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Cluster randomized trials (CRTs) often enroll large numbers of participants; yet due to resource constraints, only a subset of participants may be selected for outcome assessment, and those sampled may not be representative of all cluster members. Missing data also present a challenge: if sampled individuals with measured outcomes are dissimilar from those with missing outcomes, unadjusted estimates of arm-specific endpoints and the intervention effect may be biased. Further, CRTs often enroll and randomize few clusters, limiting statistical power and raising concerns about finite sample performance. Motivated by SEARCH-TB, a CRT aimed at reducing incident tuberculosis infection, we demonstrate interlocking methods to handle these challenges. First, we extend Two-Stage targeted minimum loss-based estimation to account for three sources of missingness: (i) subsampling; (ii) measurement of baseline status among those sampled; and (iii) measurement of final status among those in the incidence cohort (persons known to be at risk at baseline). Second, we critically evaluate the assumptions under which subunits of the cluster can be considered the conditionally independent unit, improving precision and statistical power but also causing the CRT to behave like an observational study. Our application to SEARCH-TB highlights the real-world impact of different assumptions on measurement and dependence; estimates relying on unrealistic assumptions suggested the intervention increased the incidence of TB infection by 18% (risk ratio [RR]=1.18, 95% confidence interval [CI]: 0.85-1.63), while estimates accounting for the sampling scheme, missingness, and within community dependence found the intervention decreased the incident TB by 27% (RR=0.73, 95% CI: 0.57-0.92).

ObjectivesMen in sub-Saharan Africa (SSA) have lower rates of antiretroviral therapy (ART) initiation and higher rates of early default than women. Little is known about effective interventions to improve men's outcomes. We conducted a scoping review of interventions aimed to increase ART initiation and/or early retention among men in SSA since universal treatment policies were implemented.MethodsThree databases, HIV conference databases and grey literature were searched for studies published between January 2016 to May 2021 that reported on initiation and/or early retention among men. Eligibility criteria included: participants in SSA, data collected after universal treatment policies were implemented (2016–2021), quantitative data on ART initiation and/or early retention for males, general male population (not exclusively focused on key populations), intervention study (report outcomes for at least one non-standard service delivery strategy), and written in English.ResultsOf the 4351 sources retrieved, 15 (reporting on 16 interventions) met inclusion criteria. Of the 16 interventions, only two (2/16, 13%) exclusively focused on men. Five (5/16, 31%) were randomised control trials (RCT), one (1/16, 6%) was a retrospective cohort study, and 10 (10/16, 63%) did not have comparison groups. Thirteen (13/16, 81%) interventions measured ART initiation and six (6/16, 37%) measured early retention. Outcome definitions and time frames varied greatly, with seven (7/16, 44%) not specifying time frames at all. Five types of interventions were represented: optimising ART services at health facilities, community-based ART services, outreach support (such as reminders and facility escort), counselling and/or peer support, and conditional incentives. Across all intervention types, ART initiation rates ranged from 27% to 97% and early retention from 47% to 95%.ConclusionsDespite years of data of men's suboptimal ART outcomes, there is little high-quality evidence on interventions to increase men's ART initiation or early retention in SSA. Additional randomised or quasi-experimental studies are urgently needed.

BackgroundSocial network analysis can elucidate tuberculosis transmission dynamics outside the home and may inform novel network-based case-finding strategies.MethodsWe assessed the association between social network characteristics and prevalent tuberculosis infection among residents (aged ≥15 years) of 9 rural communities in Eastern Uganda. Social contacts named during a census were used to create community-specific nonhousehold social networks. We evaluated whether social network structure and characteristics of first-degree contacts (sex, human immunodeficiency virus [HIV] status, tuberculosis infection) were associated with revalent tuberculosis infection (positive tuberculin skin test [TST] result) after adjusting for individual-level risk factors (age, sex, HIV status, tuberculosis contact, wealth, occupation, and Bacillus Calmette-Guérin [BCG] vaccination) with targeted maximum likelihood estimation.ResultsAmong 3 335 residents sampled for TST, 32% had a positive TST results and 4% reported a tuberculosis contact. The social network contained 15 328 first-degree contacts. Persons with the most network centrality (top 10%) (adjusted risk ratio, 1.3 [95% confidence interval, 1.1-1.1]) and the most (top 10%) male contacts (1.5 [1.3-1.9]) had a higher risk of prevalent tuberculosis, than those in the remaining 90%. People with ≥1 contact with HIV (adjusted risk ratio, 1.3 [95% confidence interval, 1.1-1.6]) and ≥2 contacts with tuberculosis infection were more likely to have tuberculosis themselves (2.6 [ 95% confidence interval: 2.2-2.9]).ConclusionsSocial networks with higher centrality, more men, contacts with HIV, and tuberculosis infection were positively associated with tuberculosis infection. Tuberculosis transmission within measurable social networks may explain prevalent tuberculosis not associated with a household contact. Further study on network-informed tuberculosis case finding interventions is warranted.

From January through December 2015, the California Department of Health Care Services, which administers Medi-Cal, the nation's largest Medicaid program, conducted a quality improvement collaborative (QIC) with 9 Medi-Cal managed care plans (MCPs) aimed at improving hypertension control consistent with the Million Hearts initiative. The QIC included quarterly webinars and links to local, state, and national resources that consisted of materials and consultations with subject matter experts. Participating MCPs demonstrated an average increase of 5.0 percentage points in their rates of controlled hypertension. Collaboratives can achieve substantial quality improvement in Medicaid managed care plans.

CONTEXT: Climate change is a public health crisis that disproportionately affects vulnerable populations. A 2021 joint statement from the editors of 230 healthcare journals summoned health professionals to champion a 'sustainable, fairer, resilient, and healthier world'. Despite calls for integrating climate change into medical education, few resources exist to guide curricular development. Illness scripts are an educational tool known to improve clinical reasoning and the application of new knowledge. OBJECTIVE: A series of interactive workshop sessions was developed by a multi-institutional working group in San Diego, CA using the 'illness scripts' framework to better educate Family Medicine residents about common medical conditions adversely impacted by extreme weather conditions. STUDY DESIGN: Multi-institutional survey study. POPULATION STUDIED: Residents in all 4 Family Medicine residency programs in San Diego, CA. INTERVENTION: An inaugural multi-residency 3.5 hour educational symposium, held in April 2022, consisted of breakout sessions on updating climate-centric 'illness scripts' and plenary sessions about advocacy and plant forward nutrition. OUTCOME MEASURES: Participants were asked to complete a brief survey with a QR code on their mobile devices and were asked questions about demographics, career plans, and self-reported confidence (answered on a 7-point Likert scale) in climate-focused patient counseling for common medical scenarios. Data was analyzed using the Kruskal-Wallis test by ranks analysis. RESULTS: 77 residents attended the symposium, of which 60% (46/79) completed the pretest and 38% (29/77) completed the posttest. Mean survey scores (pre;post) measuring participants' self-confidence in undertaking advocacy efforts (2.78;5.07) and discussing health impacts of extreme weather on cardiac (2.13;5.17), respiratory (2.47;5.41), psychiatric (2.50;5.17) and obstetric (2.13;5.41) conditions were all statistically significant at p50% of the time' on the posttest. CONCLUSION: A multi-residency symposium leveraging the collective expertise of local resources and application of illness scripts theory is a promising strategy for improving education and care delivery for common medical conditions adversely affected by climate change., Presenters Pareena Kaur, MD, MPH, Rachel Abbott, MD, Payam Sazegar, [...]

Background Human immunodeficiency virus (HIV) treatment reduces tuberculosis (TB) disease and mortality; however, the population-level impact of universal HIV-test-and-treat interventions on TB infection and transmission remain unclear. Methods In a sub-study nested in the SEARCH trial, a community cluster-randomized trial (NCT01864603), we assessed whether a universal HIV-test-and-treat intervention reduced population-level incident TB infection in rural Uganda. Intervention communities received annual, population-level HIV testing and patient-centered linkage. Control communities received population-level HIV testing at baseline and endline. We compared estimated incident TB infection by arms, defined by tuberculin skin test conversion in a cohort of persons aged 5 and older, adjusting for participation and predictors of infection, and accounting for clustering. Results Of the 32 trial communities, 9 were included, comprising 90 801 participants (43 127 intervention and 47 674 control). One-year cumulative incidence of TB infection was 16% in the intervention and 22% in the control; SEARCH reduced the population-level risk of incident TB infection by 27% (adjusted risk ratio = 0.73; 95% confidence interval [CI]:.57–.92, P =.005). In pre-specified analyses, the effect was largest among children aged 5–11 years and males. Conclusions A universal HIV-test-and-treat intervention reduced incident TB infection, a marker of population-level TB transmission. Investments in community-level HIV interventions have broader population-level benefits, including TB reductions. [ABSTRACT FROM AUTHOR]

Background Schools with formal sun safety polices generally show better sun safety practices than schools without. Objectives To understand the extent to which Welsh primary schools have sun safety policies; to identify the key characteristics of policies; to assess whether policy adoption varies by school characteristics; and to consider what support schools need to develop sun safety policies. Methods An online multiple-choice survey on sun safety was distributed to all 1241 primary schools in Wales. Results In total, 471 (38.0%) schools responded. Of these, 183 (39.0%) reported having a formal sun safety policy. Welsh medium schools (P = 0.036) and schools in North Wales (P = 0.008) were more likely to report having a policy. Schools with a higher percentage of pupils receiving free school meals (P = 0.046) and with lower attendance rates (P = 0.008) were less likely to report having a sun safety policy. The primary reasons for schools not having a policy included being 'not aware of the need' (34.6%); 'need assistance with policy or procedure development' (30.3%); and 'not got around to it just yet' (26.8%). Conclusions With less than half of schools reporting a sun safety policy and variation in the presence/absence of a policy by school characteristics, our survey revealed inconsistency in formal sun safety provision in Welsh schools. The findings also suggest that schools are unaware of the importance of sun safety and need support to develop and implement policies. This snapshot of the current situation in primary schools in Wales provides a basis upon which the comprehensiveness, effectiveness and implementation of sun safety policies can be further evaluated. [ABSTRACT FROM AUTHOR]

Phytoplankton offer great potential as a bioenergy crop; however, technological advances are needed to intensify their yield and reduce their footprints for water, nutrients and land. One approach to enhance productivity is to grow polycultures of mixed species, which convert abiotic resources into biomass more efficiently than any single taxon. We measured traits related to nutrient and light use, growth rate, biomass production, stoichiometry and neutral lipid concentration in 16 diverse microalgal taxa. Species with large cells (primarily Chlorophyta) showed rapid growth, high asymptotic biomass, low minimum nutrient demands, and high cellular C: N and C: P ratios. These same species also exhibited high minimum demands for light and low lipid concentrations. We grew all 119 possible species pairs and found that biomass yield exceeded the component monocultures in polycultures consisting of species with highly divergent traits. However, underyielding occurred frequently as many pairs produced less biomass than either the mean or the maximum of the two component monocultures. In terms of ecological trade-offs, competitive ability for N and P were positively correlated, but negatively related to ability to grow at low light. In terms of bioenergy production, the species with high cellular lipid concentrations showed both slow growth and high demands for nutrients. Synthesis and applications. Our results identify trade-offs among functional traits that determine the suitability of different algal species as biofuel feedstocks and narrow the search for productive and robust species combinations to maximize bioenergy productivity. An approach based on the ecology of species traits will be more effective in optimizing yield in bioenergy communities than promoting high species diversity per se. © 2014 British Ecological Society.

The Black-footed Ferret Recovery Implementation Team Executive Committee is conducting a project to develop, and (hopefully) eventually implement, a plague vaccination program for prairie dogs. The project is a component of the Western Association of Fish and Wildlife Agencies Grasslands Conservation Initiative. An effective, field-worthy vaccine against plague could be the biggest breakthrough in recovery efforts for the black-footed ferret since the 1981 rediscovery of wild ferrets near Meeteetse, Wyoming. If proven efficacious, the vaccine could help agencies and stakeholder cooperators maintain specific populations of prairie dogs at robust levels, thus enhancing range-wide conservation of those species, as well recovery of the ferret, while enabling control of other prairie dog populations to resolve site-specific agricultural and human health concerns. The results of laboratory and field-testing in the early stages of developing this vaccine are preliminary but mostly encouraging. A plan for broad-scale application is being developed for possible use when testing has been completed and (if warranted) the vaccine is registered for governmental use. An overview of all aspects of the project is discussed.

Microalgae represent one of the most promising groups of candidate organisms for replacing fossil fuels with contemporary primary production as a renewable source of energy. Algae can produce many times more biomass per unit area than terrestrial crop plants, easing the competing demands for land with food crops and native ecosystems. However, several aspects of algal biology present unique challenges to the industrial-scale aquaculture of photosynthetic microorganisms. These include high susceptibility to invading aquatic consumers and weeds, as well as prodigious requirements for nutrients that may compete with the fertiliser demands of other crops. Most research on algal biofuel technologies approaches these problems from a cellular or genetic perspective, attempting either to engineer or select algal strains with particular traits. However, inherent functional trade-offs may limit the capacity of genetic selection or synthetic biology to simultaneously optimise multiple functional traits for biofuel productivity and resilience. We argue that a community engineering approach that manages microalgal diversity, species composition and environmental conditions may lead to more robust and productive biofuel ecosystems. We review evidence for trade-offs, challenges and opportunities in algal biofuel cultivation with a goal of guiding research towards intensifying bioenergy production using established principles of community and ecosystem ecology.

Human cancer cells typically harbour multiple chromosomal aberrations, nucleotide substitutions and epigenetic modifications that drive malignant transformation. The Cancer Genome Atlas (TCGA) pilot project aims to assess the value of large-scale multi-dimensional analysis of these molecular characteristics in human cancer and to provide the data rapidly to the research community. Here we report the interim integrative analysis of DNA copy number, gene expression and DNA methylation aberrations in 206 glioblastomas--the most common type of adult brain cancer--and nucleotide sequence aberrations in 91 of the 206 glioblastomas. This analysis provides new insights into the roles of ERBB2, NF1 and TP53, uncovers frequent mutations of the phosphatidylinositol-3-OH kinase regulatory subunit gene PIK3R1, and provides a network view of the pathways altered in the development of glioblastoma. Furthermore, integration of mutation, DNA methylation and clinical treatment data reveals a link between MGMT promoter methylation and a hypermutator phenotype consequent to mismatch repair deficiency in treated glioblastomas, an observation with potential clinical implications. Together, these findings establish the feasibility and power of TCGA, demonstrating that it can rapidly expand knowledge of the molecular basis of cancer.

Sex and Relationship Education (SRE) in England has been the focus of critical scrutiny on several occasions, but there has been little attention paid to how teachers formulate their provision, especially given their crucial role in determining what is taught in the classroom. While current policy suggests that provision should be inclusive of sexual diversity, it simultaneously gives educators the scope to determine the form this takes. This is an important issue given the substantial impact that teachers' views and discourses have on what is taught. Using a discourse analytical framework, this study sought to examine how teachers of SRE formulate and account for their provision, with a particular focus on how their assumptions about young people's sexual health needs underpin their actions. Initially, teachers sought to formulate their activities in terms of an overall ethos, providing legitimacy for the key elements of their programme being aligned with official government health promotion strategy, as opposed to other areas such as pleasure and diversity. This was supported by their constructions of young people, particularly young women and individuals from "at risk" communities, as being particularly vulnerable.

Background There is a lack of national guidance specifying how skin surgery, including Mohs micrographic surgery (MMS), should be conducted, leading to a degree of heterogeneity in the set-up of skin surgery services and how skin surgeries are performed. Objectives To provide the first UK-wide cross-sectional study reporting real-world data on the set-up and waste management practices of skin surgery, including MMS. Methods A UK-wide service evaluation study was conducted between 1 March 2022 and 30 June 2022 using a standardized data collection pro forma. Twelve participating sites from England, Northern Ireland, Scotland and Wales provided data from 115 skin surgery lists involving 495 patients and 547 skin surgery procedures between 1 March 2022 and 30 June 2022. Results Mean total weight of nonsharps skin surgery waste was 0.52 kg per procedure (0.39 kg clinical waste, 0.05 kg general waste and 0.08 kg recycling waste). Data from a single site using disposable surgical instruments reported a mean of only 0.25 kg of sharps waste per procedure. The recycling rate ranged between 0% and 44% across the cohort with a mean recycling rate of 16%. Conclusions We advocate that staff transition to the British Society of Dermatological Surgery 2022 sustainability guidance, which made wide-ranging recommendations to facilitate staff to transition to sustainable practices in skin surgery. [ABSTRACT FROM AUTHOR]

Background: Absorbable or non-absorbable sutures can be used for superficial skin closure following excisional skin surgery. There is no consensus among clinicians nor high-quality evidence supporting the choice of suture. The aim of the present study was to determine current suture use and complications at 30 days after excisional skin surgery. Methods: An international, prospective service evaluation of adults undergoing excision of skin lesions (benign and malignant) in primary and secondary care was conducted from 1 September 2020 to 15 April 2021. Routine patient data collected by UK and Australasian collaborator networks were uploaded to REDCap©. Choice of suture and risk of complications were modelled using multivariable logistic regression. Results: Some 3494 patients (4066 excisions) were included; 3246 (92.9 per cent) were from the UK and Ireland. Most patients were men (1945, 55.7 per cent), Caucasian (2849, 81.5 per cent) and aged 75-84 years (965, 27.6 per cent). The most common clinical diagnosis was basal cell carcinoma (1712, 42.1 per cent). Dermatologists performed most procedures, with 1803 excisions (44.3 per cent) on 1657 patients (47.4 per cent). Most defects were closed primarily (2856, 81.9 per cent), and there was equipoise in regard to use of absorbable (2127, 57.7 per cent) or non-absorbable (1558, 42.2 per cent) sutures for superficial closure. The most common complications were surgical-site infection (103, 2.9 per cent) and delayed wound healing (77, 2.2 per cent). In multivariable analysis, use of absorbable suture type was associated with increased patient age, geographical location (UK and Ireland), and surgeon specialty (oral and maxillofacial surgery and plastic surgery), but not with complications. Conclusion: There was equipoise in suture use, and no association between suture type and complications. Definitive evidence from randomized trials is needed. [ABSTRACT FROM AUTHOR]

Dear Editor, Scalp defects not amenable to direct closure following dermatological surgery can be left open for secondary intention healing (SIH) or can be repaired with a flap or a graft. We aimed to inform design and determine the feasibility of conducting a randomized controlled trial (RCT) comparing full-thickness skin graft (FTSG) with SIH for small-moderate sized scalp wounds not amenable to primary closure (SCALP study). [Extracted from the article]

The article discusses the application of illness scripts theory to climate change through a multi-residency educational symposium. The World Health Organization has declared climate change as the single biggest health threat facing humanity. Efforts to combat climate change require collaboration in all sectors, including medical education. The article describes the use of illness scripts to develop and teach clinical reasoning skills related to climate change. A multi-residency symposium was conducted, which showed statistically significant changes in resident knowledge and skills regarding climate health. The article concludes that leveraging local resources and adapting illness scripts to clinical case scenarios is a promising strategy for improving education and care delivery for medical conditions affected by climate change. [Extracted from the article]