples of hubs that had overcome some of these barriers to integrate care for women in their area. The creation of Integrated Care Boards (ICBs) in 2022 was seen as a potential route to scale-up hubs nationally. The lack of an ICB leader with responsibility for women’s health (with the exception of maternity) was noted as a challenge. The many competing priorities for ICBs were highlighted as limiting capacity to focus on women’s health. Subsequent to the completion of our evaluation in 2023, additional national funding was announced linked to the Women’s Health Strategy, to support the setting up of a WHH in each ICB in England, along with the appointment of a Women’s Health Champion in every ICB. Hubs had largely been developed bottom up by local professionals, designed to meet the specific needs of the local population. Participants often reflected that a top-down approach to implementing hubs may limit the flexibility to adapt to local needs, context, leadership, workforce and resources. A middle ground between a bottom-up and top-down approach may be required to balance standardisation across hubs (e.g. to have a shared vision and definition) with flexibility to align with local context. Hub establishment was still in the early stages, and it will take time to scale the approach up across the NHS and to ensure long-term sustainability of services, and localities were all at different starting points. The small number of highly diverse hub models in place at the time of this evaluation and varied approaches to measurement meant that it was challenging to assess impact. However, it highlights the opportunity to develop resources to support local systems to design and establish hubs, agree on core definitions and model components, standardise approaches (where appropriate), capture learning/data and test assumptions of different ways of working. Implementation efforts should include exploring and understanding any unintended consequences, a common occurrence when introducing complex changes into health systems. Agreeing some aspects of standardisation (where appropriate), sharing learning and measuring outcomes and impact data can facilitate future and ongoing implementation and evaluation of WHHs, and allow exploration of the relative benefits of different models. This learning can inform further scale-up of and development of WHHs. Conclusions At the start of this evaluation, WHHs were a set of innovative service models spread across the UK, and at the end of the evaluation, they were an explicitly stated policy objective for the Department of Health and Social Care (DHSC). Our findings identified that the few existing WHHs are diverse, and continuously evolving, with many at an early stage of development or delivery, with some employing innovative approaches such as virtual group consultations. The launch of the Women’s Health Strategy, and the associated funding to support hub implementation announced in March 2023, provides an opportunity to expedite the spread of these models. However, the heterogeneity in models and contexts, and the complexity of women’s health care, means that rapid scale-up may be challenging, and substantial commissioning barriers must be overcome. Our findings suggest that implementing models informed by local needs and resources will be necessary, and requires input from women, particularly those who are least well served by current services. We do not yet have clear evidence for the system-level impact or costs of WHHs, and the gathering of consistent data to test assumptions, and measure and learn from WHH achievements, including impacts on inequalities, will enable evaluation of further scale-up. WHHs have the potential to transform women’s access to care, and there is a large community of experts striving to improve women’s health care. The Women’s Health Strategy for England provides a further catalyst to national-level change, alongside the emerging system-level approaches to health improvement driven by ICBs, and wider population interest in women’s health. Funding This award was funded by the National Institute for Health and Care Research (NIHR) Health and Social Care Delivery Research (NIHR award ref: NIHR135589) and is published in full in Health and Social Care Delivery Research; Vol. 12, No. 30. See the NIHR Funding and Awards website for further award information.

INTRODUCTION: Psychedelic-assisted therapy with psilocybin has shown promise in Phase 2 trials for alcohol use disorder (AUD). Set and setting, particularly factors facilitating a connection with nature, may positively influence the psychedelic experience and therapeutic outcomes. But to date, randomized controlled trials of interventions to enhance set and setting for psychedelic-assisted therapy are lacking. METHODS: This was a pilot randomized, controlled trial of Visual Healing, a nature-themed video intervention to optimize set and setting, versus Standard set and setting procedures with two open-label psilocybin 25 mg dosing sessions among 20 participants with AUD. For the first session, participants randomized to Visual Healing viewed nature-themed videos during the preparation session and the ascent and descent phases of the psilocybin dosing session while participants randomized to the Standard condition completed a meditation during the preparatory session and wore eyeshades and listened to a music playlist throughout the dosing session. For the second session 4 weeks later, participants chose either Visual Healing or Standard procedures. Primary outcomes were feasibility, safety, and tolerability of Visual Healing. Secondary and exploratory outcomes were changes in alcohol use, psychedelic effects, anxiety and stress. RESULTS: Nineteen of 20 (95%) randomized participants (mean age 49 ± 11 years, 60% female) completed the 14-week study. During the first psilocybin session, participants viewed an average of 37.9 min of the 42-min video and there were no video-related adverse events. Peak increase in post-psilocybin blood pressure was significantly less for participants randomly assigned to Visual Healing compared to Standard procedures. Alcohol use decreased significantly in both Visual Healing and Standard groups and psychedelic effects, stress, and anxiety were similar between groups. DISCUSSION: In this open-label pilot study, viewing Visual Healing videos during preparation and psilocybin dosing sessions was feasible, safe, and well-tolerated among participants with AUD. Preliminary findings suggest that Visual Healing has potential to reduce the cardiovascular risks of psychedelic therapy, without interfering with the psychedelic experience or alcohol-related treatment outcomes. Studies to replicate our findings as well as studies of different set and setting interventions with other psychedelic medications and indications are warranted.

BackgroundStrength and mobility are essential for activities of daily living. With aging, weaker handgrip strength, mobility, and asymmetry predict poorer cognition. We therefore sought to quantify the relationship between handgrip metrics and volumes quantified on brain magnetic resonance imaging (MRI).ObjectiveTo model the relationships between handgrip strength, mobility, and MRI volumetry.MethodsWe selected 38 participants with Alzheimer's disease dementia: biomarker evidence of amyloidosis and impaired cognition. Handgrip strength on dominant and non-dominant hands was measured with a hand dynamometer. Handgrip asymmetry was calculated. Two-minute walk test (2MWT) mobility evaluation was combined with handgrip strength to identify non-frail versus frail persons. Brain MRI volumes were quantified with Neuroreader. Multiple regression adjusting for age, sex, education, handedness, body mass index, and head size modeled handgrip strength, asymmetry and 2MWT with brain volumes. We modeled non-frail versus frail status relationships with brain structures by analysis of covariance.ResultsHigher non-dominant handgrip strength was associated with larger volumes in the hippocampus (p = 0.02). Dominant handgrip strength was related to higher frontal lobe volumes (p = 0.02). Higher 2MWT scores were associated with larger hippocampal (p = 0.04), frontal (p = 0.01), temporal (p = 0.03), parietal (p = 0.009), and occipital lobe (p = 0.005) volumes. Frailty was associated with reduced frontal, temporal, and parietal lobe volumes.ConclusionGreater handgrip strength and mobility were related to larger hippocampal and lobar brain volumes. Interventions focused on improving handgrip strength and mobility may seek to include quantified brain volumes on MR imaging as endpoints.

Background General practices are facing challenges such as rising patient demand and difficulties recruiting and retaining general practitioners. Greater use of digital technology has been advocated as a way of mitigating some of these challenges and improving patient access. This includes Digital First Primary Care, when a patient’s first contact with primary care is through a digital route, either through a laptop or smartphone. The use of Digital First Primary Care has been expedited since COVID-19. There is little evidence of staff experiences of using Digital First Primary Care with more complex patients, such as those with multiple long-term conditions. Objective To understand the experiences of those with multiple long-term conditions of Digital First Primary Care from the perspectives of healthcare professionals and stakeholders. Design This was a qualitative evaluation, comprised of four distinct work packages: Work package 1: Locating the study within the wider context, engaging with literature, and co-designing the study approach and research questions with patients. Work package 2: Interviews with health professionals working across general practice and key expert topic stakeholders, including academics and policy-makers. Work package 3: Analysis of data and generation of themes, and testing findings with patients. Work package 4: Synthesis, reporting and dissemination. Results The study commenced in January 2021 and in total 28 interviews were conducted with 14 health professionals and 15 stakeholders between January and August 2022. From the perspective of health professionals, Digital First Primary Care approaches could enable patients to speak with a clinician more quickly than traditional approaches. Those with multiple long-term conditions could submit healthcare readings from home, though health professionals felt patients may struggle navigating digital systems not designed to capture the nuances associated with living with multiple conditions. Clinicians expressed preferences for seeing patients face-to-face, particularly those with multiple long-term conditions, to identify non-verbal cues about a patient’s health. Digital First Primary Care approaches provided an opportunity for clinicians to engage with the carers of patients living with multiple long-term conditions, yet there were concerns around obtaining consent and confidentiality. There remain debates among stakeholders about the nature and extent to which Digital First Primary Care impacts on staff workload. Limitations At the time of data collection, general practices were facing considerable pressure to deliver care and respond to the COVID-19 pandemic. While it was originally intended that the study would include interviews with patients with multiple long-term conditions and their carers, none of the general practices that took part in the study were willing and/or able to recruit patients and carers in the time available. Conclusions The rapid implementation of Digital First Primary Care, at a time of immense pressures, meant there has been little time for considering the impact on patients, including those with multiple long-term conditions. The impacts on care continuity depended largely on how surgeries implemented their approaches. Staff and stakeholders felt that Digital First Primary Care, as an additional route for accessing primary care, could be useful for patients with multiple long-term conditions but not at the expense of face-to-face consultations. Future work Future research obtaining patient and carer views of digital-first approaches, understanding the impacts on carers and how approaches are designed with patients with more complex conditions in mind, is essential. Funding This award was funded by the National Institute for Health and Care Research (NIHR) Health and Social Care Delivery Research programme (NIHR award ref: 16/138/31) and is published in full in Health and Social Care Delivery Research; Vol. 12, No. 21. See the NIHR Funding and Awards website for further award information. Plain language summary Healthcare professionals want to provide the best primary care in the face of increasing pressures, as well as improve access to care for patients. Digital First Primary Care is one response to this situation, when a patients’ first contact with primary care is through a digital route, either through a laptop or smartphone. Online systems allow the patient to provide information to their practice about their symptoms or needs and request a response from a health professional. Our study aimed to understand how Digital First Primary Care works for healthcare professionals providing care to increasing numbers of patients with multiple long-term conditions and their carers. Firstly, we examined the relatively limited existing findings and then interviewed healthcare professionals and key stakeholders experienced in digital approaches within primary care (e.g. from policy organisations, universities and the National Health Service). While we attempted to speak to patients and carers directly, unfortunately the pressures in general practice meant we were unable to do so. However, the study was co-designed with patients. Healthcare professionals and stakeholders felt that patients with multiple long-term conditions faced additional challenges with the use of Digital First Primary Care compared to other patients. For example, they reported difficulties navigating online forms and not being able to speak with a general practitioner who knew them well. There were differing views from healthcare professionals and stakeholders about how far Digital First Primary Care could help staff in general practice and enhance care. For some clinicians, the workload was easier to manage and some simple tasks (e.g. sick notes) could be completed quickly. This could reduce stress for staff and mean more patients could be seen per day. Others felt that the digital system had shortcomings. This could be important for patients with multiple long-term conditions; for example, when a digital form may not fully inform the general practitioner as to the exact nature of the problem, potentially requiring a further follow-up appointment. Health professionals reported that carers of patients with multiple long-term conditions generally liked the new systems as they helped to improve contact with general practice staff. The summary was co-authored by members of the BRACE Patient and Public Involvement group. Scientific summary Background Digital First Primary Care has become widespread in England, particularly since the COVID-19 pandemic. Digital First Primary Care is when a patients’ first contact with primary care is through a digital route, either through a laptop or smartphone. The design of Digital First Primary Care platforms varies by commercial provider, although the main principles are the same. The patient inputs their symptoms and concerns through a digital platform, either via a set of questions within a digital algorithm or through a free text submission. The patient is then given an appropriate response, which could be from a staff member within the practice or automatically generated by the algorithm. The consultation which results may be traditional in nature, for example by telephone or face-to-face, or be in the form of a message from a health professional to a patient or a video consultation. These approaches have been advocated by policy-makers in England since 2016, as it is believed they can enable clinicians to prioritise the care of patients. Despite the policy shift towards digital approaches, most general practitioner (GP) surgeries were not operating in this way in early 2020, with an analysis of primary care data suggesting that 13–15% of consultations were conducted remotely in January 2020. The COVID-19 pandemic has seen a rapid change in modes of service delivery in general practice, with all GP surgeries having to quickly adapt their services and offer some form of non-face-to-face consultation, to prevent viral transmission. Several studies have been conducted on the use of digital approaches in the National Health Service (NHS). The findings from these studies are wide-ranging. To summarise, digital approaches can provide a benefit to both staff and patients (e.g. greater convenience, including no need to travel to a general practice, and better monitoring of conditions), although there are some challenges. These include issues such as remote consultations taking longer than face-to-face care, potential problems with missed or delayed diagnoses, safeguarding issues, marginalising those who are digitally excluded due to poverty and digital literacy and seeing an increase in referrals to wider services. A mapping of the literature identified potential issues for patients with more complex health conditions accessing digital approaches, as well as the impact on staff in general practice, such as an increased clinical workload. Notably, there is a paucity of evidence in relation to staff experiences of using digital approaches with patients living with multiple long-term conditions. This rapid evaluation examined the views of health professionals in general practice and expert stakeholders to understand how the introduction of Digital First Primary Care influences the nature of the care delivered, any facilitators or barriers and how its use may help patients living with multiple long-term conditions. The findings provide insights that are helpful to primary care NHS staff treating patients with multiple long-term health conditions. Objectives Originally, our aim was to understand the experiences of those with multiple long-term conditions of Digital First Primary Care from the perspectives of patients, their carers and healthcare professionals. However, due to challenges related to COVID-19, GP practices were unable to recruit patients/carers to the study. The team reviewed and refined the research questions with respect to the ongoing challenges and changes occurring in general practice more widely. As a result, our research questions have been amended not only due to recruitment challenges, but also how general practice has responded to the COVID-19 pandemic. The research questions addressed in this rapid evaluation are: What is the experience of Digital First Primary Care for health professionals and stakeholders (including academics, policy makers and Digital First Primary Care providers), both before and during the COVID-19 pandemic? What is the impact of Digital First Primary Care on the nature of consultations, from the perspective of health professionals and stakeholders and for patients with multiple long-term conditions and their carers? This includes aspects of communication, timeliness of care and continuity of care. What, if any, are the advantages or disadvantages of Digital First Primary Care for health professionals when providing care for patients with multiple long-term conditions? What lessons can be learnt from staff and stakeholders, for future service delivery for patients with multiple long-term conditions in primary care? Are there individual groups within the community where there is particular learning for future service provision? Methods The evaluation comprised four interlinked work packages (WPs): WP1. Locating the study within the wider context, engaging with literature, as well as co-designing the study approach and research questions with patients–engaging with relevant literature on the use of Digital First Primary Care services by patients with multiple long-term conditions; a workshop with patients [members of the BRACE patient and public involvement (PPI) group] to shape the research questions (September 2020) as well as co-design research tools alongside continued engagement during data collection, analysis, and write up of findings. WP2. Interviews with health professionals working across general practice and key expert topic stakeholders–through in-depth interviews with GPs and nurses, at eight purposively selected general practice sites, identified via a range of strategies; analysis of data; testing findings with members from our BRACE steering group and BRACE PPI panel. The study included a variety of general practices covering differences across: (1) practice size; (2) mix of urban and rural; (3) the ethnic composition of patients; (4) the number of patients registered aged 65 years and over; (5) the nature of the digital-first applications implemented. Individual interviewees, 14 in all, were identified and approached through contacts in general practices. We also interviewed expert stakeholders (n = 15) from academia, policy think tanks and primary care-related member organisations. WP3. Analysis of data, generation of themes and testing findings with patients and carers–Data collection was undertaken between April and August 2022. We adopted a pragmatic approach to enable a comprehensive analysis within a rapid timescale: the collection and analysis of interview data were completed in parallel and facilitated through the use of one-page summaries of codes, frequent team meetings, data analysis workshops and systematic categorisation and coding according to an analytical framework based on the relevant literature identified in WP1. WP4. Synthesis, reporting and dissemination–Synthesis across WP1–3 and writing of the final report. Sharing of the findings with leading researchers and organisations in this field. Results We undertook interviews across eight general practice sites completing 14 interviews. Six of our eight practices were situated in rural locations, five were part of a single GP super-partnership and one practice was vertically integrated with an acute trust, while all practices used one of two different digital-first providers. All practices had introduced a programme of Digital First Primary Care prior to the COVID-19 pandemic, although its use had increased dramatically as a result of the pandemic. In addition, we undertook a further 15 interviews with a purposive selection of expert stakeholders. Owing to the small sample size, our findings cannot be assumed to be representative of general practice nationally, but they provide detailed insight from a diverse sample of practices where learning may be transferable to other primary care settings. The findings provide valuable insights into the use of Digital First Primary Care, both pre and post the COVID-19 pandemic. The implementation of Digital First Primary Care by health professionals providing care to patients with multiple long-term conditions The COVID-19 pandemic led to the rapid adoption and extensive roll out of Digital First Primary Care on a larger scale than pre-pandemic. The implementation of Digital First Primary Care across general practice was at speed and there was little opportunity for health care professionals to reflect on the impact that such an introduction would have on patient groups, such as those with multiple long-term conditions. In addition, the participants interviewed in our study felt that little consideration was given to the impact that the widespread use of these approaches might have on healthcare professionals who care for those with multiple long-term conditions. Some healthcare professionals felt that the introduction of Digital First Primary Care had led to an increase in demand from patients, as it was easier to access services in general practice. As a result, health professionals reported restricting the times Digital First Primary Care was available to patients in order to manage their workload and, ultimately, limited access (e.g. closing Digital First Primary Care platforms over weekends or for set times during the day). It was perceived by interviewees that patients with multiple long-term conditions may face additional challenges with the use of Digital First Primary Care compared to other patients. These challenges included navigating Digital First Primary Care systems (particularly those systems that used digital questionnaires for patients to report their symptoms/the reason they were seeking to consult, which followed algorithm approaches and restricted the opportunity to provide a descriptive narrative) and, potentially, reducing the likelihood of being able to speak with a health professional who knew them and their conditions well. Advantages and disadvantages of Digital First Primary Care for patients with multiple long-term conditions from the perspective of health professionals and stakeholders Participants reported that Digital First Primary Care could provide some benefits to patients with multiple long-term conditions, such as being seen or having their health-related queries addressed more quickly, receiving an initial response from their general practice within 1–2 days for non-urgent matters and avoiding the need to wait in long telephone queues for appointments. Where this was the case, it reduced the need for unnecessary face-to-face appointments and supported patients’ preferences where possible. Digital First Primary Care was also reported to be useful for patients with some long-term health conditions (e.g. diabetes, cardiovascular conditions, mental health conditions and hearing loss). For example, health professionals felt that patients with multiple long-term conditions found Digital First Primary Care platforms useful when submitting readings (e.g. blood sugar levels, blood pressure) from home compared to coming into the general practice, a feature which was particularly helpful for patients with well-managed long-term conditions. In addition, participants felt that younger patients, those working full-time and those who did not speak English as a first language (if translation was available within the system) benefitted from Digital First Primary Care. However, patient group participants who it was felt may benefit less from Digital First Primary Care included those who are older/frail and those without access to digital technology (or the skills or abilities to use it). Participants felt that there were some notable drawbacks when using Digital First Primary Care programmes for patients with multiple long-term conditions. Participants had concerns regarding how the introduction and application of Digital First Primary Care programmes impacts the quality of relationships patients have with healthcare professionals, as well as the impact on patient safety. Digital First Primary Care also puts the onus on the patient to articulate their problem through written means, and this can be challenging for patients who have difficulties with literacy. Further, several health professionals expressed a preference for seeing patients face-to-face, particularly those with multiple long-term conditions, so as to have the opportunity to holistically assess the patient. Finally, the participants felt that the carers of patients with long-term conditions may benefit from Digital First Primary Care as they can have more direct communication with healthcare professionals and can be more actively involved in their care. However, there are some concerns regarding confidentiality, privacy and consent when it comes to carers accessing medical information. Impact of Digital First Primary Care on the general-practice workforce within and outside of consultations with patients with multiple long-term conditions With regards to healthcare professionals, Digital First Primary Care can offer advantages in terms of better information sharing and communication across staff and patients, improved relationships with patients and greater efficiencies and flexibility. However, some felt that Digital First Primary Care was detrimental to the clinician–patient relationship, creating some inefficiencies. There were also concerns raised over the confidence staff have in their own clinical decision-making when using Digital First Primary Care and the issue of increased (unmanageable) patient demand. Conclusions Conducting interviews with clinical general-practice staff and expert stakeholders following the height of the pandemic was challenging. Useful insights have, nevertheless, been obtained. Digital First Primary Care approaches have been rapidly rolled out and COVID-19 has dramatically changed the way in which general practice operates. The implementation of Digital First Primary Care has been undertaken at great speed, with many in general practice reconsidering how best to use a suite of digital approaches, from initial patient contact to consultation, at a time of immense pressures on staff. The push for greater access to general practice and the corresponding focus on seeing and speaking to a patient rapidly have occurred at the expense of other aspects of general-practice care which the health professionals and stakeholders who were interviewed felt are valued by patients with multiple long-term conditions. These included continuity of care (particularly during the COVID-19 pandemic) and an established doctor–patient relationship which enables the clinician and patient to have clear communication. For the participants in our study, the overwhelming view was that Digital First Primary Care could be useful for patients with multiple long-term conditions, but it should be available in addition to, not at the expense of, face-to-face consultations. The authors see that there is important future work in obtaining the views of patients and their carers and comparing those alongside the views of health professionals and stakeholders obtained in this study; a cost-effectiveness analysis across providers; and understanding how individual providers of Digital First Primary Care are designed with the needs of complex patients in mind. Funding This award was funded by the National Institute for Health and Care Research (NIHR) Health and Social Care Delivery Research programme (NIHR award ref: 16/138/31) and is published in full in Health and Social Care Delivery Research; Vol. 12, No. 21. See the NIHR Funding and Awards website for further award information.

BackgroundModifiable lifestyle-related factors heighten the risk and severity of coronavirus disease 2019 (COVID-19) in patients with cancer. Whether exercise lowers susceptibility or severity is not known.MethodsWe identified 944 cancer patients from Memorial Sloan Kettering Cancer Center (mean age: 64; 85% female; 78% White) completing an exercise survey before receiving a confirmed positive or negative SARS-CoV-2 test. Exercise was defined as reporting moderate-intensity ≥5 days per week, ≥30 minutes/session or strenuous-intensity ≥3 days per week, ≥20 minutes/session. Multivariable logistic regression was used to determine the relationship between exercise and COVID-19 susceptibility and severity (i.e., composite of hospital admission or death events) with adjustment for clinical-epidemiologic covariates.ResultsTwenty-four percent (230/944) of the overall cohort were diagnosed with COVID-19 and 35% (333/944) were exercisers. During a median follow-up of 10 months, 26% (156/611) of nonexercising patients were diagnosed with COVID-19 compared with 22% (74/333) of exercising patients. The adjusted OR for risk of COVID-19 was 0.65 [95% confidence interval (CI), 0.44-0.96, P = 0.03] for exercisers compared with nonexercisers. A total of 20% (47/230) of COVID-19 positive patients were hospitalized or died. No difference in the risk of severe COVID-19 as a function of exercise status was observed (P > 0.9).ConclusionsExercise may reduce the risk of COVID-19 infection in patients with a history of cancer, but not its severity.ImpactThis study provides the first data showing that exercise might lower the risk of COVID-19 in cancer patients, but further research is required.

It is my honor and privilege to deliver the AAP Presidential Address to this esteemed audience. The Presidential Address of the Spring meeting is a tradition dating back to the [...]

Acquired mutations are pervasive across normal tissues. However, understanding of the processes that drive transformation of certain clones to cancer is limited. Here we study this phenomenon in the context of clonal hematopoiesis (CH) and the development of therapy-related myeloid neoplasms (tMNs). We find that mutations are selected differentially based on exposures. Mutations in ASXL1 are enriched in current or former smokers, whereas cancer therapy with radiation, platinum and topoisomerase II inhibitors preferentially selects for mutations in DNA damage response genes (TP53, PPM1D, CHEK2). Sequential sampling provides definitive evidence that DNA damage response clones outcompete other clones when exposed to certain therapies. Among cases in which CH was previously detected, the CH mutation was present at tMN diagnosis. We identify the molecular characteristics of CH that increase risk of tMN. The increasing implementation of clinical sequencing at diagnosis provides an opportunity to identify patients at risk of tMN for prevention strategies.

Khan Academy is a large and popular open educational resource (OER) with little empirical study into its impact on student achievement in mathematics when used in schools. In this study, we examined the use of Khan Academy as a mathematics intervention among seventh grade students over a 4-week period versus a control group. We also compared differences between students who had supplemental mathematics instruction and those who had not. In both cases, we found no statistically significant differences in student test scores. Khan Academy has several internal metrics used to track student performance and use. We found significant relationships between these metrics and student test scores in this study. Khan Academy and other OER provide access to information and knowledge to large numbers of the population. This research adds to the discourse methods by which Khan Academy and other OER may affect learners.

Aim: Genomically matched trials in primary brain tumors (PBTs) require recent tumor sequencing. We evaluated whether circulating tumor DNA (ctDNA) could facilitate genomic interrogation in these patients. Methods: Data from 419 PBT patients tested clinically with a ctDNA NGS panel at a CLIA-certified laboratory were analyzed. Results: A total of 211 patients (50%) had ≥1 somatic alteration detected. Detection was highest in meningioma (59%) and gliobastoma (55%). Single nucleotide variants were detected in 61 genes, with amplifications detected in ERBB2, MET, EGFR and others. Conclusion: Contrary to previous studies with very low yields, we found half of PBT patients had detectable ctDNA with genomically targetable off-label or clinical trial options for almost 50%. For those PBT patients with detectable ctDNA, plasma cfDNA genomic analysis is a clinically viable option for identifying genomically driven therapy options.

During the development of heart failure (HF), the capacity for cardiomyocyte (CM) fatty acid oxidation (FAO) and ATP production is progressively diminished, contributing to pathologic cardiac hypertrophy and contractile dysfunction. Receptor-interacting protein 140 (RIP140, encoded by Nrip1) has been shown to function as a transcriptional corepressor of oxidative metabolism. We found that mice with striated muscle deficiency of RIP140 ([strNrip1.sup1.-/-]) exhibited increased expression of a broad array of genes involved in mitochondrial energy metabolism and contractile function in heart and skeletal muscle. [strNrip1.sup.-/-] mice were resistant to the development of pressure overload-induced cardiac hypertrophy, and CM- specific RIP140-deficient ([csNrip1.sup.-/-]) mice were protected against the development of HF caused by pressure overload combined with myocardial infarction. Genomic enhancers activated by RIP140 deficiency in CMs were enriched in binding motifs for transcriptional regulators of mitochondrial function (estrogen-related receptor) and cardiac contractile proteins (myocyte enhancer factor 2). Consistent with a role in the control of cardiac fatty acid oxidation, loss of RIP140 in heart resulted in augmented triacylglyceride turnover and fatty acid utilization. We conclude that RIP140 functions as a suppressor of a transcriptional regulatory network that controls cardiac fuel metabolism and contractile function, representing a potential therapeutic target for the treatment of HF., Introduction The remarkable energy demands of the heart are largely met by the oxidation of fatty acids and glucose in high-capacity mitochondrial networks. Fatty acid oxidation (FAO) is the chief [...]

AIM: Seasonally dry tropical forest (SDTF) of the Caribbean Islands (primarily West Indies) is floristically distinct from Neotropical SDTF in Central and South America. We evaluate whether tree species composition was associated with climatic gradients or geographical distance. Turnover (dissimilarity) in species composition of different islands or among more distant sites would suggest communities structured by speciation and dispersal limitations. A nested pattern would be consistent with a steep resource gradient. Correlation of species composition with climatic variation would suggest communities structured by broad‐scale environmental filtering. LOCATION: The West Indies (The Bahamas, Cuba, Hispaniola, Jamaica, Puerto Rico, US Virgin Islands, Guadeloupe, Martinique, St. Lucia), Providencia (Colombia), south Florida (USA) and Florida Keys (USA). TAXON: Seed plants—woody taxa (primarily trees). METHODS: We compiled 572 plots from 23 surveys conducted between 1969 and 2016. Hierarchical clustering of species in plots, and indicator species analysis for the resulting groups of sites, identified geographical patterns of turnover in species composition. Nonparametric analysis of variance, applied to principal components of bioclimatic variables, determined the degree of covariation in climate with location. Nestedness versus turnover in species composition was evaluated using beta diversity partitioning. Generalized dissimilarity modelling partitioned the effect of climate versus geographical distance on species composition. RESULTS: Despite a set of commonly occurring species, SDTF tree community composition was distinct among islands and was characterized by spatial turnover on climatic gradients that covaried with geographical gradients. Greater Antillean islands were characterized by endemic indicator species. Northern subtropical areas supported distinct, rather than nested, SDTF communities in spite of low levels of endemism. MAIN CONCLUSIONS: The SDTF species composition was correlated with climatic variation. SDTF on large Greater Antillean islands (Hispaniola, Jamaica and Cuba) was characterized by endemic species, consistent with their geological history and the biogeography of plant lineages. These results suggest that both environmental filtering and speciation shape Caribbean SDTF tree communities.

The oxygen isotope (δ18O) compositions of final chamber fragments of individual shells of the planktic foraminifer Orbulina universa were measured in situ via secondary ion mass spectrometry (SIMS) and by traditional gas-source mass spectrometry (GSMS) entailing acid digestion of sampled calcite. The paired SIMS-GSMS analyses were performed on final chamber fragments of fossil shells taken from the top of a sediment core (Holocene) as well as shells grown in laboratory culture. Multiple iterations of SIMS-GSMS analyses were conducted on final chamber fragments treated with a variety of cleaning protocols. The series of paired analyses yielded an average SIMS-GSMS δ18O offset (Δ18OSIMS-GSMS) of −0.9 ± 0.1‰ (±2 SE). The volume of material analyzed in 10-μm SIMS spots is ~105 times smaller than that analyzed by GSMS; hence, the extent to which these Δ18OSIMS-GSMS values represent real differences in analyte vs. instrumental factors remains unclear. Possible contributing factors to the SIMS-GSMS δ18O difference include sample-standard mismatch by SIMS, differences in standardization of SIMS and GSMS, and non-calcite contaminants in samples. Although the two datasets are consistently offset, SIMS values reproduce inter-shell δ18O variability delineated by shell fragment GSMS values. This strong positive covariance proved useful for bringing the two datasets into agreement (i.e. Δ18OSIMS-GSMS = 0), and confirms that SIMS-based foraminifer δ18O values record changes in calcification temperature and/or δ18O of seawater. Whether shells of foraminifer taxa with differing microcrystalline structures, chemical composition, and/or preservation histories register a similar Δ18OSIMS-GSMS value is a subject of ongoing testing.

Knowledge about the biogeographic affinities of the world's tropical forests helps to better understand regional differences in forest structure, diversity, composition, and dynamics. Such understanding will enable anticipation of region-specific responses to global environmental change. Modern phylogenies, in combination with broad coverage of species inventory data, now allow for global biogeographic analyses that take species evolutionary distance into account. Here we present a classification of the world's tropical forests based on their phylogenetic similarity. We identify five principal floristic regions and their floristic relationships: (i) Indo-Pacific, (ii) Subtropical, (iii) African, (iv) American, and (v) Dry forests. Our results do not support the traditional neo- versus paleotropical forest division but instead separate the combined American and African forests from their Indo-Pacific counterparts. We also find indications for the existence of a global dry forest region, with representatives in America, Africa, Madagascar, and India. Additionally, a northern-hemisphere Subtropical forest region was identified with representatives in Asia and America, providing support for a link between Asian and American northern-hemisphere forests.

Transfusion-related immunomodulation (TRIM) in the intensive care unit (ICU) is difficult to define and likely represents a complicated set of physiologic responses to transfusion, including both proinflammatory and immunosuppressive effects. Similarly, the immunologic response to critical illness in both adults and children is highly complex and is characterized by both acute inflammation and acquired immune suppression. How transfusion may contribute to or perpetuate these phenotypes in the ICU is poorly understood, despite the fact that transfusion is common in critically ill patients. Both hyperinflammation and severe immune suppression are associated with poor outcomes from critical illness, underscoring the need to understand potential immunologic consequences of blood product transfusion. In this review we outline the dynamic immunologic response to critical illness, provide clinical evidence in support of immunomodulatory effects of blood product transfusion, review preclinical and translational studies to date of TRIM, and provide insight into future research directions.

Part of a more extensive National Science Foundation-funded study, this study presents the findings and analysis of the effect on three-dimensional modeling self-efficacy (3DSE) by the inclusion of online active learning modules (ALM). Using multiple datasets, we found that the use of ALM in an introductory engineering graphics course, closed a gap in 3DSE scores between majority and minority students, populations historically underrepresented in engineering. Although limited to a single university, the results support that the inclusion of active online learning may address an important construct known to be a factor in academic success and persistence in engineering.

The Purdue Spatial Visualization Test: Visualization of Rotations (PSVT: R) is a widely used assessment of spatial ability. In this report, the factor structure of the PSVT: R test items was examined through confirmatory factor analysis with data from 541 engineering design graphics students. Stata 15 and Mplus 8.2 statistical software were used to examine a hypothesized 30 item one-factor model. Upon initial examination, data from engineering design graphics students produced a poor model-fit for the hypothesized one-factor 30 item model in both statistical programs. Respecified one-factor models with 10 test items and eight test items produced acceptable model-fit for the data employing Stata 15 and Mplus 8.2, respectively.

Mitochondrial biology is the sum of diverse phenomena from molecular profiles to physiological functions. A mechanistic understanding of mitochondria in disease development, and hence the future prospect of clinical translations, relies on a systems-level integration of expertise from multiple fields of investigation. Upon the successful conclusion of a recent National Institutes of Health, National Heart, Lung, and Blood Institute initiative on integrative mitochondrial biology in cardiovascular diseases, we reflect on the accomplishments made possible by this unique interdisciplinary collaboration effort and exciting new fronts on the study of these remarkable organelles.

The high species richness of tropical forests has long been recognized, yet there remains substantial uncertainty regarding the actual number of tropical tree species. Using a pantropical tree inventory database from closed canopy forests, consisting of 657,630 trees belonging to 11,371 species, we use a fitted value of Fisher's alpha and an approximate pantropical stem total to estimate the minimum number of tropical forest tree species to fall between ∼ 40,000 and ∼ 53,000, i.e., at the high end of previous estimates. Contrary to common assumption, the Indo-Pacific region was found to be as species-rich as the Neotropics, with both regions having a minimum of ∼ 19,000-25,000 tree species. Continental Africa is relatively depauperate with a minimum of ∼ 4,500-6,000 tree species. Very few species are shared among the African, American, and the Indo-Pacific regions. We provide a methodological framework for estimating species richness in trees that may help refine species richness estimates of tree-dependent taxa.