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A letter to the editor is presented which discusses the case of a 65-year-old man with superomedial eyelid lesion.

Common to all inflammatory arthritides, namely rheumatoid arthritis, psoriatic arthritis, axial spondyloarthritis, and juvenile idiopathic arthritis, is a potential for reduced mobility that manifests through joint pain, swelling, stiffness, and ultimately joint damage. Across these conditions, consensus has been reached on the need to capture outcomes related to mobility, such as functional capacity and physical activity, as core domains in randomised controlled trials. Existing endpoints within these core domains rely wholly on self-reported questionnaires that capture patients' perceptions of their symptoms and activities. These questionnaires are subjective, inherently vulnerable to recall bias, and do not capture the granularity of fluctuations over time. Several early adopters have integrated sensor-based digital health technology (DHT)-derived endpoints to measure physical function and activity in randomised controlled trials for conditions including Parkinson's disease, Duchenne's muscular dystrophy, chronic obstructive pulmonary disease, and heart failure. Despite these applications, there have been no sensor-based DHT-derived endpoints in clinical trials recruiting patients with inflammatory arthritis. Borrowing from case studies across medicine, we outline the opportunities and challenges in developing novel sensor-based DHT-derived endpoints that capture the symptoms and disease manifestations most relevant to patients with inflammatory arthritis., Competing Interests: Declaration of interests HY reports receiving a personal payment via the University of Oxford for developed software licenses. APC reports being employed by the University of Oxford at the time of submission and was partially funded by GSK, at the time of publication they are employed by Sanome and no company mentioned is involved or affiliated with this Review. JG reports being an unpaid volunteer member on the Board of Directors for the Digital Medicine Society and Coalition for Health AI. WGD reports receiving consultancy fees from Google unrelated to this work. AD is supported by the Wellcome Trust [223100/Z/21/Z], Novo Nordisk, Swiss Re, the British Heart Foundation Centre of Research Excellence (grant number RE/18/3/34214), and Health Data Research UK; AD's research group reports receiving funding from GSK; reports receiving personal payments via the University of Oxford for consulting services provided to Harvard University and the University of Wisconsin; reports receiving a personal payment via the University of Oxford for developed software licenses. LCC reports receiving research grants from AbbVie, Amgen, Celgene, Eli Lilly, Janssen, Novartis, Pfizer, and UCB; reports receiving consulting fees from AbbVie, Amgen, Bristol Myers Squibb, Celgene, Eli Lilly, Gilead, Galapagos, Janssen, Moonlake, Novartis, Pfizer, and UCB; reports receiving payment for lectures and presentations from AbbVie, Amgen, Biogen, Celgene, Eli Lilly, Galapagos, Gilead, GSK, Janssen, Medac, Novartis, Pfizer, and UCB. All other authors declare no competing interests., (Copyright © 2024 Elsevier Ltd. All rights reserved, including those for text and data mining, AI training, and similar technologies.)

Objective: To evaluate the association between health behaviors with mental health among tertiary education students., Methods: Six databases were searched until September 2021 for prospective cohort studies evaluating the association between health behavior(s) (dietary intake, physical activity, sedentary behavior, alcohol intake, sleep, smoking or illicit drug use) and mental health. Two independent reviewers screened records for inclusion, extracted data and completed risk of bias assessments., Results: 33 studies were included (14 assessed sleep, 14 alcohol intake, 13 physical activity, 8 smoking, 6 sedentary behavior, 4 diet, 1 illicit drug use). A consistent association between poor sleep, and physical inactivity with increased risk of poor psychological wellbeing, and between poor sleep and increased mental ill-health related outcomes was demonstrated., Conclusion: Findings suggest interventions to address poor sleep and physical inactivity among students may positively impact mental health. Further research of other health behaviors, and their association with mental health, is required.

Introduction: Despite progress in systemic lupus erythematosus (SLE) treatment, challenges persist in medication adherence due to side effects and costs. Precision nutrition, particularly adjusting fatty acid intake, offers a cost-effective strategy for enhancing SLE management. Prior research, including our own, indicates that increased consumption of omega-3 polyunsaturated fatty acids (PUFAs) correlates with improved outcomes in SLE patients. Here we build upon these findings by investigating associations between serum fatty acids-grouped as PUFAs, monounsaturated fatty acids (MUFAs), and saturated fatty acids (SFAs)-and lupus activity, pain, and sleep disturbance., Methods: Using data from 418 participants with SLE in the Michigan Lupus Epidemiology and Surveillance (MILES) Cohort, we examined associations between serum levels of 25 fatty acids determined by GC-MS and patient-reported outcomes. Disease activity, pain, and sleep quality were assessed using standardized questionnaires. Generalized additive models and partial residual plots were utilized to examine the linearity of fatty acid effects. Variable selection was performed using Least Absolute Shrinkage and Selection Operator (LASSO), followed by multiple linear regression adjusting for sociodemographic factors., Results: Findings indicated favorable associations between ω-3 PUFAs-and, to a lesser extent, ω-6 PUFAs-and patient-reported outcomes, while MUFAs and SFAs showed unfavorable associations. Docosahexaenoic acid (DHA), an omega-3 PUFA, exhibited the most robust favorable associations across all outcomes. Additionally, the omega-3 α-linolenic acid (ALA) was linked to reduced pain, whereas eicosapentaenoic acid (EPA), another omega-3, was associated with worsened disease activity and pain. Among omega-6 PUFAs, dihomo-γ-linolenic acid (DGLA) was favorably associated with disease activity, while the omega-9 PUFA Mead acid was linked to increased pain., Discussion: These findings underscore the prospect that increased tissue levels of long-chain omega-3 PUFAs, particularly DHA, are favorably associated with SLE outcomes. Although further research is needed to establish causal relationships, existing evidence supports the role of omega-3 PUFAs in managing cardiovascular and chronic kidney disease, common SLE comorbidities. Most study participants exhibited low omega-3 PUFA status, suggesting substantial potential for improvement through targeted dietary interventions and supplementation. This study supports a potential role for precision nutrition in comprehensive SLE management, considering the impact of PUFAs, SFAs and MUFAs., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest. The author(s) declared that they were an editorial board member of Frontiers, at the time of submission. This had no impact on the peer review process and the final decision., (Copyright © 2024 Gilley, Fenton, Zick, Li, Wang, Marder, McCune, Jain, Herndon-Fenton, Hassett, Barbour, Pestka and Somers.)

Background: Extended reality (XR) interventions have the potential to benefit patients undergoing elective cardiac surgical and interventional procedures. However, there are no systematic reviews with meta-analyses to guide clinical care., Aim: To critically evaluate the evidence on the effectiveness of XR interventions on patient anxiety and pain and other associated outcomes., Design: Systematic review and meta-analysis following the PRISMA 2020 statement., Data Sources: A systematic search of five databases (CENTRAL, CINAHL, MEDLINE, PsycInfo, Scopus) from inception to July 2023., Methods: Screening and data extraction was conducted independently by multiple reviewers. Stata (Version 17) was used to conduct meta-analyses for patient anxiety and pain. Secondary patient outcomes were summarised in a synthesis. The Cochrane Risk of Bias (Version 2) tool was applied to trials and the NHLBI Study Quality Assessment tools to all other study designs., Results: Of the 3372 records identified, 22 were included, 10 of which were eligible for inclusion in the meta-analyses. Fifty-seven percent of randomised trials were rated as high risk of bias. Virtual reality (VR) was the only XR technology evaluated. VR significantly reduced pre-procedural anxiety (standardised mean difference: -1.29; 95% confidence interval - 1.96, -0.62, p < 0.001), and peri-procedural anxiety (standardised mean difference: -0.50; 95% confidence interval - 0.83, -0.18, p < 0.003) but did not reduce pain levels, compared with usual care. VR increased pre-procedural knowledge and postsurgical physical and pulmonary function. VR interventions may also improve emotional wellbeing, care delivery and physiological outcomes, but evidence was inconsistent., Conclusions: XR potentially benefits cardiac patients undergoing elective invasive procedures and surgery by reducing pre- and peri-procedural anxiety and increasing procedural knowledge and physical function., Relevance to Clinical Practice: Cardiac nurses' role can be supported by VR interventions to improve the patient experience and several aspects of patient care., Patient or Public Contribution: Not applicable as this is a systematic review., (© 2024 The Author(s). Journal of Clinical Nursing published by John Wiley & Sons Ltd.)

Barium (Ba) dissolution and mobilization in groundwater are predominantly controlled by sulfate because of the low solubility of barium sulfate (BaSO 4 ) minerals. Naturally present at low concentrations in groundwater, elevated concentrations of Ba can occur as a result of anthropogenic activities, including use of barite in drill operations, and geogenic sources such as leaching from geological formations. No toxicity data exist for Ba with groundwater organisms (stygofauna) to assess the risk of elevated Ba concentrations. The present study measured Ba toxicity to two stygobiont Cyclopoida species: one collected from Wellington and the other from Somersby, New South Wales, Australia. Toxicity was measured as cyclopoid survival over 2, 4, 7, 14, 21, and 28 days in waters of varying sulfate concentration (<1-100 mg SO 4 /L). When sulfate was present, dissolved Ba concentrations decreased rapidly in toxicity test solutions forming a BaSO 4 precipitate until dissolved sulfate was depleted. Barium in excess of sulfate remained in the dissolved form. The toxicity of Ba to cyclopoids was clearly attributed to dissolved Ba. Precipitated Ba was not toxic to the Wellington cyclopoid species. Toxicity values for dissolved Ba for the Wellington and Somersby cyclopoid species included a (21-day) no-effect concentration of 3.3 mg/L and an effective concentration to cause 5% mortality of 4.8 mg/L (at 21 days). Elevated dissolved Ba concentrations due to anthropogenic and/or biogeochemical processes may pose a risk to groundwater organisms. Further toxicity testing with other stygobiont species is recommended to increase the data available to derive a guideline value for Ba that can be used in contaminant risk assessments for groundwaters. Environ Toxicol Chem 2024;43:2501-2514. © 2024 The Author(s). Environmental Toxicology and Chemistry published by Wiley Periodicals LLC on behalf of SETAC., (© 2024 The Author(s). Environmental Toxicology and Chemistry published by Wiley Periodicals LLC on behalf of SETAC.)

Objective: To explore young adult's experiences of how starting university influenced their physical activity, diet, sleep, and mental well-being, and barriers and enablers to health behavior change. Participants: University students aged 18-25 years. Methods: Three focus groups were conducted in November 2019. Inductive thematic approach was utilized to identify themes. Results: Students (female: n = 13, male: n = 2, other gender identity: n = 1, 21.2 (1.6) years) reported mental well-being, physical activity levels, diet quality and sleep health were negatively affected. Stress, study demands, university timetabling, not prioritizing physical activity, cost and availability of healthy foods, and difficulty falling asleep were key barriers. Health behavior change interventions aiming to support mental well-being need to include both information and support features. Conclusions: There is a significant opportunity to improve the transition to university for young adults. Findings highlight areas to target in future interventions to improve physical activity, diet, and sleep of university students.

Introduction: We developed a mobile phone logbook application called LogMyScan. The study objectives were to evaluate a number of domains as per the technology acceptance model., Methods: A prospective pilot cohort study was conducted using a version of LogMyScan and reported according to Statement on Reporting of Evaluation studies in Health Informatics. Prospective participants were directed to a website which provided information and links. Participants were recruited via email distribution lists and social media. A task list was provided, which included entering simulated scan data and navigating the application, prior to completing a questionnaire. Questions were aligned to technology acceptance model domains, and Cronbach's alpha was calculated to assess reliability., Results: There were 49 participants and 7 were unable to complete the image upload and editing step. Levels of agreement for usability, educational and governance/security aspects were generally good. The desirability of existing and proposed features was high for images and video clip handling, feedback and reflection and less for motivational notifications and benchmarking. Comments identified some limitations and issues on the Android platform. Cronbach's alpha demonstrated good to excellent reliability: 0.87 (95% confidence interval, 0.79-0.91) for usability, educational and governance/security and 0.86 (95% confidence interval, 0.78-0.91) for desirability of existing and proposed features., Conclusion: There was generally high perceived ease of use, usefulness, attitude towards use and behavioural intention to use LogMyScan. Further research is needed to evaluate LogMyScan for future iterations, allowing recruitment of a larger number of participants and evaluating user expectations prior to using, and at timed intervals after using., Competing Interests: The author(s) declared the following potential conflicts of interest with respect to the research, authorship, and/or publication of this article: D.A. and T.D. received remuneration for the development of the LogMyScan mobile phone application., (© The Author(s) 2024.)

Background: Dysfunction of the small airways is a precursor of COPD but is not detectable on standard spirometric testing until significant destruction has occurred. A proportion of COPD patients have a forced expiratory volume in 1 s (FEV 1 )/forced vital capacity (FVC) <0.7 which is greater than the lower limit of normal (LLN), when adjusted for their age and sex. It is not understood whether this group of patients, known as "discordant COPD", are representative of "early COPD" or overdiagnosis., Methods: We sought to characterise discordant COPD (disCOPD) using radiology, lung function, serum biomarkers, activity monitoring and quality-of-life scores, comparing with COPD patients with an FEV 1 /FVC <0.7 and

Background: Many young adults report poor diet quality. However, research evaluating whether young adult males and females differ in diet quality is limited. Additionally, although diet quality has a known inverse association with body mass index (BMI), it is unclear whether this association is observed in young adults and whether it varies by gender. The present study aimed to evaluate gender differences in diet quality in young adults, as well as the associations between diet quality and BMI., Methods: Data collected via the Healthy Eating Quiz (HEQ) in respondents aged 18-35 years between July 2019 and December 2021 were analysed, including demographics, and diet quality calculated using the Australian Recommended Food Score (ARFS). Differences in characteristics were analysed using a two-sample t-test, chi-squared and one-way analysis of covariance. Linear regressions were performed to estimate associations between diet quality and BMI. An interaction term was included in the model to test differences between genders., Results: The respondents (n = 28,969) were predominantly female (70.8%) with a mean ± SD age of 25.9 ± 5.0 years and BMI of 24.6 ± 5.2 kg/m 2 . The mean ± SD ARFS was significantly different between females and males (33.1 ± 8.6 vs. 31.4 ± 9.3 points out of 70; p < 0.001). Diet quality had a small, significant inverse association with BMI in both genders. The interaction effect between diet quality score and gender in predicting BMI was significant (p < 0.001), suggesting the impact of diet quality on BMI varies by gender, with lower diet quality more strongly associated with higher BMI in females compared to males., Conclusion: Interventions that target young adults are needed to improve diet quality and its potential contribution to BMI status. As a result of the small observed effect sizes, caution should be applied in interpreting these findings., (© 2024 The Authors. Journal of Human Nutrition and Dietetics published by John Wiley & Sons Ltd on behalf of British Dietetic Association.)

The 2023 Annual Symposium of the Fisheries Society of the British Isles hosted opportunities for researchers, scientists, and policy makers to reflect on the state of art of predicting fish distributions and consider the implications to the marine and aquatic environments of a changing climate. The outcome of one special interest group at the Symposium was a collection of questions, organized under five themes, which begin to capture the state of the field and identify priorities for research and management over the coming years. The five themes were Physiology, Mechanisms, Detect and Measure, Manage, and Wider Ecosystems. The questions, 25 of them, addressed concepts which remain poorly understood, are data deficient, and/or are likely to be impacted in measurable or profound ways by climate change. Moving from the first to the last theme, the questions expanded in the scope of their considerations, from specific processes within the individual to ecosystem-wide impacts, but no one question is bigger than any other: each is important in detecting, understanding, and predicting fish distributions, and each will be impacted by an aspect of climate change. In this way, our questions, particularly those concerning unknown mechanisms and data deficiencies, aimed to offer a guide to other researchers, managers, and policy makers in the prioritization of future work as a changing climate is expected to have complex and disperse impacts on fish populations and distributions that will require a coordinated effort to address., (© 2024 Fisheries Society of the British Isles.)

Context: Diet quality indices (DQIs) assess the level of adherence to dietary recommendations and a specified dietary pattern in populations; however, there is limited evidence regarding the construct criteria and validation methodology of DQIs used in pregnant women., Objectives: The objectives of this study were to (i) identify and describe characteristics of DQIs that have been validated for use in pregnant women in high-income countries, and (ii) evaluate criteria used to develop DQIs and validation methodologies employed., Data Sources: CINAHL, Embase, Medline, SCOPUS, and Web of Science were systematically searched for eligible articles published between 1980 and November 2022 that focused on DQIs validated for use in pregnant women from high-income countries., Data Extraction: Characteristics, development criteria, and validation methodologies used in the included articles were extracted by one reviewer and checked by a second reviewer., Data Analysis: A narrative synthesis and descriptive statistics were used to summarize the review findings. Reporting was guided by the Preferred Reporting Items for Systematic Reviews and Meta-analyses statement., Results: Six articles with 5 validated DQIs were identified. In total, 3777 participants were included - five articles had pregnant women aged 31-50 years and in their second trimester. Food frequency questionnaires were used as the dietary assessment method in all studies, and 3 DQIs were used to assess dietary intake at 1 time point, using 2 different dietary assessment methods. No indices fulfilled preferred features for the DQI development criteria developed by Burggraf et al (2018). Construct validity was assessed by all DQIs, followed by criterion validity (n = 4) and test-retest reliability (n = 2)., Conclusion: Limited high-quality validated DQIs for use in pregnant women in high-income countries were identified. Scoring for DQI components were not specific to nutrient requirements for pregnant women. Findings from this review may inform the development of DQIs that evaluate specific dietary requirements and specific food safety considerations applicable to pregnancy., Systematic Review Registration: https://osf.io/u2hrq., (© The Author(s) 2024. Published by Oxford University Press on behalf of the International Life Sciences Institute. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Background: Chimeric antigen receptor (CAR) T-cells have demonstrated significant efficacy in targeting hematological malignancies, and their use continues to expand. Despite substantial efforts spent on the optimization of protocols for CAR T-cell manufacturing, critical parameters of cell culture such as pH or oxygenation are rarely actively monitored during cGMP CAR T-cell generation. A comprehensive understanding of the role that these factors play in manufacturing may help in optimizing patient-specific CAR T-cell therapy with maximum benefits and minimal toxicity., Methods: This retrospective study examined cell culture supernatants from the manufacture of CAR T-cells for 20 patients with B-cell malignancies enrolled in a phase 1/2 clinical trial of anti-CD22 CAR T-cells. MetaFLEX was used to measure supernatant pH, oxygenation, and metabolites, and a Bio-Plex assay was used to assess protein levels. Correlations were assessed between the pH of cell culture media throughout manufacturing and cell proliferation as well as clinical outcomes. Next-generation sequencing was conducted to examine gene expression profiles of the final CAR T-cell products., Results: A pH level at the lower range of normal at the beginning of the manufacturing process significantly correlated with measures of T-cell expansion and metabolism. Stable or rising pH during the manufacturing process was associated with clinical response, whereas a drop in pH was associated with non-response., Conclusions: pH has potential to serve as an informative factor in predicting CAR T-cell quality and clinical outcomes. Thus, its active monitoring during manufacturing may ensure a more effective CAR T-cell product., (© 2024. This is a U.S. Government work and not under copyright protection in the US; foreign copyright protection may apply.)

Objective: The primary objective of this review is to investigate the effectiveness of machine learning and deep learning methodologies in the context of extracting adverse drug events (ADEs) from clinical benchmark datasets. We conduct an in-depth analysis, aiming to compare the merits and drawbacks of both machine learning and deep learning techniques, particularly within the framework of named-entity recognition (NER) and relation classification (RC) tasks related to ADE extraction. Additionally, our focus extends to the examination of specific features and their impact on the overall performance of these methodologies. In a broader perspective, our research extends to ADE extraction from various sources, including biomedical literature, social media data, and drug labels, removing the limitation to exclusively machine learning or deep learning methods., Methods: We conducted an extensive literature review on PubMed using the query "(((machine learning [Medical Subject Headings (MeSH) Terms]) OR (deep learning [MeSH Terms])) AND (adverse drug event [MeSH Terms])) AND (extraction)", and supplemented this with a snowballing approach to review 275 references sourced from retrieved articles., Results: In our analysis, we included twelve articles for review. For the NER task, deep learning models outperformed machine learning models. In the RC task, gradient Boosting, multilayer perceptron and random forest models excelled. The Bidirectional Encoder Representations from Transformers (BERT) model consistently achieved the best performance in the end-to-end task. Future efforts in the end-to-end task should prioritize improving NER accuracy, especially for 'ADE' and 'Reason'., Conclusion: These findings hold significant implications for advancing the field of ADE extraction and pharmacovigilance, ultimately contributing to improved drug safety monitoring and healthcare outcomes., Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2024. Published by Elsevier Inc.)

Across its Holarctic range, Arctic charr (Salvelinus alpinus) populations have diverged into distinct trophic specialists across independent replicate lakes. The major aspect of divergence between ecomorphs is in head shape and body shape, which are ecomorphological traits reflecting niche use. However, whether the genomic underpinnings of these parallel divergences are consistent across replicates was unknown but key for resolving the substrate of parallel evolution. We investigated the genomic basis of head shape and body shape morphology across four benthivore-planktivore ecomorph pairs of Arctic charr in Scotland. Through genome-wide association analyses, we found genomic regions associated with head shape (89 SNPs) or body shape (180 SNPs) separately and 50 of these SNPs were strongly associated with both body and head shape morphology. For each trait separately, only a small number of SNPs were shared across all ecomorph pairs (3 SNPs for head shape and 10 SNPs for body shape). Signs of selection on the associated genomic regions varied across pairs, consistent with evolutionary demography differing considerably across lakes. Using a comprehensive database of salmonid QTLs newly augmented and mapped to a charr genome, we found several of the head- and body-shape-associated SNPs were within or near morphology QTLs from other salmonid species, reflecting a shared genetic basis for these phenotypes across species. Overall, our results demonstrate how parallel ecotype divergences can have both population-specific and deeply shared genomic underpinnings across replicates, influenced by differences in their environments and demographic histories., (© 2024 The Authors. Molecular Ecology published by John Wiley & Sons Ltd.)

Background: The Active Connected Engaged [ACE] study is a multi-centre, pragmatic, two-arm, parallel-group randomised controlled trial [RCT] with an internal pilot phase. The ACE study incorporates a multi-level mixed methods process evaluation including a systems mapping approach and an economic evaluation. ACE aims to test the effectiveness and cost-effectiveness of a peer-volunteer led active ageing intervention designed to support older adults at risk of mobility disability to become more physically and socially active within their communities and to reduce or reverse, the progression of functional limitations associated with ageing., Methods/design: Community-dwelling, older adults aged 65 years and older (n = 515), at risk of mobility disability due to reduced lower limb physical functioning (Short Physical Performance Battery (SPPB) score of 4-9 inclusive) will be recruited. Participants will be randomised to receive either a minimal control intervention or ACE, a 6-month programme underpinned by behaviour change theory, whereby peer volunteers are paired with participants and offer them individually tailored support to engage them in local physical and social activities to improve lower limb mobility and increase their physical activity. Outcome data will be collected at baseline, 6, 12 and 18 months. The primary outcome analysis (difference in SPPB score at 18 months) will be undertaken blinded to group allocation. Primary comparative analyses will be on an intention-to-treat (ITT) basis with due emphasis placed on confidence intervals., Discussion: ACE is the largest, pragmatic, community-based randomised controlled trial in the UK to target this high-risk segment of the older population by mobilising community resources (peer volunteers). A programme that can successfully engage this population in sufficient activity to improve strength, coordination, balance and social connections would have a major impact on sustaining health and independence. ACE is also the first study of its kind to conduct a full economic and comprehensive process evaluation of this type of community-based intervention. If effective and cost-effective, the ACE intervention has strong potential to be implemented widely in the UK and elsewhere., Trial Registration: ISRCTN, ISRCTN17660493. Registered on 30 September 2021. Trial Sponsor: University of Birmingham, Contact: Dr Birgit Whitman, Head of Research Governance and Integrity; Email: researchgovernance@contacts.bham.ac.uk. Protocol Version 5 22/07/22., (© 2023. The Author(s).)

Introduction: Smartphone and social media use is prevalent during adolescence, with high levels of use associated with lower levels of mental well-being. Secondary schools in the UK have introduced policies that restrict daytime use of smartphones and social media, but there is no evaluation on the impact of these policies on adolescent mental well-being. The SMART Schools Study aims to determine the impact of daytime restrictions of smartphone and social media use on indicators of adolescent mental well-being, anxiety, depression, physical activity, sleep, classroom behaviour, attainment and addictive social media use., Methods and Analysis: This is a natural experimental observational study using mixed methods. Secondary schools within a 100 mile radius of the recruiting centre in the West Midlands (UK) have been categorised into two groups: Schools that restrict (intervention) and permit (comparator) daytime use of smartphones. We aim to recruit 30 schools (20 restrictive, 10 permissive) and 1170 pupils aged 12-13 and 14-15 years. We will collect data on mental well-being, anxiety and depressive symptoms, phone and social media use, sleep and physical activity from pupil surveys, and accelerometers. Policy implementation measures and data on individual pupil factors will be collected through school staff surveys, and website/policy analysis. Six case study schools will explore individual, school and family/home factors that influence relationships between school smartphone policies, smartphone/social media use, and mental well-being. Economic evaluation will be completed through a cost-consequence analysis from an education sector perspective., Ethics and Dissemination: Ethical approval was obtained from the University of Birmingham's Research Ethics Committee (ERN&#95;22-0723). Parents/carers of pupil participants can complete a form to opt their child out of the study. Pupil, school staff and parent/carer participants are asked to complete online/written consent (or assent). Findings will be disseminated through policy briefings, resources for schools, social media, reports, and open access publications., Trial Registration Number: ISRCTN77948572., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2023. Re-use permitted under CC BY. Published by BMJ.)

Physical activity (PA) is a key strategy for improving symptoms in people with rheumatic and musculoskeletal diseases (RMDs). The aim of this study was to investigate and rank the importance of known barriers and facilitators for engaging in PA, from the perspective of people living with RMD. Five hundred thirty-three people with RMD responded to a survey (nine questions) disseminated by the People with Arthritis and Rheumatism (PARE) network of the European Alliance of Associations for Rheumatology (EULAR). The survey required participants to rank - based on their perceived importance - known PA barriers and facilitators from the literature, and specifically RMD symptoms as well as healthcare and community factors that may affect PA participation. Of the participants, 58% reported rheumatoid arthritis as their primary diagnosis, 89% were female, and 59% were between 51 and 70 years of age. Overall, participants reported fatigue (61.4%), pain (53.6%) and painful/swollen joints (50.6%) as the highest ranked barriers for engaging in PA. Conversely, less fatigue (66.8%) and pain (63.6%), and being able to do daily activities more easy (56.3%) were identified as the most important facilitators to PA. Three literature identified PA barriers, i.e., general health (78.8%), fitness (75.3%) and mental health (68.1%), were also ranked as being the most important for PA engagement. Symptoms of RMDs, such as pain and fatigue, seem to be considered the predominant barriers to PA by people with RMD; the same barriers are also the ones that they want to improve through increasing PA, suggesting a bi-directional relationship between these factors. Key Points • Symptoms of rheumatic and musculoskeletal disease (RMD) are the predominant barriers for lack of physical activity engagement. • RMD symptoms are the factors that people with RMDs want to improve when engaging in PA. • The barriers that stop people living with RMDs to do more PA are the ones that can be significantly improved through PA engagement., (© 2023. The Author(s), under exclusive licence to International League of Associations for Rheumatology (ILAR).)

Objective: Asbestos use has decreased over time but occupational exposure still exists today due to the presence of asbestos in older buildings. The objective of this study was to update CAREX Canada's prevalence of exposure estimate from 2006 to 2016, and to assess the level of occupational exposure by industry, occupation, province/territory, and sex., Methods: Estimates by occupation, industry, province/territory, and sex were calculated using labor force data from the 2016 Census of Population and proportions of workers exposed by occupation and industry, which were previously developed for the 2006 estimates and updated here to reflect new knowledge and changes in exposures. Statistics Canada concordance tables were used to account for changes between the 2006 and 2016 job and industry coding systems. Expert assessment was used to qualitatively assign levels of exposure (low, moderate, or high) for each occupation and industry, with consideration of workers' proximity and access to asbestos-containing material, and the condition and content of asbestos., Results: Approximately 235 000 workers are exposed to asbestos on the job in Canada. The majority of Canadian workers exposed to asbestos are male (89%). Only 5% of all exposed workers are in the high-exposure category, while most workers are in the low (49%) or moderate (46%) exposure categories. The construction sector and associated jobs (e.g. carpenters, trades helpers and laborers, electricians) accounted for the majority of exposed workers., Conclusions: Occupational exposure to asbestos continues to occur in Canada. Updating the prevalence of exposure estimate and adding exposure levels highlights the shift from high to lower-lever exposures associated with asbestos-containing materials remaining in the built environment., (© The Author(s) 2022. Published by Oxford University Press on behalf of the British Occupational Hygiene Society.)

The COVID-19 pandemic has produced widespread behaviour changes that shifted how people split their time between different environments, altering health risks. Here, we report an update of North American activity patterns before and after pandemic onset, and implications to radioactive radon gas exposure, a leading cause of lung cancer. We surveyed 4009 Canadian households home to people of varied age, gender, employment, community, and income. Whilst overall time spent indoors remained unchanged, time in primary residence increased from 66.4 to 77% of life (+ 1062 h/y) after pandemic onset, increasing annual radiation doses from residential radon by 19.2% (0.97 mSv/y). Disproportionately greater changes were experienced by younger people in newer urban or suburban properties with more occupants, and/or those employed in managerial, administrative, or professional roles excluding medicine. Microinfluencer-based public health messaging stimulated health-seeking behaviour amongst highly impacted, younger groups by > 50%. This work supports re-evaluating environmental health risks modified by still-changing activity patterns., (© 2023. The Author(s).)

Background: Lower-limb osteoarthritis (OA) causes high levels of pain and disability in adults over 45 years of age. Adopting and maintaining appropriate levels of physical activity (PA) can help patients with lower-limb OA self-manage their symptoms and reduce the likelihood of developing secondary noncommunicable diseases. However, patients with lower-limb OA are less active than people without musculoskeletal pain. This single-arm feasibility trial seeks to determine the feasibility and acceptability of a complex multicomponent physiotherapy behaviour change intervention that aims to aid patients with lower-limb OA to adopt and maintain optimal levels of PA., Methods: This trial will be conducted at one site in a National Health Service physiotherapy outpatient setting in the West Midlands of England. Up to thirty-five participants with lower-limb OA will be recruited to receive a physiotherapy intervention of six sessions that aims to optimise their PA levels during phases of behavioural change: adoption, routine formation and maintenance. The intervention is underpinned by self-determination theory (and other motivational frameworks) and seeks to foster a motivationally optimal (empowering) treatment environment and implement behaviour change techniques (BCTs) that target PA behaviours across the three phases of the intervention. Physiotherapists (n = 5-6) will receive training in the why and how of developing a more empowering motivational environment and the delivery of the intervention BCTs. Participants will complete patient-reported and performance-based outcome measures at baseline and 3-month (to reflect behavioural adoption) and 6-month (maintenance) post-baseline. Feasibility and acceptability will be primarily assessed through semi-structured interviews (purposively recruiting participants) and focus groups (inviting all physiotherapists and research staff). Further evaluation will include descriptive analysis of recruitment rates, loss of follow-up and intervention fidelity., Discussion: A novel complex, multicomponent theoretical physiotherapy behaviour change intervention that aims to create a more empowering motivational treatment environment to assist patients with lower-limb OA to adopt and maintain optimal PA levels has been developed. Testing the feasibility and acceptability of the intervention and its associated physiotherapist training and related trial procedures is required to determine whether a full-scale parallel group (1:1) randomised controlled trial to evaluate the interventions effectiveness in clinical practice is indicated., Trial Registration: Trial register: International Standard Randomised Controlled Trial identification number: ISRCTN12002764 . Date of registration: 15 February 2022., (© 2023. The Author(s).)

Background: Messaging surrounding skin cancer prevention has previously focused on the general public and emphasized how or when activities should be undertaken to reduce solar ultraviolet radiation (UVR) exposure. Generic messages may not be applicable to all settings, and should be tailored to protect unique and/or highly susceptible subpopulations, such as outdoor workers. The primary objective of this study was to develop a set of tailored, practical, harm-reducing sun safety messages that will better support outdoor workers and their employers in reducing the risk of solar UVR exposure and UVR-related occupational illnesses., Methods: We adapted a core set of sun safety messages previously developed for the general population to be more applicable and actionable by outdoor workers and their employers. This study used an integrated knowledge translation approach and a modified Delphi method (which uses a survey-based consensus process) to tailor the established set of sun safety messages for use for outdoor worker populations., Results: The tailored messages were created with a consideration for what is feasible for outdoor workers, and provide users with key facts, recommendations, and tips related to preventing skin cancer, eye damage, and heat stress, specifically when working outdoors., Conclusion: The resulting tailored messages are a set of evidence-based, expert- approved, and stakeholder-workshopped messages that can be used in a variety of work settings as part of an exposure control plan for employers with outdoor workers., Competing Interests: The authors declared no conflicts of interest., (© 2023 Occupational Safety and Health Research Institute.)

Background: Per- and polyfluoroalkyl substances (PFAS) are transferred from mother to infants through breastfeeding, a time when children may be particularly vulnerable to PFAS-mediated adverse health effects. Infants can also be exposed to PFAS from infant formula consumption. Our recent literature-based scoping of breast milk levels reported that four PFAS often exceeded the United States Agency for Toxic Substances and Disease Registry (ATSDR) children's drinking water screening levels in both the general population and highly impacted communities in the U.S. and Canada. This work presents a comparison of global breast milk and infant formula PFAS measurements with the only reported health-based drinking water screening values specific to children., Methods: We focused on four PFAS for which ATSDR has developed children's drinking water screening values: PFOA (perfluorooctanoic acid), PFOS (perfluorooctanesulfonic acid), PFHxS (perfluorohexanesulfonic acid), and PFNA (perfluorononanoic acid). Published literature on PFAS levels in breast milk and infant formula were identified via PubMed searches. Data were compared to children's drinking water screening values., Discussion: Breast milk concentrations of PFOA and PFOS often exceed children's drinking water screening values, regardless of geographic location. The limited information on infant formula suggests its use does not necessarily result in lower PFAS exposures, especially for formulas reconstituted with drinking water containing PFAS. Unfortunately, individuals generally cannot know whether their infant's exposures exceed children's drinking water screening values. Thus, it is essential that pregnant and lactating women and others, especially those having lived in PFAS-contaminated communities, have data required to make informed decisions on infant nutrition. An international monitoring effort and access to affordable testing are needed for breast milk, drinking water and infant formula to fully understand infant PFAS exposures. Currently, our understanding of demonstrable methods for reducing exposures to emerging PFAS is limited, making this research and the communications surrounding it even more important., Competing Interests: Declaration of competing interest The authors declare the following financial interests/personal relationships which may be considered as potential competing interest:Judy S. LaKind reports a relationship with National Academies of Sciences Engineering and Medicine that includes: consulting or advisory. Marc-Andre Verner served as a member on a National Academies of Sciences, Engineering and Medicine committee on PFAS, and reviewed documents related to PFAS for multiple agencies., (Copyright © 2022 The Authors. Published by Elsevier Inc. All rights reserved.)

Radon is an established lung carcinogen concentrating in indoor environments with importance for many workers worldwide. However, a systematic assessment of radon levels faced by all workers, not just those with direct uranium or radon exposure, has not previously been completed. The objective of this study was to estimate the prevalence of workers exposed to radon, and the level of exposure (> 100-200 Bq/m 3 , 200-400 Bq/m 3 , 400-800 Bq/m 3 , and > 800 Bq/m 3 ) in a highly exposed country (Canada). Exposures among underground workers were assessed using the CAREX Canada approach. Radon concentrations in indoor workplaces, obtained from two Canadian surveys, were modelled using lognormal distributions. Distributions were then applied to the susceptible indoor worker population to yield the number of exposed workers, by occupation, industry, province, and sex. In total, an estimated 603,000 out of Canada's 18,268,120 workers are exposed to radon in Canada. An estimated52% of exposed workers are women, even though they comprise only 48% of the labour force. The majority (68%) are exposed at a level of > 100-200 Bq/m 3 . Workers are primarily exposed in educational services, professional, scientific and technical services, and health care and social assistance, but workers in mining, quarrying, and oil and gas extraction have the largest number of exposed workers at high levels (> 800 Bq/m 3 ). Overall, a significant number of workers are exposed to radon, many of whom are not adequately protected by existing guidelines. Radon surveys across multiple industries and occupations are needed to better characterize occupational exposure. These results can be used to identify exposed workers, and to support lung cancer prevention programs within these groups., (© 2022. The Author(s).)

Introduction: Many university students have poor mental health, and co-occurring health risk behaviors. Targeting health behavior change in this population may improve mental health outcomes. This scoping review describes the extent and range of randomized controlled trials (RCT) evaluating interventions targeting health risk behaviors and measuring a mental health outcome, among university students., Methods: Six electronic databases were searched for RCTs published until the 18 th May 2021. Eligible RCTs included university students, evaluated interventions that promoted health behavior change (i.e., dietary intake, physical activity, sedentary behavior, alcohol and drug use, smoking, and sleep), and measured a mental health-related outcome., Results: Fifty-nine RCTs met the inclusion criteria that were published from 2000 to 2021, and over half ( n = 33) were conducted in the United States. Interventions evaluated within the RCTs ( n = 92) predominantly targeted changes to dietary intake ( n = 41 interventions), physical activity ( n = 39), or alcohol intake ( n = 35). Most interventions targeted one ( n = 51) or two ( n = 27) health behaviors only. Included RCTs considered mental ill health outcomes ( n = 24), psychological wellbeing outcomes ( n = 20), or both ( n = 15)., Discussion: This scoping review identified a moderate volume of experimental research investigating the impact of health behavior interventions on university students' mental health. There is scope for further research examining health behavior interventions targeting university students, particularly interventions taking a multi-behavioral approach., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2022 Hutchesson, Whatnall, Yazin, Fenton, Duncan, Kay-Lambkin and Burrows.)

Social desirability and approval biases can influence self-report of diet, contributing to inaccurate assessment. Biases may be influenced by sex. This study examined gender differences in social desirability and approval, and diet quality in young adults, and relationships between social biases and diet quality. Data from 1003 young adults participating in the Advice, Ideas and Motivation for My Eating trial, median age 21.7 years, BMI 24.7 kg/m 2 were included. Biases were measured using Marlowe-Crowne Social Desirability Scale Short-Form, Martin Larsen Approval Motivation Scale, and diet quality using the Australian Recommended Food Score. Pearson chi-square, t-test and Wilcoxon tests evaluated gender differences and Spearman's rank-order tested strengths of correlations between biases and diet quality. Social desirability did not differ by gender, however females reported higher social approval scores than males (p = 0.009). Among females, there was a positive correlation between social desirability and diet quality (p = 0.002), and between social approval and dairy sub-scale (p < 0.001); and a negative correlation between social approval and vegetable subscale (p = 0.045). Among males there were no correlations between social desirability or social approval and overall diet quality. Social approval may be more common in females and influence self-reported diet. To address bias and mis-reporting errors, future studies should account for participants' social desirability and/or social approval status, especially among young adult females. Further research is needed to explore gender differences in social desirability and approval in young adults, and associations between social biases and diet quality., (Copyright © 2022 Elsevier Ltd. All rights reserved.)

Non-ischemic diabetic heart disease (NiDHD) is characterized by diastolic dysfunction and decreased or preserved systolic function, eventually resulting in heart failure. Accelerated apoptotic cell death because of alteration of molecular signaling pathways due to dysregulation in microRNAs (miRNAs) plays a significant role in the development of NiDHD. Here, we aimed to determine the pathological role of cardiomyocyte-enriched pro-apoptotic miR-320 in the development of NiDHD. We identified a marked upregulation of miR-320 that was associated with downregulation of its target protein insulin growth factor-1 (IGF-1) in human right atrial appendage tissue in the late stages of cardiomyopathy in type 2 diabetic db/db mice and high-glucose-cultured human ventricular cardiomyocytes (AC-16 cells). In vitro knockdown of miR-320 in high-glucose-exposed AC-16 cells using locked nucleic acid (LNA) anti-miR-320 markedly reduced high-glucose-induced apoptosis by restoring IGF-1 and Bcl-2. Finally, in vivo knockdown of miR-320 in 24-week-old type 2 diabetic db/db mice reduced cardiomyocyte apoptosis and interstitial fibrosis while restoring vascular density. This resulted in partial recovery of the impaired diastolic and systolic function. Our study provides evidence that miR-320 is a late-responding miRNA that aggravates apoptosis and cardiac dysfunction in the diabetic heart, and that therapeutic knockdown of miR-320 is beneficial in partially restoring the deteriorated cardiac function., Competing Interests: The authors declare they have no conflict of interest., (© 2022 The Author(s).)

Background: The "infodemic" accompanying the SARS-CoV-2 virus pandemic has the potential to increase avoidable spread as well as engagement in risky health behaviors. Although social media platforms, such as YouTube, can be an inexpensive and effective method of sharing accurate health information, inaccurate and misleading information shared on YouTube can be dangerous for viewers. The confusing nature of data and claims surrounding the benefits of vitamin D, particularly in the prevention or cure of COVID-19, influences both viewers and the general "immune boosting" commercial interest., Objective: The aim of this study was to ascertain how information on vitamin D and COVID-19 was presented on YouTube in 2020., Methods: YouTube video results for the search terms "COVID," "coronavirus," and "vitamin D" were collected and analyzed for content themes and deemed useful or misleading based on the accuracy or inaccuracy of the content. Qualitative content analysis and simple statistical analysis were used to determine the prevalence and frequency of concerning content, such as confusing correlation with causation regarding vitamin D benefits., Results: In total, 77 videos with a combined 10,225,763 views (at the time of data collection) were included in the analysis, with over three-quarters of them containing misleading content about COVID-19 and vitamin D. In addition, 45 (58%) of the 77 videos confused the relationship between vitamin D and COVID-19, with 46 (85%) of 54 videos stating that vitamin D has preventative or curative abilities. The major contributors to these videos were medical professionals with YouTube accounts. Vitamin D recommendations that do not align with the current literature were frequently suggested, including taking supplementation higher than the recommended safe dosage or seeking intentional solar UV radiation exposure., Conclusions: The spread of misinformation is particularly alarming when spread by medical professionals, and existing data suggesting vitamin D has immune-boosting abilities can add to viewer confusion or mistrust in health information. Further, the suggestions made in the videos may increase the risks of other poor health outcomes, such as skin cancer from solar UV radiation., Competing Interests: Conflicts of Interest: None declared., (©Emma K Quinn, Shelby Fenton, Chelsea A Ford-Sahibzada, Andrew Harper, Alessandro R Marcon, Timothy Caulfield, Sajjad S Fazel, Cheryl E Peters. Originally published in JMIR Infodemiology (https://infodemiology.jmir.org), 14.03.2022.)

Reduced energy intake is a major driver of weight loss and evidence suggests that physical activity, dietary, and sleep behaviours interact to influence energy intake. Energy restriction can be challenging to sustain. Therefore to improve intervention efficacy, evaluation of how changes in physical activity, diet, and sleep behaviours mediate reduced energy intake in adults with overweight/obesity who participated in a six-month multiple-behaviour-change weight loss intervention was undertaken. This was a secondary analysis of a 3-arm randomised controlled trial. Adults with body mass index (BMI) 25-40 kg/m 2 were randomised to either: a physical activity and diet intervention; physical activity, diet, and sleep intervention; or wait-list control. Physical activity, dietary intake, and sleep was measured at baseline and six-months using validated measures. The two intervention groups were pooled and compared to the control. Structural equation modelling was used to estimate the mediated effects (AB Coefficient) of the intervention on total energy intake. One hundred and sixteen adults (70% female, 44.5y, BMI 31.7 kg/m 2 ) were enrolled and 70% (n = 81) completed the six-month assessment. The significant intervention effect on energy intake at six-months (-1011 kJ/day, 95% CI -1922, -101) was partially mediated by reduced fat intake (AB = -761.12, 95% CI -1564.25, -53.74) and reduced consumption of energy-dense, nutrient-poor foods (AB = -576.19, 95% CI -1189.23, -97.26). In this study, reducing fat intake and consumption of energy-dense, nutrient-poor foods was an effective strategy for reducing daily energy intake in adults with overweight/obesity at six-months. These strategies should be explicitly targeted in future weight loss interventions., (Copyright © 2021. Published by Elsevier Ltd.)

This three-arm randomised controlled trial evaluated whether (1) a multi-component weight loss intervention targeting diet, physical activity (PA), and sleep was effective at improving dietary intake over six months and 12 months, compared with a control, and (2) the enhanced diet, PA, and sleep intervention was more effective at improving dietary intake than the traditional diet and PA intervention. A total of 116 adults (70% female, 44.5 years, BMI 31.7 kg/m 2 ) were randomised to either traditional diet and PA intervention; enhanced diet, PA, and sleep intervention; or wait-list control. To examine between-group differences, intervention groups were pooled and compared with the control. Then, the two intervention groups were compared. At six months, the pooled intervention group consumed 1011 fewer kilojoules/day (95% CI -1922, -101), less sodium (-313.2 mg/day; 95% CI -591.3, -35.0), and higher %EI from fruit (+2.1%EI; 95% CI 0.1, 4.1) than the controls. There were no differences in intake between the enhanced and traditional groups at six months. At 12 months, the pooled intervention and control groups reported no significant differences. However, compared to the traditional group, the enhanced reported higher %EI from nutrient-dense foods (+7.4%EI; 95% CI 1.3, 13.5) and protein (+2.4%EI; 95% CI 0.1, 4.6), and reduced %EI from fried/takeaway foods (-3.6%EI; 95% CI -6.5, -0.7), baked sweet products (-2.0%EI; 95% CI -3.6, -0.4), and packaged snacks (-1.1%EI; 95% CI -2.2, -0.3). This weight loss intervention reduced total energy and sodium intakes as well as increased fruit intake in adults at six months. The enhanced intervention group reported improved dietary intake relative to the traditional group at 12 months.

Background: Our knowledge of immune-mediated inflammatory disease (IMID) aetiology and pathogenesis has improved greatly over recent years, however, very little is known of the factors that trigger disease relapses (flares), converting diseases from inactive to active states. Focussing on rheumatoid arthritis (RA), the challenge that we will address is why IMIDs remit and relapse. Extrapolating from pathogenetic factors involved in disease initiation, new episodes of inflammation could be triggered by recurrent systemic immune dysregulation or locally by factors within the joint, either of which could be endorsed by overarching epigenetic factors or changes in systemic or localised metabolism., Methods: The BIO-FLARE study is a non-randomised longitudinal cohort study that aims to enrol 150 patients with RA in remission on a stable dose of non-biologic disease-modifying anti-rheumatic drugs (DMARDs), who consent to discontinue treatment. Participants stop their DMARDs at time 0 and are offered an optional ultrasound-guided synovial biopsy. They are studied intensively, with blood sampling and clinical evaluation at weeks 0, 2, 5, 8, 12 and 24. It is anticipated that 50% of participants will have a disease flare, whilst 50% remain in drug-free remission for the study duration (24 weeks). Flaring participants undergo an ultrasound-guided synovial biopsy before reinstatement of previous treatment. Blood samples will be used to investigate immune cell subsets, their activation status and their cytokine profile, autoantibody profiles and epigenetic profiles. Synovial biopsies will be examined to profile cell lineages and subtypes present at flare. Blood, urine and synovium will be examined to determine metabolic profiles. Taking into account all generated data, multivariate statistical techniques will be employed to develop a model to predict impending flare in RA, highlighting therapeutic pathways and informative biomarkers. Despite initial recruitment to time and target, the SARS-CoV-2 pandemic has impacted significantly, and a decision was taken to close recruitment at 118 participants with complete data., Discussion: This study aims to investigate the pathogenesis of flare in rheumatoid arthritis, which is a significant knowledge gap in our understanding, addressing a major unmet patient need., Trial Registration: The study was retrospectively registered on 27/06/2019 in the ISRCTN registry 16371380 ., (© 2021. The Author(s).)

Background: We implemented a systematic multidisciplinary process to engage new outpatients with cancer in selecting and preparing a medical decision-maker., Measures: Templated advance care planning notes and medical power of attorney documents were used in the electronic health record by the third office visit., Intervention: Patients were coached to meet with social work from a "culture of yes," viewed a video about the importance of selecting a prepared medical a decision-maker in English or in Spanish, and referenced cards containing simple explanations of advance directives when responding to advance directive questions., Outcomes: A total of 351 patients were evaluated. By visit 3, there was no increase in documented social work advance care planning notes in intervention or scanned medical power of attorney documents in the electronic health record., Conclusions/lessons Learned: This systematic multidisciplinary approach did not engage new outpatients with cancer in preparing a medical decision-maker. More active physician involvement and varied ways of engagement are needed., (Copyright © 2020 American Academy of Hospice and Palliative Medicine. Published by Elsevier Inc. All rights reserved.)

Objective: The prospective relationships between poor sleep health, poor diet quality, and physical inactivity with self-rated health (SRH) are not well described. The aim of this study was to assess individual and joint associations between high-risk health behaviors and incident poor SRH., Method: Participants from the Household Income and Labor Dynamics in Australia longitudinal cohort reporting "good" SRH in 2013 were included (n = 8,853) in 2020 data analysis. Logistic regression was used to assess odds of poor SRH in 2017 associated with (a) individual, (b) count, and (c) unique combinations of high-risk behaviors reported in 2013., Results: In the sample (48% female, M age = 45.2 years, SD = 16.8), poor sleep health (OR = 1.66, 95% CI [1.38, 2.01]), physical inactivity (OR = 1.18, [1.01, 1.38]), and poor diet quality (OR = 1.38, [1.16, 1.65]) were associated with increased odds of poor SRH. Reporting one (OR = 1.76, [1.27, 2.43]), two (OR = 2.16, [1.57, 2.98]), and three (OR = 2.99, [2.02, 4.41]) high-risk behaviors was associated with increased odds of poor SRH. All unique combinations of high-risk behaviors were significantly associated with greater odds of poor SRH, except "poor sleep health only" (prevalence = 1.3%). Odds of poor SRH associated with high-risk behavior combinations ranged from 1.73 (95% CI [1.21, 2.47]) for "physical inactivity only" to 4.11 ([2.66, 6.35]) for "poor sleep health + poor diet quality.", Conclusions: Reporting ≥ 1 high-risk behavior was associated with increased odds of poor SRH. The combination of poor sleep health with poor diet quality was associated with the greatest odds of poor SRH. Improving multiple high-risk behaviors in combination may be more effective in preventing decline in SRH than improving any behavior alone. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

Background: Poor dietary intake increases disease risk, and poor sleep influences diet. This systematic review and meta-analysis of intervention studies aimed to evaluate the effect of sleep health on dietary intake in adults., Methods: Five online databases were used to identify studies published between 1970 and 2019. Included studies were interventions that modified sleep and reported dietary outcomes., Results: Fifty four full texts were assessed and 24 publications were included. Following risk of bias appraisal, data were narratively summarised and a sub-group of studies (n = 15) was meta-analysed to determine the effect of sleep on dietary intake. One intervention modified sleep timing and 23 modified duration. Sleep duration was partially restricted (≤5.5 h night -1 ) (n = 16), totally restricted (n = 4), partially and totally restricted (n = 1), and extended (n = 2). Dietary outcomes were energy intake (n = 24), carbohydrate, fat, protein intake (n = 20), single nutrient intake (n = 5), diet quality (n = 1) and food types (n = 1). Meta-analysis indicated partial sleep restriction results in higher energy intake in intervention compared with control [standardised mean difference (SMD) = 0.37; 95% confidence interval (CI) = 0.21-0.52; P < 0.001], with a mean difference of 204 kcal (95% CI = 112-295; P < 0.001) in daily energy intake, and a higher percentage of energy from fat, protein, carbohydrate (fat: SMD = 0.33; 95% CI = 0.16-0.51; P < 0.001; protein: SMD = 0.30, 95% CI = 0.12-0.47, P = 0.001; carbohydrate: SMD = 0.22, 95% CI = 0.04-0.39, P = 0.014)., Conclusions: Partial sleep restriction with duration of ≤5.5 h day -1 increases daily energy intake, as well as fat, protein and carbohydrate intake. Further research is needed to determine the relationship between other dimensions of sleep health and dietary intake., (© 2020 The British Dietetic Association Ltd.)

Background: Lower-limb osteoarthritis (OA) causes high levels of pain and disability. Physiotherapists are the primary healthcare provider of non-pharmacological treatments, and incorporate strategies to optimise physical activity (PA) to aid patients with lower-limb OA to moderate their clinical symptoms. However, patients with lower-limb OA have low adherence to PA recommendations both during treatment and after discharge. This study aimed to use knowledge of identified barriers and facilitators to physiotherapy prescribed PA (during treatment and post-discharge) to develop a theoretically informed intervention to optimise adherence to PA for patients with lower-limb OA during treatment and post-discharge., Methods: 1) A purposive sample of 13 patients with lower-limb OA participated in semi-structured interviews following physiotherapy treatment. Inductive analysis identified themes/subthemes reflecting barriers and facilitators to physiotherapist prescribed PA, which were organised deductively according to personal factors, treatment and post-discharge phases. 2) Themes/subthemes were mapped onto the theoretical domains framework (TDF). 3) Behaviour change techniques (BCTs) were coded from the key identified domains and a theoretically informed physiotherapy intervention addressing barriers and using facilitators, was developed., Results: Themes of patient confidence, mind-set, motivation, OA symptoms and PA experiences were primary personal factors that influenced PA adherence; with the TDF domain 'Beliefs about capabilities' most important to target. During treatment, the theme of routine formation was the major driver of personal factors; and primarily influenced by developing a positive physiotherapist-patient relationship. Post-discharge, physical factors, psychosocial factors and ongoing access to resources were important themes influencing PA maintenance. 'Environmental context and resources' and 'social influences' emerged as the key TDF domains to target during treatment and post-discharge. The proposed theoretically informed intervention included 26 BCTs delivered across conceptual phases of adoption, routine formation, and maintenance., Conclusion: A theoretically informed physiotherapy intervention was proposed to optimise PA adherence in patients with lower-limb OA. The included BCTs primarily target patients' perceived beliefs about their capabilities, by developing a PA routine during treatment and facilitating appropriate psychosocial support and access to resources for PA maintenance post-discharge. The feasibility of delivering the intervention in clinical practice will now be evaluated.

The direct use of EHR data in research, often referred to as 'eSource', has long-been a goal for researchers because of anticipated increases in data quality and reductions in site burden. eSource solutions should rely on data exchange standards for consistency, quality, and efficiency. The utility of any data standard can be evaluated by its ability to meet specific use case requirements. The Health Level Seven (HL7 ® ) Fast Healthcare Interoperability Resources (FHIR ® ) standard is widely recognized for clinical data exchange; however, a thorough analysis of the standard's data coverage in supporting multi-site clinical studies has not been conducted. We developed and implemented a systematic mapping approach for evaluating HL7 ® FHIR ® standard coverage in multi-center clinical trials. Study data elements from three diverse studies were mapped to HL7 ® FHIR ® resources, offering insight into the coverage and utility of the standard for supporting the data collection needs of multi-site clinical research studies., (©2020 AMIA - All rights reserved.)

Background: This study compared the efficacy of two multi-component m-health interventions with a wait-list control group on body weight (primary outcome), and secondary outcomes of cardiovascular risk factors, lifestyle behaviours, and mental health., Methods: Three-arm randomised controlled trial (Enhanced: physical activity, diet, sleep, Traditional: physical activity, diet, Control) with assessments conducted at baseline, 6 and 12 months. Participants ( n = 116) were overweight or obese adults aged 19-65 (M = 44.5 [SD = 10.5]). The 6-month intervention was delivered via a smartphone app providing educational materials, goal-setting, self-monitoring and feedback, and also included one face-to-face dietary consultation, a Fitbit and scales. The trial was prospectively registered and conducted between May 2017 and September 2018. Group differences on primary and secondary outcomes were examined between the Pooled Intervention groups (Pooled Intervention = Enhanced and Traditional) and Control groups, and then between Enhanced and Traditional groups., Results: Nineteen participants (16.4%) formally withdrew from the trial. Compared with the Control group, average body weight of the Pooled Intervention group did not differ at 6 (between-group difference = -0.92, (95% CI -3.33, 1.48)) or 12 months (0.00, (95% CI -2.62, 2.62)). Compared with the Control group, the Pooled Intervention group significantly increased resistance training (OR = 7.83, (95% CI 1.08, 56.63)) and reduced energy intake at 6 months (-1037.03, (-2028.84, -45.22)), and improved insomnia symptoms at 12 months (-2.59, (-4.79, -0.39)). Compared with the Traditional group, the Enhanced group had increased waist circumferences (2.69, (0.20, 5.18)) and sedentary time at 6 months (105.66, (30.83, 180.48)), and improved bed time variability at 12 months (-1.08, (-1.86, -0.29)). No other significant differences were observed between groups., Conclusions: Relative to Controls, the Pooled Intervention groups did not differ on body weight but improved resistance training, and reduced energy intake and insomnia symptom severity. No additional weight loss was apparent when targeting improvements in physical activity, diet and sleep in combination compared with physical activity and diet.

Background: Recent research has demonstrated an association between dietary intake and sleep health that can influence chronic disease risk factors. A scoping review of research studies investigating dietary intake and sleep was undertaken to determine the extent and scope of research in laboratory-based, free-living and mixed settings. Additionally, this review determines how well subpopulations and geographical locations are represented and the methodologies used to assess outcome measures., Methods: Five online databases were used to identify papers published between 1970 and 2017. Included studies were those conducted in adults and reported both outcomes of interest: (i) sleep health, including sleep restriction and sleep hygiene and (ii) dietary outcomes, including altered nutrients, dietary patterns and supplements., Results: In total, 129 publications were included with the majority being dietary interventions investigating sleep outcomes (n = 109) with fewer being sleep interventions investigating and reporting dietary outcomes (n = 20). Dietary interventions were most often carried out in free-living environments, in contrast to sleep interventions that were most often carried out in laboratory-based environments. The majority of dietary interventions investigated use of a supplement (n = 66 studies), which was predominantly caffeine (n = 49). Sleep interventions investigated sleep duration only, with the majority (n = 17) investigating the effect of partial sleep restriction under 5.5 h per night on dietary intake, while three studies investigating total sleep deprivation., Conclusions: Investigating broader aspects of dietary such as overall diet quality and dietary patterns and other components of sleep health such as quality,  timing and sleep hygiene are important aspects for future research., (© 2020 The British Dietetic Association Ltd.)

Background: Mortality and ECMO rates for congenital diaphragmatic hernia (CDH) remain ~30%. In 2016, we changed our CDH guidelines to minimize stimulation while relying on preductal oxygen saturation, lower mean airway pressures, stricter criteria for nitric oxide (iNO), and inotrope use. We compared rates of ECMO, survival, and survival without ECMO between the two epochs., Design/methods: Retrospective review of left-sided CDH neonates at the University of Utah/Primary Children's Hospital NICUs during pre (2003-2015, n = 163) and post (2016-2019, n = 53) epochs was conducted. Regression analysis controlled for defect size and intra-thoracic liver., Results: Following guideline changes, we identified a decrease in ECMO (37 to 13%; p = 0.001) and an increase in survival without ECMO (53 to 79%, p = 0.0001). Overall survival increased from 74 to 89% (p = 0.035)., Conclusion(s): CDH management guideline changes focusing on minimizing stimulation, using preductal saturation and less aggressive ventilator/inotrope support were associated with decreased ECMO use and improved survival.

Walking interventions can be effective in increasing physical activity amongst physically inactive employees. However, despite their promising potential regarding sustainability and scalability, peer-led workplace walking interventions have not been tested. We evaluated a peer-led workplace group walking intervention designed to engage physically inactive employees. A 16-week pilot cluster randomized controlled trial consisted of enhanced (5 worksites; n = 50 participants) and minimal treatment (3 worksites; n = 47) conditions. All participants were provided with a Fitbit Zip and information on health benefits of walking. Enhanced treatment participants had access to a mobile phone app incorporating behavior change techniques, were trained on principles of autonomous motivation, and had a peer leader trained in a motivationally supportive communication style. Feasibility assessments included recruitment and drop-out rates, assessment completion rates, training acceptability (walkers and peer leaders), and intervention acceptability (walkers only). Outcomes assessed included movement-related behaviors (assessed via activPAL devices), cardio-metabolic risk factors, motivation to walk, and well-being, and these measures were taken at baseline and post-intervention. The results supported intervention feasibility. Preliminary efficacy evidence was mixed. Markers of cardio-metabolic risk improved in the enhanced treatment only. Autonomous motivation increased in both conditions. There were no changes in step counts, standing, and sitting time, or well-being. Further fine tuning is needed before a definitive RCT. Australian and New Zealand Clinical Trials Registry: ACTRN12618000807257., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Cardiovascular disease (CVD) morbidity and mortality is highly prevalent in patients with rheumatoid arthritis (RA) with debilitating effects for the individual as well as significant healthcare impact. Current evidence demonstrates that engaging in aerobic and resistance exercise (i.e. structured physical activity) can significantly improve patient-reported and clinical index-assessed outcomes in RA. In addition to this, engagement in exercise programmes improves, in a dose-dependent manner, the risk of developing CVD as well as CVD symptoms and outcomes. The present narrative review uses evidence from systematic reviews and meta-analyses as well as controlled trials, to synthesize the current state-of-the-art on the potential effects of aerobic and resistance exercise on CVD risk factors as well as on cardiac and vascular function and structure in people with RA. Where there is a lack of evidence in RA to explain potential mechanisms, relevant studies from the general population are also discussed and linked to RA.

Purpose: Advance care planning (ACP) supports national priorities of patient engagement, person-centered care, and safety. A systematic approach is uncommon in most care settings. Our institution offers all patients with cancer new to the institution an opportunity to select and prepare a medical decision maker (MDM) after social work counseling. The goals of this study were to determine the success of a systematic institutional process for selecting a prepared MDM. The primary objectives were that (1) 70% or more of new patients would have one or more documented social work ACP discussions by the third office visit within 4 months, and (2) there would be a two-fold increase in scanned medical power of attorney (MPOA) documents available in the electronic health record (EHR). The secondary objectives were (1) improved surrogate preparedness for medical decision making, and (2) to determine whether patients with metastatic disease demonstrated greater readiness for selection of an MDM than those with localized disease., Materials and Methods: We conducted a retrospective chart review of consecutive gynecology oncology outpatients., Results: Of 133 patients, 93 (70%) had metastatic disease. The median number of visits was two (one to three). Forty-seven patients (39.3%) met with social work by visit 3. Review of ACP notes suggested that most patients were in the early stages of selecting a prepared MDM. At visit 1, 39 (29.3%) reported having an advance directive document; 14 (10.5%) had an MPOA in the EHR. There was no increase by visit 3. Fewer patients with metastatic disease than those with localized cancer (32.3% v 67.5%; P = .001) had three visits; no other parameter, including presence of MPOA documents in the EHR, achieved statistical significance between groups., Conclusion: Current processes fail to engage patients in selecting and preparing an MDM.