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Trauma care in the UK is a rapidly developing subspecialty of multiple disciplines from pre-hospital care through to rehabilitation medicine. In its infancy, the Advanced Trauma Life Support (ATLS) approach was designed for a sole provider to critically assess and manage a multiply injured patient with life-threatening injuries through a systematic resuscitation. With the advent of modern trauma systems, major trauma centres and their trauma teams the Airway, Breathing, Circulation, Disability and Exposure approach (ABCDE) of ATLS often play out simultaneously, during which it is vital that the providers have a common understanding of each contributor's roll in the assessment and care of the patient. The 10th Edition of the ATLS Student Manual has an additional new section on Teamwork, reflecting the most up-to-date scientific knowledge on the importance of the team system in trauma resuscitation. ATLS is also one of the seven pillars of change which have been adopted by the Royal College of Surgeons England for reforming the trauma systems in the UK. This article focuses on the ATLS guidelines as the founding principle of good trauma care and incorporates discussion upon some other important modern concepts utilized in the care of the multiply injured patient.

Ground penetrating radar (GPR) is a well-known useful tool for subsurface exploration. GPR data can be recorded at a relatively high speed in a continuous way with hyperbolas being artifacts and evidence of disturbances in the soil. Automatic and accurate detection and interpretation of hyperbolas in GPR remains an open challenge. Recently deep learning techniques have achieved remarkable success in image recognition tasks and this has potential for interpretation of GPR data. However, training reliable deep learning models requires massive labeled data, which is challenging. To address the challenges, this work proposes a Generative Adversarial Nets (GANs)-based deep learning framework, which generates new training data to address the scarcity of GPR data, automatically learns features and detects subsurface objects (via hyperbola) through an end-to-end solution. We have evaluated our proposed approach using real GPR B-scan images from rail infrastructure monitoring applications and compared this with the state-of-the-art methods for object detection (i.e. Faster-RCNN, Cascade R-CNN, SSD and YOLO V2). The proposed approach outperforms the existing methods with high accuracy of 97% being the mean Average Precision (mAP). Moreover, the proposed approach also demonstrates the good generalizability through cross-validation on independent datasets.

The KC-135 Stratotanker has been a workhorse aircraft for the U.S. Air Force and Air National Guard for over 60 years. The aircraft and its technologies have had many modifications and updates over the decades, but the Emergency Procedures (EPs) section of the KC-135 In-Flight Manual has only been updated based on engineering modifications and incident and accident reports. The goal of this project was to systematically assess, identify, and document issues in the KC-135 EPs using aviation checklist design guidance and a crew-centric human factors approach. Electronic checklists were then created to address the issues in the KC-135 EPs. The number of emergency procedures was reduced by over 50%: 351 KC-135 EPs were streamlined into 154 electronic checklists. The revised electronic checklists for emergency procedures will optimize KC-135 crew responses to non-normal situations and ensure safe and efficient operation of the KC-135 beyond its projected sunset in 2040.

Background Life expectancy (LE) improvements have stalled, and UK tax and welfare ‘reforms’ have been proposed as a cause. We estimated the effects of tax and welfare reforms from 2010/2011 to 2021/2022 on LE and inequalities in LE in Scotland. Methods We applied a published estimate of the cumulative income impact of the reforms to the households within Scottish Index of Multiple Deprivation (SIMD) quintiles. We estimated the impact on LE by applying a rate ratio for the impact of income on mortality rates (by age group, sex and SIMD quintile) and calculating the difference between inflation-only changes in benefits and the reforms. Results We estimated that changes to household income resulting from the reforms would result in an additional 1041 (+3.7%) female deaths and 1013 (+3.8%) male deaths. These deaths represent an estimated reduction of female LE from 81.6 years to 81.2 years (−20 weeks), and male LE from 77.6 years to 77.2 years (−23 weeks). Cuts to benefits and tax credits were modelled to have the most detrimental impact on LE, and these were estimated to be most severe in the most deprived areas. The modelled impact on inequalities in LE was widening of the gap between the most and least deprived 20% of areas by a further 21 weeks for females and 23 weeks for males. Interpretation This study provides further evidence that austerity, in the form of cuts to social security benefits, is likely to be an important cause of stalled LE across the UK.

For a typical coach, interior seats and partitions are considered as secondary collision objects in the event of a frontal collision. When a seat back has a deployable leaf-table, the additional ef...

Simple Summary Myelofibrosis (MF) is a progressive myeloproliferative neoplasm with tendency towards leukemic transformation and has the poorest prognosis amongst the Philadelphia-negative classical myeloproliferative neoplasms (MPN). Ruxolitinib, the first FDA-approved JAK1/2 tyrosine kinase inhibitor, is efficient in reducing spleen size and improving patient symptoms, but it has not been shown to eradicate the MF clone. In this study, using functional genomics techniques, we identified the proteasome family as an additional therapeutic target and demonstrated that inhibition of the proteasome family by carfilzomib in combination with ruxolitinib enhanced suppression of primary MF cells in vitro. Abstract As the first FDA-approved tyrosine kinase inhibitor for treatment of patients with myelofibrosis (MF), ruxolitinib improves clinical symptoms but does not lead to eradication of the disease or significant reduction of the mutated allele burden. The resistance of MF clones against the suppressive action of ruxolitinib may be due to intrinsic or extrinsic mechanisms leading to activity of additional pro-survival genes or signalling pathways that function independently of JAK2/STAT5. To identify alternative therapeutic targets, we applied a pooled-shRNA library targeting ~5000 genes to a JAK2V617F-positive cell line under a variety of conditions, including absence or presence of ruxolitinib and in the presence of a bone marrow microenvironment-like culture medium. We identified several proteasomal gene family members as essential to HEL cell survival. The importance of these genes was validated in MF cells using the proteasomal inhibitor carfilzomib, which also enhanced lethality in combination with ruxolitinib. We also showed that proteasome gene expression is reduced by ruxolitinib in MF CD34+ cells and that additional targeting of proteasomal activity by carfilzomib enhances the inhibitory action of ruxolitinib in vitro. Hence, this study suggests a potential role for proteasome inhibitors in combination with ruxolitinib for management of MF patients.

This article provides a critical review of the evidence on ‘thinking and working politically’ (TWP) in development. Scholars and practitioners have increasingly recognised that development is a fundamentally political process, and there are concerted efforts underway to develop more politically-informed and adaptive ways of thinking and working in providing development assistance. However, while there are interesting and engaging case studies in the emerging, largely practitioner-based literature, these do not yet constitute a strong evidence base that shows these efforts can be clearly linked to more effective aid programming. Much of the evidence used so far to support these approaches is anecdotal, does not meet high standards for a robust body of evidence, is not comparative and draws on a small number of self-selected, relatively well-known success stories written primarily by programme insiders. The article discusses the factors identified in the TWP literature that are said to enable politically-informed programmes to increase aid effectiveness. It then looks at the state of the evidence on TWP in three areas: political context, sector, and organisation. The aim is to show where research efforts have been targeted so far and to provide guidance on where the field might focus next. In the final section, the article outlines some ways of testing the core assumptions of the TWP agenda more thoroughly, to provide a clearer sense of the contribution it can make to aid effectiveness.

Camera traps are increasingly used to monitor wildlife populations and management activities. Failing to detect target occurrence and/or behaviour inhibits the robustness of wildlife surveys. Based on user‐testing, it is reasonable to expect some equipment to malfunction but other sources of failure, such as those caused by theft and vandalism, are largely unquantified. Between May 2016 and October 2017, we undertook an international survey of professional practitioners who use camera traps for wildlife research and management projects to quantify theft and vandalism, and to document the subsequent effects on project outcomes. We also sought to record the methods used by practitioners to avoid theft and vandalism and whether or not practitioners believed those actions were effective. Most (59%) of the 407 respondents were wildlife researchers and university academics. The survey results revealed that camera trap theft and vandalism is a global issue that not only adds to costs via equipment loss (approx. USD $1.48 million from n = 309 respondents between 2010 and 2015) and theft prevention (c. USD $800 000 spent by respondents between 2010 and 2015) but also influences survey design. Vandalism and theft are clearly a global problem, with responses suggesting that they occur across a diverse array of geographic locations, at varying proximity to human settlements, in multiple habitat types and across device placements. Methods to deter human interference included using camouflaging (73%), security devices such as chains (63%) and boxes (43%), use of decoy camera traps, shortening deployment periods, setting the camera relatively high or low to the ground, or moving away from human traffic. Despite this, the responses suggest that attempts to mitigate losses are often not effective. In review of our findings, we make recommendations for the future of camera trapping that requires implementation and testing.

Gridlock is a term to describe the breakdown in cooperation of countries in international institutions to address policy problems that span borders; it refers both to deadlock in existing organisations and the difficulty of countries to come to new agreements as issues arise. Global science mega‐projects and their communities have seemingly been remarkably effective in evolving complex processes and mechanisms to enable collaboration. Previous research into CERN has focused on recounting the stories of CERN's scientific feats and technical innovations. This research has investigated the reasons behind these triumphs from a social sciences’ perspective to see why it is an exemplar of organisational success. The CERN communities’ governance and leadership regimes are examined. Extensive field work has added insights into two themes that emerge from the literature: the primacy of the state and the employment of combined routes through and beyond gridlock. Through exercising consensual governance with its Member States to manage multi‐polarity and using a light leadership approach with collaborative partners and international staff, CERN consistently achieves outstanding results. This research contributes to the global gridlock debate by being part of the examination of pathways and mechanisms in successful international collaborations.

During the last two decades, new archaeological projects which systematically integrate a variety of plant recovery techniques, along with palaeoecology, palaeoclimate, soil science and floristic inventories, have started to transform our understanding of plant exploitation, cultivation and domestication in tropical South America. Archaeobotanical studies are providing a far greater appreciation of the role of plants in the diets of early colonists. Since ∼13ka, these diets relied mainly on palm, tree fruits, and underground tubers, along with terrestrial and riverine faunal resources. Recent evidence indicates two areas of precocious plant cultivation and domestication: the sub-Andean montane forest of NW South America and the shrub savannahs and seasonal forests of SW Amazonia. In the latter area, thousands of anthropic keystone structures represented by forest islands show a significant human footprint in Amazonia from the start of the Holocene. While radiocarbon date databases show a decline in population during the middle Holocene, important developments happened during this epoch, including the domestication of cacao, the adoption of maize and the spread of manioc across the basin. The late Holocene witnessed the domestication of rice and the development of agricultural landscapes characterised by raised fields and Amazonian Dark Earths (ADEs). Our multi-proxy analysis of 23 late Holocene ADEs and two lakes from southern Amazonia provides the first direct evidence of field polyculture agriculture including the cultivation of maize, manioc, sweet potato, squash, arrowroot and leren within closed-canopy forest, as well as enrichment with palms, limited clearing for crop cultivation, and low-severity fire management. Collectively, the evidence shows that during the late Holocene Amazonian farmers engaged in intensive agriculture marked by the cultivation of both annual and perennial crops relying on organic amendments requiring soil preparation and maintenance. Our study has broader implications for sustainable Amazonian futures.

Introduction In 2020, the University of Portsmouth as COVID 191 affected many other organisations and the undergraduate student nurses (USN) were unable to use the simulation centre. The USN needed to complete their health history questionnaire Cohort 4 (n=101) objective structured clinical examination’s (OSCE).2 The OSCE was designed to demonstrate the attitudes and values expected of year 2, degree level 5. We decided to introduce a similar format to the year 1 Health history working alongside SimComm Academy. We completed C4 (n=7/101) OSCE slots within a day while 1 member of the team was in another country. Methods First, we needed to ascertain any potential technical issues, time difference or internet and connection problems. We produced a business plan to ensure the correct funding for the simulated patient provided by SimComm Academy. The OSCE design included 1 student, 1 simulated patient (SP’s) and 1 member of the faculty examiner (FE). The SP’s and FE were sent the scripts for the scenarios in advance. We arranged OSCE slots via Hangout software (Google video conferencing) selected due to familiarity video recording capabilities. Moreover, the FE electronic marking criteria3 in collaborations with the SP’s feedback. We organised a brief in the morning to ensure everyone was clear with the objectives, timings, recording the scenarios, marking criteria and any miscellaneous questions. We gave additional time for the OSCE in case of any technical issues and we allowed for breaks throughout the OSCE. Part of the process included an additional member of staff in case of any technical issues and we allocated spare slots as a matter of precaution. The additional member of staff already knew the scenario so we were able to utilise the person as a verifier of the OSCE by replaying the recordings. Results The feedback from the SP’s, FE and students have been positive because the students were able to demonstrate and practice their skills similar to being in the University. These OSCE allowed the students to demonstrate their learning outcomes, attitudes and values within a less stressful environment. Discussion and Conclusions Only one student had technical issues, which were soon resolved via emails. Thus, demonstrating OSCES can be run internationally anywhere in the world. The only recommendation is to encourage the wider community to become involved worldwide. References Sebastian L, Foster CW, Hawks M, et al. Remote assessment of clinical skills during COVID-19: a virtual, high-stakes, summative pediatric objective structured clinical examination. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7273144/pdf/main.pdf [abstract]. Academic Pediatric Association 2020;20:761–762. Chan J, Humphrey‐Murto S, M Pugh, D et al. The objective structured clinical examination: can physician‐examiners participate from a distance? https://doi.org/10.1111/medu.12326 [Published Online First: 9 March 2014] Harris K, Hamilton C. Developing an electronic assessment tool for undergraduate nurses in simulation. http://dx.doi.org/10.1136/bmjstel-2019-aspihconf.68 [abstract]. BMJ Simulation 2019;5(Suppl 2):A37–A38.

Summary Background The unequal distribution of income is a fundamental determinant of health inequalities. Decision making around economic policies could be enhanced by showing their potential health effects. We used scenario modelling to assess the effects of 12 income-based policies on years of life lost (YLL) and inequalities in YLL in Scotland for the 2017–21 period. Methods In this modelling study, we used EUROMOD version H1.0+, a tax-benefit microsimulation model, to estimate the effects of hypothetical fiscal policies on household income for Scottish households in the 2014/15 Family Resources Survey (n=2871). The effects were modelled excluding housing costs. Income change from baseline was estimated for each quintile of the 2016 Scottish Index of Multiple Deprivation (SIMD) after weighting to account for differential non-response to the Family Resources Survey, and incomes were equivalised according to the Organisation for Economic Co-operation and Development's modified equivalence scale. A regression analysis of cross-sectional data was used to estimate the relationship between income change and all-cause mortality, followed up by a sensitivity analysis to account for uncertainties around the assumptions on effect size. Informing Interventions to reduce health Inequalities (Triple I), a health inequalities scenario modelling tool, was used to estimate policy effects on YLL and government spending after five years of theoretical implementation. The Triple I model used population estimates for 2016 stratified by sex, 5-year age group, and SIMD quintile, which were obtained from the National Records of Scotland. Preliminary estimates of relative policy costs were calculated from the EUROMOD-derived combined effects of each policy on tax bills, National Insurance contributions, and benefits receipts for Scottish households. Findings Taxation-based policies did not substantially affect household incomes, whereas benefits-based policies had large effects across the quintiles. The best policy for improving health and narrowing health inequalities was a 50% increase to means-tested benefits (approximately 105 177 [4·7%] YLL fewer than the baseline of 2·2 million, and a 7·9% reduction in relative index of inequality). Effects on YLL and health inequalities were inversely correlated in response to changes in taxation policy. Citizen's Basic Income (CBI) schemes also substantially narrowed inequalities (3·7% relative index of inequality for basic scheme, 5·9% for CBI with additional payments for individuals with disability), and modestly reduced YLL (0·7% for the basic scheme and 1·4% with additional payments). The estimated government spending associated with a policy was proportional to its effect on YLL, but less closely related to its effect on inequalities in YLL. Interpretation Policies that affect incomes could potentially have marked effects on health and health inequalities in Scotland. Our projections suggest that the most effective policies for reducing health inequalities appeared to be those that disproportionately increased incomes in the most deprived areas. Although modelling was subject to various assumptions, the approach can be useful to inform decisions around addressing the upstream determinants of health inequalities. Funding None.

Modular design of products can effectively reduce product development cycle with the idea of concurrent engineering, the efficient management of module interface information in the design process is the premise and foundation for module sharing. This study aims to develop a methodology for interface information management in bus chassis modular design. The characteristics of module interfaces in mechanical design are first investigated by the comparison with Universal Serial Bus interfaces. A digital expression method is then proposed to describe the characteristics of interface geometry information using two matrices with mapping relationships. An encoding method is then developed for the interface information management in modular design. Finally, the implementation of the above method was illustrated with a case study of an electric bus chassis modular design. The results indicate that the digital expression method can represent the geometric information of the module interface precisely and provide a good foundation for the establishment of the modules database for the bus chassis. Novelty of the research is to provide a methodology to represent the characteristics of interface in mechanical design through digital expression.

A significant issue worldwide is a bus frontal collision which can result in more than 10 fatalities per incident. The study aims to develop recommendations on injury risk reduction in such frontal...

BackgroundMany public health interventions cannot be evaluated using randomised controlled trials so they rely on the assessment of observational data. Techniques for evaluating public health interventions using observational data include interrupted time series analysis, panel data regression-based approaches, regression discontinuity and instrumental variable approaches. The inclusion of a counterfactual improves causal inference for approaches based on time series analysis, but the selection of a suitable counterfactual or control area can be problematic. The synthetic control method builds a counterfactual using a weighted combination of potential control units.MethodsWe explain the synthetic control method, summarise its use in health research to date, set out its advantages, assumptions and limitations and describe its implementation through a case study of life expectancy following German reunification.ResultsAdvantages of the synthetic control method are that it offers an approach suitable when there is a small number of treated units and control units and it does not rely on parallel preimplementation trends like difference in difference methods. The credibility of the result relies on achieving a good preimplementation fit for the outcome of interest between treated unit and synthetic control. If a good preimplementation fit is established over an extended period of time, a discrepancy in the outcome variable following the intervention can be interpreted as an intervention effect. It is critical that the synthetic control is built from a pool of potential controls that are similar to the treated unit. There is currently no consensus on what constitutes a ‘good fit’ or how to judge similarity. Traditional statistical inference is not appropriate with this approach, although alternatives are available. From our review, we noted that the synthetic control method has been underused in public health.ConclusionsSynthetic control methods are a valuable addition to the range of approaches for evaluating public health interventions when randomisation is impractical. They deserve to be more widely applied, ideally in combination with other methods so that the dependence of findings on particular assumptions can be assessed.

Rationale: About 75% of newly formed B-cells are autoreactive and express potentially harmful autoantibodies (Wardemann 2003). Hence, a powerful mechanism, termed central tolerance, is in place to eliminate millions of newly formed autoreactive B-cells every day. Results: B-ALL, mantle cell lymphoma (MCL) and unmutated chronic lymphocytic leukemia (U-CLL) originate from early, pre-germinal center (pre-GC) stages of B-cell development that are subject to negative B-cell selection and central tolerance mechanisms. While designed to eliminate autoreactive clones during early B-cell development, we recently discovered that B-ALL, MCL and U-CLL fully retained sensitivity to central tolerance mechanisms, which are triggered by persistent PI3K-hyperactivation. PI3K-signaling code to distinguish between normal and pathological signaling. Studying short transient pulses and chronic activation of PI3K-signaling, we discovered that pre-GC B-cells have evolved a "PI3K-signaling code" to distinguish between normal B-cell activation by antigen and pathological signaling: thereby, antigen encounter induces a short transient pulse of PI3K-activation which promotes survival and proliferation. Conversely, persistent activation of PI3K-activation reflects pathological signaling, either from an autoreactive B-cell receptor (BCR) or a transforming oncogene. Pre-GC B-cell malignancies are exempt from oncogenic PI3K-lesions. PI3K-lesions in cancer result in permanent hyperactivation as in autoreactive B-cells. The PI3K pathway is targeted by oncogenic lesions in ~25% of human cancer. The phosphatases PTEN, SHIP1 and PP2A function as negative regulators of PI3K signaling and are frequently mutated in a broad range of cancers and also occur in some GC- and post-GC lymphomas (e.g. Burkitt's, DLBCL). However, our analysis in six clinical cohorts revealed that pre-GC B-cell malignancies, including B-ALL, MCL and U-CLL critically depend on PTEN, SHIP1 and PP2A function and do not tolerate persistent hyperactivation of PI3K-signaling for more than three hours. Loss-of-function mutations of these phosphatases and activating PI3K lesions were not detected in large clinical cohorts of patients with B-ALL, MCL and CLL. Likewise, phosphorylation of AKT-S473, reflecting PI3K signaling strength, is elevated throughout multiple cancer types including post-GC DLBCL, but not in B-ALL and MCL. This is in line with previous work demonstrating that inherited mutations that cause PI3K-activation predispose to various cancers but cause profound defects in human B-lymphopoiesis (Fruman 2014). Pharmacological targeting of PI3K-dependent central tolerance mechanisms. We tested the hypothesis that PI3K-hyperactivation represents a unique vulnerability in pre-GC B-cell tumors including B-ALL, MCL and U-CLL. Sensitivity to PI3K-hyperactivation of reflects their pre-GC origin and central tolerance mechanisms during early B-cell development that are designed to eliminate autoreactive B-cells based on hyperactive PI3K-signaling. For this reason, we tested pharmacological PI3K-hyperactivation as a novel strategy to selectively target pre-GC B-cell malignancies. To this end, we tested 144 compounds for their ability to engage PI3K-dependent central tolerance mechanism in B-ALL, MCL and CLL. Small molecule inhibitors of SHIP1 (3AC, K118), PTEN (SF-1670), PP2A (LB-100) and a direct PI3K-agonist (SC79) achieved strong phosphorylation of known PI3K-substrates (AKT, S6K) in vitro and prolonged overall survival in NSG mice transplanted with refractory B-ALL and MCL PDX in vivo. Conclusions and future directions: Current treatment regimens (kinase-inhibitor paradigm) use agents that apply selective pressure in one direction (e.g., PI3K-inhibitors; BCR-ABL1, SYK- or BTK-inhibitors). Here, we are pursuing a new concept (central tolerance paradigm) based on sequential treatment regimens that alternate between kinase-inhibitors (e.g., dasatinib, ibrutinib, idelalisib) and PI3K-hyperactivation (3AC, K118, LB100). By sequentially applying selective pressures in opposite directions, our approach will subvert clonal evolution and selection for drug-resistant mutants. Figure 1 Figure 1. Disclosures No relevant conflicts of interest to declare.

Background Accurate data to measure population cigarette consumption are vital for surveillance and for evaluating the impact of tobacco control policies. This study uses cigarette retail sales data to provide novel insights into trends and patterns in cigarette consumption in Great Britain. Methods Cigarette sales estimates derived from electronic sales from most large grocery stores and a weighted representative sample of smaller convenience stores were obtained from Nielsen. Data on the number of cigarette sticks sold per calendar month and per week were obtained for Scotland and England/Wales (combined) for the period January 2008 to December 2015. Cigarette consumption per adult smoker per month was calculated using survey-based smoking prevalence estimates and mid-year population estimates. Results Population cigarette consumption in Great Britain declined between 2008 and 2013. Cigarette sales have since stabilised at around 400 cigarettes per adult smoker per month. Cigarettes sold in 14- to 19-packs have substituted a sharp decline in 20-packs and now account for over half of all cigarettes sold in Great Britain. Cigarette consumption has been consistently higher in Scotland than England/Wales. This is due to higher sales of 20-packs in Scotland between 2008 and 2013, which has been substituted by higher sales of 14- to 19-packs in recent years. Conclusions Cigarette retail sales data provide unique insights into levels and patterns of cigarette consumption and should be used for monitoring and evaluating tobacco control policy in Great Britain. Electronic supplementary material The online version of this article (10.1186/s12889-017-4950-z) contains supplementary material, which is available to authorized users.

Background and aim The introduction of the Alcohol Act in Scotland on 1 October 2011, which included a ban on multi-buy promotions, was probably associated with a fall in off-trade alcohol sales in the year after its implementation. The aim of this study was to test if the same legislation was associated with reduced levels of alcohol-related deaths and hospital admissions in the 3-year period after its introduction. Design A natural experiment design using time–series data to assess the impact of the Alcohol Act legislation in Scotland. Comparisons were made with unexposed populations in the rest of Great Britain. Setting Scotland with comparable data obtained for geographical control groups in other parts of Great Britain. Participants For alcohol-related deaths, a total of 17 732 in Scotland and 88 001 in England and Wales throughout 169 4-week periods between January 2001 and December 2013 and for alcohol-related hospital admissions, a total of 121 314 in Scotland and 696 892 in England throughout 182 4-week periods between January 2001 and December 2014. Measurements Deaths and hospital admissions in Scotland and control groups that were wholly attributable to alcohol for consecutive 4-week periods between January 2001 and December 2014. Data were obtained by age, sex and area-based socio-economic position. Findings There was no evidence to suggest that the Alcohol Act was associated with changes in the overall rate of alcohol-related deaths [incidence rate ratio (IRR) = 0.99, 95% confidence interval (CI) = 0.91–1.07)] or hospital admissions (IRR = 0.98, 95% CI = 0.95–1.02) in Scotland. In control group analyses, the pseudo intervention variable was not associated with a change in alcohol-related death rates in England/Wales (IRR = 0.99, 95% CI = 0.95–1.02), but was associated with an increase in alcohol-related hospital admission rates in England (IRR = 1.05, 95% CI = 1.03–1.07). In combined models, the interaction analysis did not provide support for a ‘net effect’ of the legislation on alcohol-related deaths in Scotland compared with England/Wales (IRR 0.99, 95% CI = 0.95–1.04), but suggested a net reduction in hospital admissions for Scotland compared with England (IRR = 0.93, 95% CI = 0.87–0.98). Conclusion The implementation of the Alcohol Act in Scotland has not been associated clearly with a reduction in alcohol-related deaths or hospital admissions in the 3-year period after it was implemented in October 2011.

Background and aims: Analytical approaches to addressing survey non-participation bias typically use only demographic information to improve estimates. We applied a novel methodology which uses health information from data linkage to adjust for non-representativeness. We illustrate the method by presenting adjusted alcohol consumption estimates for Scotland. Design: Data on consenting respondents to the Scottish Health Surveys (SHeSs) 1995-2010 were linked confidentially to routinely collected hospital admission and mortality records. Synthetic observations representing non-respondents were created using general population data. Multiple imputation was performed to compute adjusted alcohol estimates given a range of assumptions about the missing data. Adjusted estimates of mean weekly consumption were additionally calibrated to per-capita alcohol sales data. Setting: Scotland. Participants: 13 936 male and 18 021 female respondents to the SHeSs 1995-2010, aged 20-64years. Measurements: Weekly alcohol consumption, non-, binge- and problem-drinking. Findings: Initial adjustment for non-response resulted in estimates of mean weekly consumption that were elevated by up to 17.8% [26.5units (18.6-34.4)] compared with corrections based solely on socio-demographic data [22.5 (17.7-27.3)]; other drinking behaviour estimates were little changed. Under more extreme assumptions the overall difference was up to 53%, and calibrating to sales estimates resulted in up to 88% difference. Increases were especially pronounced among males in deprived areas. Conclusions: The use of routinely collected health data to reduce bias arising from survey non-response resulted in higher alcohol consumption estimates among working-age males in Scotland, with less impact for females. This new method of bias reduction can be generalized to other surveys to improve estimates of alternative harmful behaviours.

BACKGROUND AND AIMS: It has been suggested that distributing naloxone to people who inject drugs (PWID) will lead to fewer attendances by emergency medical services at opioid-related overdose incidents if peer administration of naloxone was perceived to have successfully resuscitated the overdose victim. This study evaluated the impact of a National Naloxone Programme (NNP) on ambulance attendance at opioid-related overdose incidents throughout Scotland. Specifically, we aimed to answer the following research questions: is there evidence of an association between ambulance callouts to opioid-related overdose incidents and the cumulative number of 'take-home naloxone' (THN) kits in issue?; is there evidence of an association between ambulance callouts to opioid-related overdose incidents in early adopter (pilot) or later adopting (non-pilot) regions and the cumulative number of THN kits issued in those areas? DESIGN: Controlled time series analysis. SETTING: Scotland, UK, 2008-2015. PARTICIPANTS: Pre-NNP implementation period for the evaluation was defined as 1 April 2008 to 31 March 2011 and post-implementation period as 1 April 2011 to 31 March 2015. In total, 3721 ambulance attendances at opioid-related overdose were recorded for the pre-NNP implementation period across 158â??weeks (mean 23.6 attendances per week) and 5258 attendances across 212â??weeks in the post-implementation period (mean 24.8 attendances per week). INTERVENTION: Scotland's NNP; formally implemented on 1 April 2011. MEASUREMENTS: Primary outcome measure was weekly incidence (counts) of callouts to opioid-related overdoses at national and regional Health Board level. Data were acquired from the Scottish Ambulance Service (SAS). Models were adjusted for opioid replacement therapy using data acquired from Information Services Division on monthly sums of all dispensed methadone and buprenorphine in the study period. Models were further adjusted for a control group: weekly incidence (counts) of callouts to heroin-related overdose in the London Borough area acquired from London Ambulance Service. FINDINGS: There was no significant association between SAS callouts to opioid-related overdose incidents and THN kits in issue for Scotland as a whole (coefficient 0.009, 95% Confidence Intervals (CIs): -0.01, 0.03, pâ??=â??0.39). In addition, the magnitude of association between THN kits and SAS callouts did not differ significantly between pilot and non-pilot regions (interaction test, pâ??=â??0.62). CONCLUSIONS: The supply of take-home naloxone kits through a National Naloxone Programme in Scotland was not clearly associated with a decrease in ambulance attendance at opioid-related overdose incidents in the 4-year period after it was implemented in April 2011. This article is protected by copyright. All rights reserved.

Background: The unequal distribution of income is a fundamental cause of health inequalities. Decision making around redistributive policies could be enhanced by demonstrating their potential health effects. We used scenario modelling to assess the impacts of 12 income-based policies on premature deaths and inequalities in premature deaths in Scotland. Methods: EUROMOD, a tax-benefit microsimulation model, was used to estimate policy effects on income for a representative sample of Scottish households (n=2871; 2014/15 Family Resources Survey). Income change was estimated for each quintile of the 2016 Scottish Index of Multiple Deprivation. 'Triple I', a health inequalities scenario modelling tool, was used to estimate policy impacts on premature mortality (

Summary Background Drink driving is an important risk factor for road traffic accidents (RTAs), which cause high levels of morbidity and mortality globally. Lowering the permitted blood alcohol concentration (BAC) for drivers is a common public health intervention that is enacted in countries and jurisdictions across the world. In Scotland, on Dec 5, 2014, the BAC limit for drivers was reduced from 0·08 g/dL to 0·05 g/dL. We therefore aimed to evaluate the effects of this change on RTAs and alcohol consumption. Methods In this natural experiment, we used an observational, comparative interrupted time-series design by use of data on RTAs and alcohol consumption in Scotland (the interventional group) and England and Wales (the control group). We obtained weekly counts of RTAs from police accident records and we estimated weekly off-trade (eg, in supermarkets and convenience stores) and 4-weekly on-trade (eg, in bars and restaurants) alcohol consumption from market research data. We also used data from automated traffic counters as denominators to calculate RTA rates. We estimated the effect of the intervention on RTAs by use of negative binomial panel regression and on alcohol consumption outcomes by use of seasonal autoregressive integrated moving average models. Our primary outcome was weekly rates of RTAs in Scotland, England, and Wales. This study is registered with ISRCTN, number ISRCTN38602189. Findings We assessed the weekly rate of RTAs and alcohol consumption between Jan 1, 2013, and Dec 31, 2016, before and after the BAC limit came into effect on Dec 5, 2014. After the reduction in BAC limits for drivers in Scotland, we found no significant change in weekly RTA rates after adjustment for seasonality and underlying temporal trend (rate ratio 1·01, 95% CI 0·94–1·08; p=0.77) or after adjustment for seasonality, the underlying temporal trend, and the driver characteristics of age, sex, and socioeconomic deprivation (1·00, 0·96–1·06; p=0·73). Relative to RTAs in England and Wales, where the reduction in BAC limit for drivers did not occur, we found a 7% increase in weekly RTA rates in Scotland after this reduction in BAC limit for drivers (1·07, 1·02–1·13; p=0·007 in the fully-adjusted model). Similar findings were observed for serious or fatal RTAs and single-vehicle night-time RTAs. The change in legislation in Scotland was associated with no change in alcohol consumption, measured by per-capita off-trade sales (−0·3%, −1·7 to 1·1; p=0·71), but a 0·7% decrease in alcohol consumption measured by per-capita on-trade sales (−0·7%, −0·8 to −0·5; p Interpretation Lowering the driving BAC limit to 0·05 g/dL from 0·08 g/dL in Scotland was not associated with a reduction in RTAs, but this change was associated with a small reduction in per-capita alcohol consumption from on-trade alcohol sales. One plausible explanation is that the legislative change was not suitably enforced—for example with random breath testing measures. Our findings suggest that changing the legal BAC limit for drivers in isolation does not improve RTA outcomes. These findings have significant policy implications internationally as several countries and jurisdictions consider a similar reduction in the BAC limit for drivers. Funding National Institute for Health Research Public Health Research Programme.

In this article, we examine the emergence of the funerary mound and enclosure complexes of the southern Brazilian highlands during the last 1000 years in relation to processes of population expansion, contact, conflict and the establishment of frontiers. We test the hypothesis that such monuments emerged among the local southern proto-Je peoples as a response to the migration of a foreign group, the Tupi-Guarani. We compared the spatio-temporal distribution of mound and enclosure complexes in respect to sites of interaction between the two groups. The results indicate that the rise of funerary architecture coincides with the first incursions of the Tupi-Guarani to the southern proto-Je heartland, and that mounds are concentrated in areas devoid of interaction. We conclude that highly monumentalized landscapes emerged in areas where local groups chose not to interact with the Tupi-Guarani, showing that funerary monuments were an important component in the establishment of impermeable frontiers to resist outsiders.

Objective:\ud \ud To provide a basis for evaluating post-2007 alcohol policy in Scotland, this paper tests the extent to which pre-2007 policy, the alcohol market, culture or clinical changes might explain differences in the magnitude and trends in alcohol-related mortality outcomes in Scotland compared to England & Wales (E&W).\ud \ud Study design:\ud \ud Rapid literature reviews, descriptive analysis of routine data and narrative synthesis.\ud \ud Methods:\ud \ud We assessed the impact of pre-2007 Scottish policy and policy in the comparison areas in relation to the literature on effective alcohol policy. Rapid literature reviews were conducted to assess cultural changes and the potential role of substitution effects between alcohol and illicit drugs. The availability of alcohol was assessed by examining the trends in the number of alcohol outlets over time. The impact of clinical changes was assessed in consultation with key informants. The impact of all the identified factors were then summarised and synthesised narratively.\ud \ud Results:\ud \ud The companion paper showed that part of the rise and fall in alcohol-related mortality in Scotland, and part of the differing trend to E&W, were predicted by a model linking income trends and alcohol-related mortality. Lagged effects from historical deindustrialisation and socio-economic changes exposures also remain plausible from the available data.\ud \ud This paper shows that policy differences or changes prior to 2007 are unlikely to have been important in explaining the trends. There is some evidence that aspects of alcohol culture in Scotland may be different (more concentrated and home drinking) but it seems unlikely that this has been an important driver of the trends or the differences with E&W other than through interaction with changing incomes and lagged socio-economic effects. Substitution effects with illicit drugs and clinical changes are unlikely to have substantially changed alcohol-related harms: however, the increase in alcohol availability across the UK is likely to partly explain the rise in alcohol-related mortality during the 1990s.\ud \ud Conclusions:\ud \ud Future policy should ensure that alcohol affordability and availability, as well as socio-economic inequality, are reduced, in order to maintain downward trends in alcohol-related mortality in Scotland.

This paper describes a simplified practical approach to the impact damage assessment of flying ballast or debris in composite materials, which could potentially be used for passenger rail vehicles. With the development of high-speed lines in order to guarantee the safety of primarily the driver and passengers, the vehicle body shell must be strong enough to resist the penetration of these types of objects into the vehicle. Currently the EN12663 standard has insufficient information on missile impact requirements for car bodies. Using the requirements of British Railway Group Standard GM/RT2100, GFRP composite material was analyzed in both static and dynamic events. Impact events at high velocities (V>50 m/s) lead to difficulties in testing due to the requirements for specific and expensive equipment and safety issues in the test application process. The simpler assessment and testing method described in this paper aims to provide a more cost effective, less time consuming, easily applicable method, with accurate results compared to existing methods. Previous research found that high-velocity impact behavior of composite materials can be mimicked by quasi-static punch tests (QSP). In this study, QSP tests were performed with E-glass/polyester composite laminates and FE simulations were carried out to match the experiments. The resulting numerical material and modelling data was used to simulate high velocity impact cases to assess the response of the material and to determine the connection between static and dynamic cases.

The European Transport White Paper 2011 sets high modal shift targets from road freight to rail 50% by 2050. The objective of this paper is to determine the rolling stock fleet size and type up to the year 2050 and associated challenges for stakeholders. Considering the White paper targets, three scenarios are considered; a) Business as usual or Reference Scenario – extrapolation of current trends without major policy change; b) White Paper 2011 Low Scenario (WPL) based on a partial implementation of the modal shift targets and c) White Paper 2011 High Scenario (WPH) based on the full implementation of modal shift targets. To determine the future fleet size, the current paper also conducts a sensitivity analysis assuming 60% productivity level as a base line. The study finds, among others, that significantly more rolling stock (in particular flat wagons, covered wagons and covered hopper wagons) as well as improved asset utilisation will be vital to facilitate the transport of increased freight volume. A unified rail freight system starting with nine Rail Freight Corridors and cooperation among the rail freight operators, wagons manufacturers and companies involved in leasing and hiring wagons will be very important to achieve the modal shift.

This chapter examines the potential for the Resilience Markers Framework (RMF) to provide guidance for development of an interview script aimed at uncovering resilience strategies used by anaesthetists. Anaesthetists work in a variety of areas of the hospitals which would make observations challenging. The chapter had two main aims: to see if the Resilience Markers Framework can be used to shape interviews to elicit the details of resilience strategies; and to explore resilience strategies in anaesthetists' work. Following data collection the individual resilience strategies were classified in terms of four main themes. These themes represent perceived vulnerabilities and opportunities in anaesthetists' work. Each grouping reflected the activities and goals of the anaesthetists. The groups of resilience strategies were then evaluated in terms of the RMF. The interviews were fairly straightforward to develop using the RMF, which suggests it's a strong framework for this purpose.

Background The synthetic control method (SCM) improves causal inference in non-randomised studies by building a counterfactual using a weighted combination of potential control units. Although it has been widely used in other disciplines it is not widely used in public health research. Our objectives were to identify the use of SCM studies in health and to summarise strengths and limitations identified in the literature. Methods We included studies that used a SCM design to investigate a health outcome of any intervention in any population. We searched for the term ‘synthetic control method’ in 26 health, social science and grey literature databases as well as checking for additional studies by key authors. No restrictions were placed on language or date. Searches were completed in February 2016. We summarised key information about the studies including setting, number of treated and control units, intervention and outcome, number of pre- and post-intervention data-points available and other methods used in the same study. Results Searches identified 35 health-related studies of which 23 were from US settings and investigated a single treated unit. Most studies had at least 10 control units. Interventions investigated included health finance and health systems reform, industry regulation and taxation policies. Common outcomes were mortality rates and insurance rates/health care access. Most studies had more than 4 pre- and post-implementation data-points. SCM is most commonly used alongside difference-in-difference methods. Advantages of SCM are that it does not rely on parallel pre-implementation trends and that it allows for time-varying unmeasured confounders. Limitations include the need for suitable data on both the treated unit and a pool of potential controls, difficulties if the treated unit is an outlier and the inapplicability of traditional statistical tests due to the small number of treated and control units and the fact that they have not been randomly allocated. Falsification tests are generally used as an alternative. Conclusion This comprehensive literature review suggests thatSCM has been little used in health despite some advantages over existing methods. Future research incorporating the method, ideally in combination with other methods, would be of value.

Background Improving health and reducing health inequalities are important joint policy objectives. Income is a key social determinant of health, but robust evidence about the relative impacts of redistributive policies is rare. Our study aimed to estimate the potential impacts on health (premature mortality) and health inequalities of 15 fiscal policies in Scotland, including changes to income tax, council tax, and benefits, and two Universal Basic Income (UBI) schemes. Methods EUROMOD, a detailed tax-benefit microsimulation model, was used to estimate changes in household income for each quintile of the Scottish Index of Multiple Deprivation (SIMD). Parametric survival models were used to model baseline mortality rates, and log-log models were used to estimate policy effect sizes. We estimated the impacts of each policy on premature mortality across the Scottish population after 3 years of follow up, compared to the baseline no-policy scenario, and assessed inequalities between SIMD quintiles. Data processing and modelling was conducted in R, Stata and Excel. Results Policies predicted to both improve health and reduce health inequalities included one UBI scheme (while the other UBI scheme worsened health), replacing council tax with a local income tax, increasing Job Seeker’s Allowance and Income Support, increasing tax credits, and increasing the Carer’s Allowance. The health-beneficial UBI scheme would result in a 0.2% reduction in premature mortality for the whole Scottish population, a 6.1% reduction for the most deprived quintile, and a 24.7% reduction in relative inequality (as measured by the relative index of inequality). Policies that were less targeted to deprived communities either worsened health but reduced inequalities, or improved health while worsening inequalities. Conclusion Fiscal policies have the potential for substantial effects on health and health inequalities in Scotland. The most effective policies for reducing health inequalities were those that disproportionately increased incomes in the most deprived areas. The modelling is subject to various assumptions and sources of uncertainty, but nonetheless highlights the importance of applying an inequalities lens to economic policy options.

Background and Objectives: The I3 POP Collaborative sought to improve health of patients attending North Carolina, South Carolina, and Virginia primary care teaching practices using the triple aim framework of better quality, appropriate utilization, and enhanced patient experience. We examined change in triple aim measures over 3 years, and identified correlates of improvement. Methods: Twenty-nine teaching practices representing 23 residency programs participated. The Institute for Health Care Improvement Breakthrough Series Collaborative model was tailored to focus on at least one triple aim goal and programs submitted data annually on all collaborative measures. Outcome measures included quality (chronic illness, prevention); utilization (hospitalization, emergency department visits, referrals) and patient experience (access, continuity). Participant interviews explored supports and barriers to improvement. Results: Six of 29 practices (21%) were unable to extract measures from their electronic health records (EHR). All of the remaining 23 practices reported improvement in at least one measure, with 11 seeing at least 10% improvement; seven (24%) improved measures in all three triple aim areas, with two experiencing at least 10% improvement. Practices with a greater number of patient visits were more likely to show improved measures (odds ratio [OR] 10.8, 95% confidence interval [CI]: .68-172.2, P=0.03). Practice interviews revealed that engaged leadership and systems supports were more common in higher performing practices. Conclusions: Simultaneous attainment of improvement in all three triple aim goals by teaching practices is difficult. I3 POP practices that were able to pull and report data improved on at least one measure. Future work needs to focus on cultivating leadership and systems supporting large scale improvement.

BackgroundHealth selection has been proposed to explain the patterning of alcohol-related mortality by area deprivation. This study investigated whether persons who die from alcohol-related conditions are more likely to experience social drift than those who die from other causes.MethodsDeaths recorded in Scotland (2013,>21 years) were coded as ‘alcohol-related’ or ‘other’ and by deprivation decile of residence at death. Acute hospital admissions data from 1996 to 2012 were used to provide premortality deprivation data. χ² tests estimated the difference between observed and expected alcohol-related deaths by first Scottish Index of Multiple Deprivation (SIMD) decile and type of death. Logistic regression models were fitted using type of death as the outcome of interest and change in SIMD decile as the exposure of interest.ResultsOf 47 012 deaths, 1458 were alcohol-related. Upward and downward mobility was observed for both types of death. An estimated 31 more deaths than expected were classified ‘alcohol-related’ among cases whose deprivation score decreased, while 204 more deaths than expected were classified ‘alcohol-related’ among cases whose initial deprivation ranking was in the four most deprived deciles. Becoming more deprived and first deprivation category were both associated with increased odds of type of death being alcohol-related after adjusting for confounders.ConclusionThis study suggests that health selection appears to contribute less to the deprivation gradient in alcohol-related mortality in Scotland than an individual’s initial area deprivation category.

Purchase of the sales data was funded by the Scottish Government as part of the wider Monitoring and Evaluating Scotland's Alcohol Strategy portfolio of studies. Funding to pay the Open Access publication charges for this article was provided by NHS Health Scotland. Aims: To highlight the importance of monitoring biases when using retail sales data to estimate population alcohol consumption. Methods: Previously, we identified and where possible quantified sources of bias that may lead to under- or overestimation of alcohol consumption in Scotland. Here, we update findings by using more recent data and by quantifying emergent biases. Results: Underestimation resulting from the net effect of biases on population consumption in Scotland increased from -4% in 2010 to -7% in 2013. Conclusion: Biases that might impact on the validity and reliability of sales data when estimating population consumption should be routinely monitored and updated. Publisher PDF

In this paper, the authors investigate the characterisation of the structural collapse of steel-bodied rail vehicles and propose modifications to a cab structure for improved structural crashworthiness. This is a mechanical- and simulation-based investigation, comprising three parts: after a mechanical description of the impact forces and energy conservation in collisions between trains, the characteristics of rail vehicle structures are examined to identify structural weaknesses in the context of impact stability. This is followed by a computer simulation of a cab structure to validate the conclusions from the theoretical analysis and to demonstrate the effectiveness of the design modifications. Focusing on the correlation between structural characterisation and impact stability, the authors highlight the following three findings: first, rail vehicles have a propensity to be unstable in the vertical direction due to the asymmetrical geometry and unbalanced impact loads; second, high shear stresses tend to be generated at the top corners of the rear pillars of the door region, leading to a localised fracture tendency; and third, impact stability can be enhanced through structural modifications by adopting symmetric cross sections or enhancing the stiffness in the weak direction for asymmetric structures, i.e. achieving geometric symmetry or stiffness balance on impact. The findings result in a better understanding of the mechanisms in structural crushing and advance the research into passive safety of rail vehicles.

This paper describes the design, validation and prototyping of a lightweight crashworthy rail vehicle driver's cab using advanced composite sandwich materials. By exploiting the lightweighting, energy absorption and design integration benefits of composites, an innovative modular cab structure was developed that provides significant savings in mass, cost and part count compared to conventional cab designs.

Introduction This study aimed to assess training of Senior House Officer-grade equivalent doctors in postgraduate surgical training or service (SHO-DIPST) in surgical specialties across the United Kingdom (UK), against nationally agreed Joint Committee on Surgical Training Quality Indicators (JCST QIs). Specific recommendations are made, with a view to improving quality of training, workforce retention and recruitment to Higher Surgical Training. Method Prospective, observational, multicentre study conducted by the Association of Surgeons in Training, using the UK National Research Collaborative model. Any centres in the UK providing acute surgical services were eligible. SHO-DIPST with a permanent contract, on out-of-hours ‘on-call rota' were included across four, one-week data capture periods (September to October 2016, February to March 2017). Adherence to five quality indicators was reported using descriptive statistics. P-values were calculated using Student's t-test for continuous data, with a 5% level of significance. Results 2569 SHO-DIPST were included from all ten surgical specialties in 141 NHS trusts across all 16 Local Education and Training Boards in the UK. 960 SHO-DIPST were in registered ‘training' posts (37.3%). The median number of SHO-DIPST per rota was 7.0 (IQR 5.0–9.0). Adherence to the five included JCST QIs ranged from 6.0 to 53.1%. Only four SHO-DIPST posts across the study population met all five JCST QIs (0.3%). The total number of training sessions was higher for those in registered training posts (p Conclusions Only four early years postgraduate surgical training posts in the UK meet nationally approved minimum quality standards. Specific recommendations are made to improve training in this cohort and to bolster recruitment and retention into Higher Surgical Training.

Background Physician burnout is a problem that often is attributed to the use of the electronic health record (EHR). Objective To estimate the prevalence of burnout and work-life balance satisfaction in primary care residents and teaching physicians, and to examine the relationship between these outcomes, EHR use, and other practice and individual factors. Methods Residents and faculty in 19 primary care programs were anonymously surveyed about burnout, work-life balance satisfaction, and EHR use. Additional items included practice size, specialty, EHR characteristics, and demographics. A logistic regression model identified independent factors associated with burnout and work-life balance satisfaction. Results In total, 585 of 866 surveys (68%) were completed, and 216 (37%) respondents indicated 1 or more symptoms of burnout, with 162 (75%) attributing burnout to the EHR. A total of 310 of 585 (53%) reported dissatisfaction with work-life balance, and 497 (85%) indicated that use of the EHR affected their work-life balance. Respondents who spent more than 6 hours weekly after hours in EHR work were 2.9 times (95% confidence interval [CI] 1.9–4.4) more likely to report burnout and 3.9 times (95% CI 1.9–8.2) more likely to attribute burnout to the EHR. They were 0.33 times (95% CI 0.22–0.49) as likely to report work-life balance satisfaction, and 3.7 times (95% CI 2.1–6.7) more likely to attribute their work-life balance satisfaction to the EHR. Conclusions More after-hours time spent on the EHR was associated with burnout and less work-life satisfaction in primary care residents and faculty.

Shifting employment patterns in the Western world, particularly the move from manufacturing to service industries, has had a negative impact on male employment, especially for working-class men. Many men, particularly from poor socioeconomic backgrounds, are said to lack the interpersonal skills required for service industries and the concomitant emotional labour this entails. Such shifts, changes and related challenges are known to impact the health of individuals and populations. In particular, the embedding of work as fundamental to a positive male identity can lead to mental and physical health issues for men during times of economic change and uncertainty. This chapter draws together and integrates currently disparate literature relating to neoliberal policy agendas and employment patterns; masculinities; and men’s health and wellbeing.

Background: With the growing need to train medical professionals how to engage their patients in advance care planning, this study examines medical students' experience using an interactive, online decision aid to help consenting adults complete an advance directive. Methods: Third-year medical students at the University of California, Davis (UC Davis) used an online, multimedia decision aid to help an adult discuss his or her wishes for medical treatment and create a formal advance directive for health care. Students then wrote essays about their experiences, and an iterative analysis was used for thematic categorization. Results: Four distinct thematic categories emerged from students' essays: 1) students' personal experiences with advance care planning; 2) participants' experiences; 3) recommendations for practice regarding advance care planning; and 4) feedback about the online decision aid. Conclusions: An interactive, online decision aid can play a meaningful role in educating medical profe...

As workload in general practice increases, it is becoming more important to further develop the practice team. Many have spoken about the need for a multidisciplinary approach and the introduction of pharmacists into the practice team. Nurses and pharmacists working in the practice can bring their skills and knowledge together to improve care for patients with long-term conditions.

Objective: To understand the views of men and service providers concerning the health information needs of men. Design: A men’s health programme was implemented aimed at developing new health information resources designed for use by local organizations with men in socially disadvantaged groups. Research was carried out at the scoping stage to assess the views of men and other programme stakeholders. Setting: The research was conducted within the north of England between Manchester, Bradford and Leeds. The region was selected as it is characterized by socio-economic and ethnic diversity. Method: A structured evidence review was conducted on current provision of health information. Qualitative interviews were carried out with men ( n = 46) across four groups, young men (aged 16–21), new fathers (25–45), middle-aged men (40–55), and older men (60+). Telephone interviews were carried out with stakeholders with expertise in men’s health, including health professionals, service providers and commissioners ( n = 20). All interviews were fully transcribed and analysed thematically. Results: Key themes emerging concerned: routines men follow for engaging with health information; support required for making effective use of information; preferred settings and media approaches; and what men would like to see in the future. The importance of personalization and settings-based approaches was explored, and factors engendering trust were outlined. Conclusion: The research outlined common themes and differences among men according to age and life stage. There is a need for targeting materials to more fine-grained ‘segments’ of men. The project contributes to producing actionable insights, while it remains important to explore complexities of men’s health information needs.

Importance Observational studies demonstrate links between patient-centered communication, quality of life (QOL), and aggressive treatments in advanced cancer, yet few randomized clinical trials (RCTs) of communication interventions have been reported. Objective To determine whether a combined intervention involving oncologists, patients with advanced cancer, and caregivers would promote patient-centered communication, and to estimate intervention effects on shared understanding, patient-physician relationships, QOL, and aggressive treatments in the last 30 days of life. Design, setting, and participants Cluster RCT at community- and hospital-based cancer clinics in Western New York and Northern California; 38 medical oncologists (mean age 44.6 years; 11 (29%) female) and 265 community-dwelling adult patients with advanced nonhematologic cancer participated (mean age, 64.4 years, 146 [55.0%] female, 235 [89%] white; enrolled August 2012 to June 2014; followed for 3 years); 194 patients had participating caregivers. Interventions Oncologists received individualized communication training using standardized patient instructors while patients received question prompt lists and individualized communication coaching to identify issues to address during an upcoming oncologist visit. Both interventions focused on engaging patients in consultations, responding to emotions, informing patients about prognosis and treatment choices, and balanced framing of information. Control participants received no training. Main outcomes and measures The prespecified primary outcome was a composite measure of patient-centered communication coded from audio recordings of the first oncologist visit following patient coaching (intervention group) or enrollment (control). Secondary outcomes included the patient-physician relationship, shared understanding of prognosis, QOL, and aggressive treatments and hospice use in the last 30 days of life. Results Data from 38 oncologists (19 randomized to intervention) and 265 patients (130 intervention) were analyzed. In fully adjusted models, the intervention resulted in clinically and statistically significant improvements in the primary physician-patient communication end point (adjusted intervention effect, 0.34; 95% CI, 0.06-0.62; P = .02). Differences in secondary outcomes were not statistically significant. Conclusions and relevance A combined intervention that included oncologist communication training and coaching for patients with advanced cancer was effective in improving patient-centered communication but did not affect secondary outcomes. Trial registration clinicaltrials.gov Identifier: NCT01485627.

This demo introduces an automated collaborative requirements engineering tool, called TestMEReq, which is used to promote effective communication and collaboration between client-stakeholders and requirements engineers for better requirements validation. Our tool is augmented with real time communication and collaboration support to allow multiple stakeholders to collaboratively validate the same set of requirements. We have conducted a user study focusing on validating requirements using TestMEReq with a few groups of requirements engineers and client stakeholders. The study shows that our automated tool support is able to assist requirements engineers to effectively communicate with client-stakeholders to better validate the requirements virtually in real time. (Demo video: https://www.youtube.com/watch?v=7sWLOx-N4Jo).

The European Railway Agency (ERA) has estimated that over 500 freight train derailments are happening every year on open line, costing the EU27 Member States more than 200 million Euros per year. Given the projected freight market growth in Europe, it is essential to ensure the reduction of the number of freight train derailments. The paper summarises the most relevant results achieved within the first part of the European FP7 funded project D-RAIL, which aims to make significant improvements in the detection and prevention of derailments, and the mitigation of their subsequent effects. It presents a comprehensive overview of recent mainline freight train derailments in Europe (with a major focus on their causes and impacts), and an extensive investigation on supervision and monitoring systems and their efficiency. This work also provides conclusions and recommendations to the safety authorities and European key organisations, responsible for accident reporting methodologies and impact analysis.