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Abstract Introduction Remote monitoring can strengthen postoperative care in the community and minimise the burden of complications. However, implementation requires a clear understanding of how to sustainably integrate such complex interventions into existing care pathways. This study aimed to explore perceptions of potential facilitators and barriers to the implementation of digital remote postoperative monitoring from key stakeholders and derive recommendations for an implementable service. Methods A qualitative implementation study was conducted of digital remote postoperative wound monitoring across two UK tertiary care hospitals. All enrolled patients undergoing general surgery, and all staff involved in postoperative care were eligible. Criterion-based purposeful sampling was used to select stakeholders for semi-structured interviews on their perspectives and experiences of digital remote postoperative monitoring. A theory-informed deductive-inductive qualitative analysis was conducted; drawing on normalisation process theory (NPT) to determine facilitators for and barriers to implementation within routine care. Results There were 28 semi-structured interviews conducted with patients (n = 14) and healthcare professionals (n = 14). Remote postoperative monitoring was perceived to fulfil an unmet need in facilitating the diagnosis and treatment of postoperative complications. Participants perceived clear benefit to both the delivery of health services, and patient outcomes and experience, but some were concerned that this may not be equally shared due to potential issues with accessibility. The COVID-19 pandemic demonstrated telemedicine services are feasible to deliver and acceptable to participants, with examples of nurse-led remote postoperative monitoring currently supported within local care pathways. However, there was a discrepancy between patients’ expectations regarding digital health to provide more personalised care, and the capacity of healthcare staff to deliver on these. Without further investment into IT infrastructure and allocation of staff, healthcare staff felt remote postoperative monitoring should be prioritised only for patients at the highest risk of complications. Conclusion The COVID-19 pandemic has sparked the digital transformation of international health systems, yet the potential of digital health interventions has yet to be realised. The benefits to stakeholders are clear, and if health systems seek to meet governmental policy and patient expectations, there needs to be greater organisational strategy and investment to ensure appropriate deployment and adoption into routine care. Trial registration NCT05069103.

Abstract Plants growing at high densities can detect competitors through changes in the composition of light reflected by neighbours. In response to this far-red-enriched light, plants elicit adaptive shade avoidance responses for light capture, but these need to be balanced against other input signals, such as nutrient availability. Here, we investigated how Arabidopsis integrates shade and nitrate signalling. We unveiled that nitrate modulates shade avoidance via a previously unknown shade response pathway that involves root-derived trans-zeatin (tZ) signal and the BEE1 transcription factor as an integrator of light and cytokinin signalling. Under nitrate-sufficient conditions, tZ promotes hypocotyl elongation specifically in the presence of supplemental far-red light. This occurs via PIF transcription factors-dependent inhibition of type-A ARRs cytokinin response inhibitors. Our data thus reveal how plants co-regulate responses to shade cues with root-derived information about nutrient availability, and how they restrict responses to this information to specific light conditions in the shoot.

Given growing interest in the phenomenon of responsible investing (RI) in South Africa, this study set out to identify and empirically evaluate the most pertinent drivers, barriers and enablers of RI locally. Telephone interviews were conducted with a sample of pension funds, asset managers and advisory service providers during 2007. All three groups of respondents viewed fiduciary responsibility as one of the most important barriers to RI in South Africa. More legislation/regulation and evidence for increased risk-adjusted returns from local RIs were identified as key drivers of RI in South Africa, whereas the two most important enablers were seen as mainstream RI benchmarks and co-operative initiatives.

A growing number of investors, globally and in South Africa, are embracing the concept of Responsible Investing (RI). In essence RI refers to a combination of investment strategies that integrate ethical as well as environmental, social and corporate governance considerations into investment analysis and decision making processes. Given the growing influence that investors are exerting on corporate decision making, the purpose of this paper was to position RI within an appropriate ethical framework. It is shown that RI constitutes a form of moral investing as responsible investors express a concern for universal principles which exceed the prescriptions of the law. The practice of RI was further contextualised in relation to seven approaches to ethical reasoning, namely ethical egoism, utilitarianism, deontological ethics, the ethics of care, virtue theory, the conventional approach to ethics as well as emotivism. From the evidence presented, it seems as if responsible investors in South Africa give preference to the principles underlying deontological ethics as well as the ethics of care (particularly with regard to the protection of human rights and equality as well as the promotion of distributive and compensatory justice).

There is a continuous interest in cannabinoids like Δ9-tetrahydrocannabinol (Δ9-THC) and cannabidiol (CBD). Previous experimental research has described the conversion of CBD to either Δ8-THC or Δ9-THC, depending on the acid catalyst applied. The use of para-toluene sulfonic acid (pTSA) has led to the formation of Δ8-THC, while boron trifluoride etherate (BF3·Et2O) has mainly yielded Δ9-THC. The enormous difference in product selectivity between these two catalysts was investigated with Molecular Modeling, applying quantum chemical density functional theory. It was found that pTSA leads to fast isomerization of Δ9-CBD to Δ8-CBD and subsequent ring closure to Δ8-THC. BF3·Et2O catalysis leads to the formation of tertiary carbenium ions in the transition states, which yield Δ9-THC and some iso THC. Under dry conditions in refluxing toluene, it was found that pTSA is predominantly present as a dimer, and only a small fraction is available as monomeric catalyst. Applying the computationally derived activation barriers in transition state theory yielded reaction rates that predicted the amounts of cannabinoids that are in close agreement with the experimental findings from the previous literature.

The concept of Nature-based Solutions (NbS) has gained interest as an approach to make significant contributions to the transformation towards more liveable, sustainable, and climate-resilient cities. However, the uptake of NbS into urban development practice is hindered by knowledge and governance barriers. Knowledge plays an essential role in evidence-based decision-making processes and in building the capacity to co-design sustainable pathways. In turn, governance processes can greatly support the acquisition, dissemination and application of knowledge. However, little is known about how these interactions between governance and knowledge manifest in practice. Therefore, we aim to understand the interplay between governance and monitoring & assessment (M&A) and the associated challenges and opportunities for NbS implementation in European and Latin American cities. Considering different socio-economic and cultural contexts allows us to draw from a wider range of practitioners’ experiences in different governance settings. We conducted an explorative qualitative content analysis on ten semi-structured expert interviews with thirteen city experts from local governments and academia based in seven cities: Bogota (CO), Buenos Aires (AR), Santiago (CL), São Paulo (BR), Barcelona (ES), Lisbon (PT) and Turin (IT). Our findings show that M&A provides agency for individual, institutional actors to steer political commitment and can support integrated working. The potential of collaborative M&A with non-governmental actors is still largely untapped, which requires acknowledgement of the capacities of non-governmental actors to contribute to M&A and raise awareness of the value of M&A to civil society. Furthermore, we recommend integrating more reflective learning opportunities in M&A processes, paying more attention to data sharing, and considering of more feasible M&A processes.

The aim of this study was to gain insight in knowledge mobilization (KM) in educational research, focusing on the type of collaboration, the strategies and the conditions. KM reflects the interaction and relationship between educational research and practice and requires specific effort over time. We studied 69 research reports and held 12 group interviews with consortia of researchers and teachers. Results show that the research projects could be characterized as researcher-directed or school-and- researcher directed collaboration. Strategies for KM found in these collaborations were mainly ‘transferring’ and ‘implementing’. ‘Co-creation’ as a strategy was found more often in school- and researcher collaboration projects. Finally, the conditions enabling or constraining KM were found at the level of research knowledge, the individual teacher and researcher, school organization, research organization, consortium, and communication. Implications for future research are discussed.

Abstract Twenty percent of children with T‐cell lymphoblastic lymphoma (T‐LBL) will relapse and have an extremely poor outcome. Currently, we can identify a genetically low‐risk subgroup in pediatric T‐LBL, yet these high‐risk patients who need intensified or alternative treatment options remain undetected. Therefore, there is an urgent need to recognize these high‐risk T‐LBL patients through identification of molecular characteristics and biomarkers. By using RNA sequencing which was performed in 29/49 T‐LBL patients who were diagnosed in the Princess Maxima Center for Pediatric Oncology between 2018 and 2023, we discovered a previously unknown high‐risk biological subgroup of children with T‐LBL. This subgroup is characterized by NOTCH1 gene fusions, found in 21% of our T‐LBL cohort (6/29). All patients presented with a large mediastinal mass, pleural/pericardial effusions, and absence of blasts in the bone marrow, blood, and central nervous system. Blood CCL17 (C‐C Motif Chemokine Ligand 17, TARC) levels were measured at diagnosis in 26/29 patients, and all six patients with NOTCH1 gene fusions patients exclusively expressed highly elevated blood CCL17 levels, defining a novel and previously not known clinically relevant biomarker for T‐cell lymphoblastic lymphoma. Four out of these six patients relapsed during therapy, a fifth developed a therapy‐related acute myeloid leukemia during maintenance therapy. These data indicate that T‐LBL patients with a NOTCH1 fusion have a high risk of relapse which can be easily identified using a blood CCL17 screening at diagnosis. Further molecular characterization through NOTCH1 gene fusion analysis offers these patients the opportunity for treatment intensification or new treatment strategies.

Objectives Interhospital patient transfers have become routine. Known drivers are access to specialty care and non-clinical reasons, such as limited capacity. While emergency medical services (EMS) providers act as main patient transfer operators, the impact of interhospital transfers on EMS service demand and fleet management remains understudied. This study aims to identify patterns in regional interhospital patient transfer volumes and their spatial distribution, and to discuss their potential implications for EMS service demand and fleet management.Design A retrospective study was performed analysing EMS transport data from the province of Drenthe in the Netherlands between 2013 and 2019 and public hospital listings. Yearly volume changes in urgent and planned interhospital transfers were quantified. Further network analysis, including geomapping, was used to study how transfer volumes and their spatial distribution relate to hospital specialisation, and servicing multihospital systems. Organisational data were considered for relating transfer patterns to fleet changes.Setting EMS in the province of Drenthe, the Netherlands, 492 167 inhabitants.Participants Analyses are based on routinely collected patient data from EMS records, entailing all 248 114 transports (137 168 patients) of the Drenthe EMS provider (2013–2019). From these interhospital transports were selected (24 311 transports).Results Interhospital transfers represented a considerable (9.8%) and increasing share of transports (from 8.6% in 2013 to 11.3% in 2019). Most transfers were related to multihospital systems (47.3%, 11 509 transports), resulting in a considerable growth of planned EMS transports (from 2093 in 2013 to 3511 in 2019). Geomapping suggests increasing transfer distances and diminishing resource efficiencies due to lacking follow-up rides. Organisational data clarify how EMS fleets were adjusted by expanding resources and reorganising fleet operation.Conclusions Emerging interhospital network transfers play an important role in EMS service demand. Increased interhospital transport volumes and geographical spread require a redesign of current EMS fleets and management along regional lines.

Technological advances in radiation therapy impact on the role and scope of practice of the radiation therapist. The European Society of Radiotherapy and Oncology (ESTRO) recently held two workshops on this topic and this position paper reflects the outcome of this workshop, which included radiation therapists from all global regions.Workflows, quality assurance, research, IGRT and ART as well as clinical decision making are the areas of radiation therapist practice that will be highly influenced by advancing technology in the near future. This position paper captures the opportunities that this will bring to the radiation therapist profession, to the practice of radiation therapy and ultimately to patient care.

Tel is an Ets transcription factor that is the target of chromosome translocations in lymphoid and myeloid leukemias and in solid tumors. It contains two functional domains, a pointed oligomerization domain and a DNAbinding domain. Retroviral transduction of a wild-type Tel cDNA into a clonal subline of NIH3T3 fibroblasts resulted in a striking morphologic change: at confluency, the cells reorganized into a specific “bridge-like” pattern over the entire surface of the culture dish, started migrating, thereby leaving circular holes in the monolayer. Thereafter, formation of cellular cords became apparent. This sequence of events was inhibited by coating the culture dishes with fibronectin and collagen IV. Retroviral transduction of Tel into MS1 endothelial cells reproduced the aggregation phenotype, but not the cellular cord formation. Tel -mutagenesis showed that both the pointed domain and the DNAbinding domain of Tel are required for the morphologic change. Other Ets family genes, Fli-1 and Ets-1 that are both endogenously expressed in endothelial cells, could not induce this morphologic change. Exogenous Tel expression is associated with transcriptional upregulation of entactin/nidogen, Smad5, Col3a1, CD44 and fibronectin, downregulation of Coliai and secretory leukocyte protease inhibitor. Interestingly, Tel, Smad5, fibronectin, Coliai and Col3a1 all have essential roles during vascular development.

Artificial intelligence (AI) is a promising tool for diagnosing rib fractures. To date, only a few studies have quantified its performance. The objective of this systematic review was to assess the accuracy of AI as an independent tool for rib fracture detection on CT scans or radiographs. This was defined as the combination of sensitivity and specificity. PubMed (including MEDLINE and PubMed Central) was systematically reviewed according to the PRISMA statement followed by citation searching among studies up to December 2022. Methods of the analysis and inclusion criteria were prespecified in a protocol and published on PROSPERO (CRD42023479590). Only diagnostic studies of independent AI tools for rib fracture detection on CT scans and X-rays reporting on sensitivity and/or specificity and written in English were included. Twelve studies met these criteria, which included 11,510 rib fractures in total. A quality assessment was performed using an altered version of QUADAS-2. Random-effects meta-analyses were performed on the included data. If specificity was not reported, it was calculated on a set of assumptions. Pooled sensitivity and specificity were 0.85 (95% CI, 0.78–0.92) and 0.96 (95% CI, 0.94–0.97), respectively. None of the included studies used X-rays. Thus, it can be concluded that AI is accurate in detecting rib fractures on CT scans. Overall, these findings seemed quite robust, as can be concluded from the study quality assessment, therefore AI could potentially play a substantial role in the future of radiological diagnostics.

Background: About 20% of proximal humerus fractures (PHFs) are unstable and/or markedly displaced and therefore require surgery. Locking plate fixation after anatomical reduction has become the current treatment of choice for these fractures in the active population. However, studies have shown complication rates up to 36%, such as loss of reduction and avascular necrosis. To date, data from literature are inconclusive on outcomes following the use of an intramedullary fibula allograft in PHFs, possibly due to the case mix. It is hypothesized that the use of a fibula allograft is beneficial to prevent secondary displacement of the fracture in cases where the medial hinge is markedly displaced and unstable, resulting in better clinical and patient reported outcomes. Methods: In this multicenter matched cohort study, patients with an unstable, displaced PHF, including anatomic neck fractures and significantly displaced surgical neck fractures, were included. Patients that were treated with a locking plate augmented with a fibula allograft were matched to patients who had undergone locking plate reconstruction without the allograft. The matches were made based on fracture characteristics, age, and performance status. Functional outcomes, Patient Reported Outcome Measures, complications, and radiographic results were compared. Results: Twelve patients with fibula allograft augmented osteosyntheses were included and matched to 12 control patients. The mean age was 58 years in the fibula allograft group compared to 62 years in the control group. Minimum follow-up was 12 months. Disability of the Arm Shoulder and Hand score, Constant Shoulder score, abduction, and external rotation were significantly better in the fibula allograft group (17.4 ± 8.6 vs. 26.1 ± 19.2, P = .048; 16.5 ± 11.5 vs. 19.8 ± 16.5 P = .040; mean 127° ± 38° vs. mean 92° ± 49° P = −.045; 50° ± 21° vs. mean 26° ± 23°, P = .004). There was no statistically significant difference in the Oxford Shoulder score between groups (P = .105). The Visual Analog Scale was not significantly different between groups (3.1 ± 1.8 vs. 1.6 ± 1.9, P = .439). Radiographic union was reached in 11 patients of the fibula allograft group compared to 8 in the control group (P = .317). The complication rate was twice as high in the control group (3 vs. 7). Conclusion: Additional support of the medial hinge in unstable PHFs with a locking plate in combination with a fibula allograft appears to create a more stable construct without compromising the viability of the articular surface of the head. The use of a fibula allograft in selected complex cases could therefore result in better clinical outcomes with lower complication rates.

Abstract CT imaging under external valgus and varus loading conditions and consecutive image analysis can be used to detect tibial implant loosening after total knee arthroplasty. However, the applied load causes the tibia to deform, which could result in an overestimation of implant displacement. This research evaluates the extent of tibia deformation and its effect on measuring implant displacement. Ten cadaver specimen with TKA were CT-scanned under valgus/varus loading (20 Nm), first implanted without bone cement fixation (mimicking a loose implant) and subsequently with bone cement fixation (mimicking a fixed implant). By means of image analysis, three relative displacements were assessed: (1) between the proximal and distal tibia (measure of deformation), (2) between the implant and the whole tibia (including potential deformation effect) and (3) between the implant and the proximal tibia (reduced deformation effect). Relative displacements were quantified in terms of translations along, and rotations about the axes of a local coordinate system. As a measure of deformation, the proximal tibia moved relative to the distal tibia by, on average 1.27 mm (± 0.50 mm) and 0.64° (± 0.25°). Deformation caused an overestimation of implant displacement in the cemented implant. The implant displaced with respect to the whole tibia by 0.45 mm (± 0.22 mm) and 0.79° (± 0.38°). Relative to the proximal tibia, the implant moved by 0.23 mm (± 0.10 mm) and 0.62° (± 0.34°). The differentiation between loose and fixed implants improved when tibia deformation was compensated for by using the proximal tibia rather than the whole tibia.

In this opening lecture for the 2022 Budapest Conference on "Building Community in Fractured Societies: Challenges for Christians in Higher Education," an overview is given of recent societal developments, (geo-) political, economic, ecological, sociological, psychological, and spiritual. A basic framework is presented on how to analyze today's, late-modern world. It is a world in which instrumental rationality is highly dominant. Next to this, powerful societal complexes exert deep influence on the lives of humans: political, economic, media, and medical. Over against this is posed the "real human world" of meaning and responsibility, as the key focus of Christian higher education.