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Background The share of people over 80 years in the European Union is estimated to increase two-and-a-half-fold from 2000 to 2100. A substantial share of older persons experiences fear of falling. This fear is partly associated with a fall in the recent past. Because of the associations between fear of falling, avoiding physical activity, and the potential impact of those on health, an association between fear of falling and low health-related quality of life, is suggested. This study examined the association of fear of falling with physical and mental Health-Related Quality of Life (HRQoL) among community-dwelling older persons in five European countries. Methods A cross-sectional study was conducted using baseline data of community-dwelling persons of 70 years and older participating in the Urban Health Centers Europe project in five European countries: United Kingdom, Greece, Croatia, the Netherlands and Spain. This study assessed fear of falling with the Short Falls Efficacy Scale-International and HRQoL with the 12-Item Short-Form Health Survey. The association between low, moderate or high fear of falling and HRQoL was examined using adjusted multivariable linear regression models. Results Data of 2189 persons were analyzed (mean age 79.6 years; 60.6% females). Among the participants, 1096 (50.1%) experienced low fear of falling; 648 (29.6%) moderate fear of falling and 445 (20.3%) high fear of falling. Compared to those who reported low fear of falling in multivariate analysis, participants who reported moderate or high fear of falling experienced lower physical HRQoL (β = -6.10, P P P P Conclusions This study observed a negative association between fear of falling and physical and mental HRQoL in a population of older European persons. These findings emphasize the relevance for health professionals to assess and address fear of falling. In addition, attention should be given to programs that promote physical activity, reduce fear of falling, and maintain or increase physical strength among older adults; this may contribute to physical and mental HRQoL.

Background/Aims Interleukin 6 inhibitors (IL-6i) can increase LDL cholesterol levels, which raises concerns about the risk of myocardial infarction (MI) in patients with rheumatoid arthritis (RA) receiving this therapy. This study aims to compare the risk of MI between people with RA in the UK clinical setting receiving IL-6i or tumour necrosis factor inhibitors (TNFi) overall or by line of therapy (LoT). Methods Patients with RA registered between 01/10/2001 and 27/05/2022 with BSRBR-RA starting IL-6i or TNFi treatments were included. Occurrence of MI was identified from clinical follow-up forms and through cause of death reported by the national UK death register. Only those MIs occurring whilst the patient was actively receiving drug were included. The risk of MI in patients receiving IL6i compared to TNFi was compared using Cox regression, adjusted for baseline co-variates using propensity scores (PS, see Table 1). Follow-up commenced at the start of the drug of interest and patients were censored at occurrence of MI, death, discontinuation of therapy or last follow-up visit, whichever came first. Multiple imputation was used for missing data. To account for known differences in LoT use of TNFi and IL6i (with IL6i more likely as a later line bDMARD), overall analyses adjusted for LoT in PS and secondary analyses by LoT were conducted. Direct switches between originator to biosimilars were considered the same treatment. Results A total of 29,596 IL6i or TNFi treatments in 20,725 patients were included (3,098 IL-6i; 26,498 TNFi), representing 153,913 person-years of exposure. Compared to patients receiving TNFi, patients starting IL-6i treatment were older, had longer disease duration, less likely to use methotrexate and steroids, and had more comorbidities. During follow-up, 372 MIs occurred, 27 on IL-6i and 345 on TNFi, with an overall lower crude rate of MI in patients receiving IL6i compared to TNFi. After PS adjustment, the risk of MI was not significantly different between the two treatment overall (HR 0.77, 95% CI 0.48-1.24) or when stratified by LoT (Table 1). Conclusion This study could not identify any difference in risk of MI between IL-6i and TNFi treatment after patient characteristics and LoT were considered. Disclosure Z. Tian: None. L. Kearsley-Fleet: None. K. Lauper: Honoraria; Celltrion, Pfizer, Viatris, Galapagos. S. Haughton: None. K. Watson: None. M. Lunt: None. J. Mclaughlin: None. A. Verma: None. K.L. Hyrich: Honoraria; Abbvie. Grants/research support; Pfizer, BMS.

OBJECTIVES: Schizophrenia is a severe mental illness with heterogeneous etiology, range of symptoms, and course of illness. Cost-effectiveness analysis often applies averages from populations, which disregards patient heterogeneity even though there are a range of methods available to acknowledge patient heterogeneity. This review evaluates existing economic evaluations of interventions in schizophrenia to understand how patient heterogeneity is currently reflected in economic evaluation.METHODS: Electronic searches of MEDLINE, Embase, and PsycINFO via Ovid and the Health Technology Assessment database were run to identify full economic evaluations of interventions aiming to reduce the symptoms associated with schizophrenia. Two levels of screening were used, and explicit inclusion criteria were applied. Prespecified data extraction and critical appraisal were performed.RESULTS: Seventy-six relevant studies were identified. More than half (41 of 76) of the articles acknowledged patient heterogeneity in some way through discussion or methods. There was a range of patient characteristics considered, including demographics and socioeconomic factors (eg, age, educational level, ethnicity), clinical characteristics (eg, symptom severity, comorbidities), and preferences (eg, preferences related to outcomes or symptoms). Subgroup analyses were rarely reported (8 of 76).CONCLUSIONS: Patient heterogeneity was frequently mentioned in studies but was rarely thoroughly investigated in the identified economic evaluations. When investigated, included patient characteristics and methods were found to be heterogeneous. Understanding and acknowledging patient heterogeneity may alter the conclusions of cost-effectiveness evaluations; subsequently, we would encourage further research in this area.

The evidence of an association between diabetes and latent tuberculosis infection (LTBI) remains limited and inconsistent. Thus, the study aims to delineate the role of diabetes in activation of latent tuberculosis infection. Murine model of latent tuberculosis and diabetes was developed, bacillary load and gene expression of resuscitation promoting factors (rpfA-E) along with histopathological changes in the lungs and spleen were studied. Treatment for LTBI [Rifampicin (RIF) + Isoniazid (INH)] was also given to latently infected mice with or without diabetes for 4 weeks. Diabetes was found to activate latent tuberculosis as the colony forming unit (CFU) counts were observed to be > 104in lungs and spleen. The gene expression ofhspXwas downregulated and that ofrpfBandrpfDwas observed to be upregulated in latently infected mice with diabetes compared to those without diabetes. However, no significant reduction in the CFU counts was observed after 4 weeks of treatment with RIF and INH. Diabetes helps in the progression of LTBI to active disease mainly through altered expression of resuscitation promoting factorsrpfBandrpfD, which can serve as important targets to reduce the shared burden of tuberculosis and diabetes.

The use of population averages in cost-effectiveness analysis may hide important differences across subgroups, potentially resulting in suboptimal resource allocation, reduced population health and/or increased health inequalities. We discuss the factors that limit subgroup analysis in cost-effectiveness analysis and propose more thorough and transparent reporting. There are many issues that may limit whether subgroup analysis can be robustly included in cost-effectiveness analysis, including challenges with prespecifying and justifying subgroup analysis, identifying subgroups that can be implemented (identified and targeted) in practice, resource and data requirements, and statistical and ethical concerns. These affect every stage of the design, development and reporting of cost-effectiveness analyses. It may not always be possible to include and report relevant subgroups in cost effectiveness, e.g. due to data limitations. Reasons for not conducting subgroup analysis may be heterogeneous, and the consequences of not acknowledging patient heterogeneity can be substantial. We recommend that when potentially relevant subgroups have not been included in a cost-effectiveness analysis, authors report this and discuss their rationale and the limitations of this. Greater transparency of subgroup reporting should provide a starting point to overcoming these challenges in future research.

BACKGROUND Mass gatherings (MGs; eg, religious, sporting, musical, sociocultural, and other occasions that draw large crowds) pose public health challenges and concerns related to global health. A leading global concern regarding MGs is the possible importation and exportation of infectious diseases as they spread from the attendees to the general population, resulting in epidemic outbreaks. Governments and health authorities use technological interventions to support public health surveillance and prevent and control infectious diseases. OBJECTIVE This study aims to review the evidence on the effectiveness of public health digital surveillance systems for infectious disease prevention and control at MG events. METHODS A systematic literature search was conducted in January 2022 using the Ovid MEDLINE, Embase, CINAHL, and Scopus databases to examine relevant articles published in English up to January 2022. Interventional studies describing or evaluating the effectiveness of public health digital surveillance systems for infectious disease prevention and control at MGs were included in the analysis. Owing to the lack of appraisal tools for interventional studies describing and evaluating public health digital surveillance systems at MGs, a critical appraisal tool was developed and used to assess the quality of the included studies. RESULTS In total, 8 articles were included in the review, and 3 types of MGs were identified: religious (the Hajj and Prayagraj Kumbh), sporting (the Olympic and Paralympic Games, the Federation International Football Association World Cup, and the Micronesian Games), and cultural (the Festival of Pacific Arts) events. In total, 88% (7/8) of the studies described surveillance systems implemented at MG events, and 12% (1/8) of the studies described and evaluated an enhanced surveillance system that was implemented for an event. In total, 4 studies reported the implementation of a surveillance system: 2 (50%) described the enhancement of the system that was implemented for an event, 1 (25%) reported a pilot implementation of a surveillance system, and 1 (25%) reported an evaluation of an enhanced system. The types of systems investigated were 2 syndromic, 1 participatory, 1 syndromic and event-based, 1 indicator- and event-based, and 1 event-based surveillance system. In total, 62% (5/8) of the studies reported timeliness as an outcome generated after implementing or enhancing the system without measuring its effectiveness. Only 12% (1/8) of the studies followed the Centers for Disease Control and Prevention guidelines for evaluating public health surveillance systems and the outcomes of enhanced systems based on the systems’ attributes to measure their effectiveness. CONCLUSIONS On the basis of the review of the literature and the analysis of the included studies, there is limited evidence of the effectiveness of public health digital surveillance systems for infectious disease prevention and control at MGs because of the absence of evaluation studies.

Background: Patient and public involvement and engagement (PPIE) can improve the relevance, quality, ethics and impact of research thus contributing to high quality research. Currently in the UK, people who get involved in research tend to be aged 61 years or above, White and female. Calls for greater diversity and inclusion in PPIE have become more urgent especially since the COVID-19 pandemic, so that research can better address health inequalities and be relevant for all sectors of society. Yet, there are currently no routine systems or requirements to collect or analyse the demographics of people who get involved in health research in the UK. Methods: We developed a questionnaire to assess the demographics of people taking part in PPIE activities run by Vocal. Vocal is a non-profit organisation which supports PPIE in health research across the region of Greater Manchester in England. We implemented the questionnaire across Vocal activities between December 2018 and March 2022. We analysed our findings and compared them against local population demographic data, and available national data related to public contributors to health research. Results: Our results show that it is feasible to assess the demographics of people who take part in PPIE activities, through a questionnaire system. Further, our emerging data indicate that we are involving a greater diversity of people in health research, as compared to available national data. Specifically, we involve more people of Asian, African and Caribbean heritage, and include a wider range of ages in our PPIE activities. Conclusion: Our ‘learn by doing’ approach to assessing who does and doesn’t take part in Vocal’s PPIE activities has informed our practice and continues influence our strategic priorities for PPIE. Our system and learning reported here may be applicable and transferable to other similar settings in which PPIE is carried out. We attribute the greater diversity of our public contributors to our strategic priority and activities to promote more inclusive research since 2018.

Aim Many people delay presenting to health services with cancer symptoms due to lack of awareness, particularly in areas of high socio-economic deprivation. A three-year community-based intervention was launched in Northwest England to improve public awareness of cancer symptoms. In this study, we aimed to evaluate this intervention by exploring the views of those involved in its management and delivery. Methods Ten semi-structured interviews were conducted with volunteers as well as members of the project management and steering group. Interviews were analysed qualitatively using thematic analysis. Results Participants felt they succeeded in raising awareness, influencing behaviour, connecting with local communities and engaging with vulnerable people. Participants perceived some weaknesses in the delivery of the intervention, including limited engagement of stakeholders, particularly general practitioners (GPs), and socially excluded groups. Conclusions Future public health interventions should pay particular attention to engagement of socially excluded individuals who do not interact with community events or groups, and to the engagement of stakeholders in early planning stages of the intervention. This should involve a specific GP engagement plan.

Background: Polypharmacy and inappropriate medication use among older people is associated with adverse health consequences due to drug-drug interactions, drug-disease interactions, and adverse drug effects. The aim of this study is to assess the factors that are associated with polypharmacy and inappropriate medication use among community-dwelling older people in Europe.Method: This longitudinal study used baseline and follow-up data from 1791 participants of the Urban Health Center European project in five European countries. We studied factors in the domains (a) demographic characteristics, (b) lifestyle and nutrition, and (c) health and health care use, Hierarchical logistic regression models were used to examine the factors associated with polypharmacy and inappropriate medication.Results: Mean age was 79.6 years (SD±5.6 years); 60.8% were women; 45.2% had polypharmacy, and 41.8% had a high risk of inappropriate medication use. Participants who were women had higher odds of both having polypharmacy (OR=0.55;95%CI:0.42-0.72) and inappropriate medication use (OR=0.50;95%CI:0.39-0.65). Participants with a migration background (OR=1.67;95%CI:1.08-2.59), overweight (OR=1.37; 95%CI:1.04-1.79) and obesity (OR=1.78;95%CI:1.26-2.51) compared to ‘normal weight’, with lower physical HRQoL (OR=0.96, 95%CI:0.95-0.98), multi-morbidity (OR=3.73, 95%CI:2.18-6.37), frailty (OR=1.69, 95%CI:1.24-2.30), visited outpatient services (OR=1.77, 95%CI: 1.09-2.88) had higher odds of having polypharmacy. The associations with inappropriate medication use were similar.Conclusions: Multiple factors in the domains of demography, lifestyle, nutrition, and health care use are associated with polypharmacy and inappropriate medication use. These provide starting points to improve interventions to reduce polypharmacy and inappropriate medication use. In the meantime, health professionals can apply these insights to identify subgroups of patients are at a high risk of polypharmacy and inappropriate medication use. Trial registration: The intervention of the UHCE project was registered in the ISRCTN registry as ISRCTN52788952. The date of registration is 13/03/2017.

Narcolepsy is hypothesized to be an autoimmune disease targeting the hypocretin/orexin producing neurons within the hypothalamus and is categorised into subsets based on the symptoms presented. Epidemiological studies have proposed that there is an additional requirement for an environmental trigger combined with potential genetic predisposition to trigger the onset of this spectrum of disorders. Despite epidemiological evidence which suggests the condition arises due to a breach of immunological tolerance, the absence of a defined autoantigen remains an element of debate in the aetiology of the disorder. Currently there are no definitive diagnostically useful genetic variants observed in narcolepsy suffers which could be exploited at disease onset to support its diagnosis or clinical managementThe most impactful genetic risk factor is the presence of Human Leukocyte Antigen (HLA) allele, DQB1*06:02, which increases the risk of Narcolepsy over 20-fold. The discovery of the strong association of HLA-DQB1*06:02 and disease onset was the original trigger to shift the focus from its classification as a neurological disease to that of an immune-mediated condition. However, the presence of HLA-DQB1*06:02 alone cannot be the sole genetic risk factor to explain disease onset. Primarily, not all narcolepsy patients express DQB1*06:02 (>95%) and more importantly not all people who express DQB1*06:02 suffer from narcolepsy – only 16% of the global population who express DQB1*06:02 suffer from Narcolepsy. This has resulted in low usage of this definition test in the clinical setting due to its lack of specificity and because it is of most clinical utility if the result is negative, reducing the likelihood of a diagnosis of narcolepsy.The diagnosis of narcolepsy is often suspected from the clinical history of the patient, supported by the results of a multiple sleep latency test (MSLT). Combined with the determination of hypocretin/orexin in the cerebral spinal fluid, these two tests are still considered the gold standard tests for diagnosis. However, there are also documented issues surrounding both tests in terms of level of sensitivity, specificity and potential complications which limit their reliability as a diagnostic resource. This review focuses on emerging evidence of genetic and environmental risk factors linked with narcolepsy onset, their link to its pathophysiology and we speculate how genetic traits could be better utilised to effectively aid a diagnosis.

ObjectiveWe aimed to use mathematical models of SARS-COV-2 to assess the potential efficacy of non-pharmaceutical interventions on transmission in the parcel delivery and logistics sector.MethodsWe developed a network-based model of workplace contacts based on data and consultations from companies in the parcel delivery and logistics sectors. We used these in stochastic simulations of disease transmission to predict the probability of workplace outbreaks in this settings. Individuals in the model have different viral load trajectories based on SARS-CoV-2 in-host dynamics, which couple to their infectiousness and test positive probability over time, in order to determine the impact of testing and isolation measures.ResultsThe baseline model (without any interventions) showed different workplace infection rates for staff in different job roles. Based on our assumptions of contact patterns in the parcel delivery work setting we found that when a delivery driver was the index case, on average they infect only 0.14 other employees, while for warehouse and office workers this went up to 0.65 and 2.24 respectively. In the LIDD setting this was predicted to be 1.40, 0.98, and 1.34 respectively. Nonetheless, the vast majority of simulations resulted in 0 secondary cases among customers (even without contact-free delivery). Our results showed that a combination of social distancing, office staff working from home, and fixed driver pairings (all interventions carried out by the companies we consulted) reduce the risk of workplace outbreaks by 3-4 times.ConclusionThis work suggests that, without interventions, significant transmission could have occured in these workplaces, but that these posed minimal risk to customers. We found that identifying and isolating regular close-contacts of infectious individuals (i.e. house-share, carpools, or delivery pairs) is an efficient measure for stopping workplace outbreaks. Regular testing can make these isolation measures even more effective but also increases the number of staff isolating at one time. It is therefore more efficient to use these isolation measures in addition to social distancing and contact reduction interventions, rather than instead of, as these reduce both transmission and the number of people needing to isolate at one time.Author summaryDuring the COVID-19 pandemic the home-delivery sector was vital to maintaining people’s access to certain goods, and sustaining levels of economic activity for a variety of businesses. However, this important work necessarily involved contact with a large number of customers as well as colleagues. This means that questions have often been raised about whether enough was being done to keep customers and staff safe. Estimating the potential risk to customers and staff is complex, but here we tackle this problem by building a model of workplace and customer contacts, from which we simulate SARS-CoV-2 transmission. By involving industry representatives in the development of this model, we have simulated interventions that have either been applied or considered, and so the findings of this study are relevant to decisions made in that sector. Furthermore, we can learn generic lessons from this specific case study which apply to many types of shared workplace as well as highlighting implications of the highly stochastic nature of disease transmission in small populations.

To present a case of successful pregnancy outcome in a granulomatosis with polyangiitis (GPA) patient with renal insufficiency. GPA, formerly known as Wegener's granulomatosis, is a rare necrotizing systemic vasculitis, presenting with classical clinical triad of manifestations involving upper and lower airway and glomerulonephritis. An association of Antineutrophil cytoplasmic antibodies with GPA has been established and the antibodies are present in most patients with active disease. Pregnancy with GPA is burdened with the risk of possible maternal and fetal complications, further leading to higher morbidity and mortality rate. Due to sparsity of studies of GPA in pregnancy, management needs to be individualised. Diagnostic workup should include serological markers, radiological and histopathological examination. Cyclophosphamide combined with prednisolone is the standard induction regimen. A 22-year-old woman, multigravida at 35 weeks of gestation was referred to our department owing to 1-year diagnosis of GPA. During active phase, the disease manifested as pneumonia and acute kidney injury and perinuclear anti-neutrophil cytoplasmic antibodies (P-ANCAs) were positive. She received pulse therapy of injection cyclophosphamide and methylprednisolone as induction regimen, followed by tapering doses of oral prednisolone and azathioprine for maintenance therapy. The disease was in remission at the onset of pregnancy but had flare up at 34 - 35 weeks of gestation and she presented with renal dysfunction. Neither the disease nor the treatment adversely affected the pregnancy and she delivered a healthy baby at 37 weeks. The unpredictable disease course and complications at unexpected gestation appears to be a major variable to take into account when assessing the risk of pregnancy with GPA. Early diagnosis, monitoring and timely intervention resulted in favourable pregnancy outcome in our patient.

For over a decade, pandemics have been on the UK National Risk Register as both the likeliest and most severe of threats. Non-infectious ‘lifestyle’ diseases were already crippling our healthcare services and our economy. COVID-19 has exposed two critical vulnerabilities: firstly, the UK’s failure to adequately assess and communicate the severity of non-communicable disease; secondly, the health inequalities across our society, due not least to the poor quality of our urban environments. This suggests a potentially disastrous lack of preventative action and risk management more generally, notably with regards to the existential risks from the climate and ecological crises.

Objectives: To examine the longitudinal association between frequency of moderate physical activity (PA) and overall, physical, psychological, and social frailty among community-dwelling older adults older than 70 years. Second, we assessed the association between a 12-month change in frequency of moderate PA and frailty. Design: Longitudinal cohort study. Setting: Community settings in Spain, Greece, Croatia, the Netherlands, and the United Kingdom. Participants: A total of 1735 participants (61.1% female ; mean age = 79.6 years ; SD = 5.5 years). Measurements: The frequency of self-reported moderate PA was measured and classified into two categories: "regular frequency" and "low frequency." The 12-month change in frequency of moderate PA between baseline and follow-up was classified into four categories: "continued regular frequency, " "decreased frequency, " "continued low frequency, " and "increased frequency." The 15-item Tilburg Frailty Indicator assessed overall, physical, psychological, and social frailty. Results: Participants who undertook moderate PA with a regular frequency at baseline were less frail at 12-month follow-up than participants with a low frequency. Participants who undertook moderate PA with a continued regular frequency were least frail at baseline and at 12-month follow-up. After controlling for baseline frailty and covariates, compared with participants with a continued regular frequency, participants with a decreased frequency were significantly more overall (B = 1.31 ; 95% confidence interval [CI] = 0.99- 1.63), physically (B = 0.80 ; 95% CI = 0.58- 1.03), psychologically (B = 0.43 ; 95% CI = 0.30-0.56), and socially frail (B = 0.14 ; 95% CI = 0.04-0.23) at 12-month follow-up ; participants with a continued low frequency were significantly more overall (B = 1.16 ; 95% CI = 0.84-1.49), physically (B = 0.73 ; 95% CI = 0.51-0.96), psychologically (B = 0.42 ; 95% CI = 0.29-0.55), and socially frail (B = 0.13 ; 95% CI = 0.04-0.23) at 12-month follow-up ; the 12- month follow-up frailty level of participants who undertook moderate PA with an increased frequency was similar to those with a continued regular frequency. Conclusion: Maintaining a regular frequency of PA as well as increasing to a regular frequency of PA are associated with maintaining or improving overall, physical, psychological, and social frailty among European community- dwelling older adults older than 70 years. J Am Geriatr Soc 68:1484-1493, 2020.

Promoting health and preventing ill health are key standards of proficiency for pre-registration nursing education in the UK. The knowledge and skills required to fulfil this role is dependent on students developing a clear understanding of population health during their educational experience. The websites of the 60 undergraduate adult nursing programmes in England that lead to registration were explored, to see how the population health agenda is presented in the information for future candidates. It was found that only 26% of universities promote a population health agenda in the general description of the adult nursing programme, emphasising clinical skills teaching and partnerships with hospital trusts for placement provision. To embrace the breadth of 21st century nursing practice, universities should be marketing nursing proficiencies and raising awareness of the wider context in which care is delivered during recruitment. This approach to branding has the potential to challenge stereotypes and widen participation.

Introduction: Kidney dysfunction is a highly significant disease, both in the United Kingdom and globally. Many previous studies have reported associations between human leukocyte antigens (HLA) and renal function; this systematic review attempts to identify, summarize and appraise all published studies of these associations. Methods: A literature search was performed using Medline, Embase and Cochrane Central Register of Controlled Trials to identify papers whose keywords included each of the following concepts: HLA, renal failure and genetic association. A total of 245 papers were identified and assessed for eligibility; 35 of these were included in the final study. Results: A total of 95 HLA types and 14 three-locus haplotypes were reported to be associated with either increased or decreased renal function. A number of these findings were replicated by independent studies that reported 16 types were protective against renal dysfunction and 15 types were associated with reduced renal function. A total of 20 HLA types were associated with both increased risk of renal disease and decreased risk by independent studies. Discussion: There is very little consensus on which HLA types have a protective or deleterious effect on renal function. Ethnicity may play a role, with HLA types possibly having different effects among different populations, and it is possible that the different primary diseases that lead to ESRD may have different HLA associations. Some of the studies may contain type I and type II errors caused by insufficient sample sizes, cohort selection and statistical methods. Although we have compiled a comprehensive list of published associations between renal function and HLA, in many cases, it is unclear which associations are reliable. Further studies are required to confirm or refute these findings.

Background To effectively realise their role in health promotion nurses need a clear understanding of the social determinants of health. In 1987 the WHO recommended that students participate in meaningful community based problem-solving to prepare them for health promotion practice, including actual or simulated community health projects. Objective To explore the use of community problem-solving in undergraduate nurse education and its impact on students' understanding of population health. Method This literature review used a five-stage iterative method, to explore the following research question; how is community problem-solving being used in undergraduate nurse education and to what effect? Following a systematic database search (CINAHL, MEDLINE, ERIC and ProQuest BNI), forward citation and snowballing, 82 studies were screened against the inclusion and exclusion criteria. A critical appraisal of the studies was conducted using COREQ and data was extracted using a summary table. Thematic analysis was used to identify major themes from the literature. Results Ten studies were identified which explore the use of community problem-solving these provide some useful insight into the design, application and the apparent benefits of the approach in undergraduate nurse education. Three key themes emerge: students develop a broader vison of their future role in health promotion, a deeper understanding of community and social determinants, as well as identifying the role of community assets for health. Only one of the studies included in the review evaluated the impact of community problem-solving on health promotion practice after graduation. Conclusion The concept of CPS in undergraduate nurse education has been around for many years, but there has never been a comprehensive review of its implementation or effectiveness. Research into its impact is needed to examine whether it increases students' understanding of their future role in health promotion. If nurses are expected to play a key role in public health, nurse educators need research evidence to support the design and delivery of CPS to implement a population health approach to undergraduate nurse education.

Preventing SARS-CoV-2 transmission and protecting people from COVID-19 is the most significant public health challenge faced in recent years. COVID-19 outbreaks are occurring in workplaces and evidence is needed to support effective strategies to prevent and control these outbreaks. Investigations into these outbreaks are routinely undertaken by public health bodies and regulators in the United Kingdom (UK); however, such investigations are typically disparate in nature with a lack of consistency across all investigations, preventing meaningful analysis of the data collected. The COVID-OUT (COVID-19 Outbreak investigation to Understand Transmission) study aims to collect a consistent set of data in a systematic way from workplaces that are experiencing outbreaks, to understand SARS-CoV-2 transmission risk factors, transmission routes, and the role they play in the COVID-19 outbreaks. Suitable outbreak sites are identified from public health bodies. Following employer consent to participate, the study will recruit workers from workplaces where there are active outbreaks. The study will utilise data already collected as part of routine public health outbreak investigations and collect additional data through a comprehensive questionnaire, viral and serologic testing of workers, surface sampling, viral genome sequencing, and an environmental assessment of building plans, ventilation and current control measures. At each site, a detailed investigation will be carried out to evaluate transmission routes. A case-control approach will be used to compare workers who have and have not had SARS-CoV-2 infections during the outbreak period to assess transmission risk factors. Data from different outbreaks will be combined for pooled analyses to identify common risk factors, as well as factors that differ between outbreaks. The COVID-OUT study can contribute to a better understanding of why COVID-19 outbreaks associated with workplaces occur and how to prevent these outbreaks from happening in the future.

ObjectiveThis study explores the impact of the COVID 19 lockdown measures on the mental health and well-being of unpaid carers, who make up the largest number of the carer population in England.Study designA systematic review research protocol was designed and used to conduct the review along with the Enhancing Transparency in Reporting the synthesis of Qualitative Research - ENTREQ statement [43]. Pre-determined inclusion and exclusion criteria were used. EndNote X9 reference management was used and the search process was represented using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) flow diagram [76]. Appraisal of the included research was carried out using the Critical Appraisal Skills Programme (CASP) [57]. Line by line coding was done using inductive thematic synthesis and EPPI Reviewer 4 software [60].ResultsFour themes emerged; immediate worries or fears, adapting to change, post pandemic fears and use of technology.ConclusionThe measures put in place during the first lockdown period have had detrimental impacts on unpaid carers, putting them at greater risk of burnout. However, use of digital platforms could have a positive impact on well-being. Recommendations for further research are provided.What is new?Key findings?Discontinued or reduced access to activities and services during the first lockdown during the pandemic has had a negative impact on both people who require care and their carers.Carers prioritise the mental health and wellbeing needs of the people they care for over their own.Further qualitative research from different groups of carers would be useful to gain a deeper understanding of the impact of the COVID 19 pandemic measures on unpaid carers.Use of digital technology and digital platforms may be useful tools for carers both during the pandemic and after.What this adds to what is known?There have been very few qualitative studies on the impact of the COVID 19 pandemic on the mental health and wellbeing of unpaid carers, this review has synthesised their findings and will contribute to future research.Unpaid carers are known to be at risk of poor mental health and wellbeing outcomes, this review demonstrates that they are even more at risk due to the increased reliance on them during the pandemic.What is this implication and what should change?There is limited qualitative data available from a range of different groups of carers for example, spouse carers, parent carers, carers of people who have specific needs or conditions. Therefore, purposeful sample research to determine the needs of groups of carers during the COVID 19 pandemic could be valuable.Unpaid carers who do not have appropriate support are more at risk of poor mental health and wellbeing outcomes. During the pandemic services have had to adapt to the various rules implemented. Digital adaptations to the provision of support to both carers and the people they care for could be beneficial both during and after the pandemic.

Mycobacterium tuberculosis has the potential to escape various cellular defense mechanisms for its survival which include various oxidative stress responses, inhibition of phagosome-lysosomes fusion and alterations in cell death mechanisms of host macrophages that are crucial for its infectivity and dissemination. Diabetic patients are more susceptible to developing tuberculosis because of impairement of innate immunity and prevailing higher glucose levels. Our earlier observations have demonstrated alterations in the protein profile of M. tuberculosis exposed to concurrent high glucose and tuberculosis conditions suggesting a crosstalk between host and pathogen under high glucose conditions. Since high glucose environment plays crucial role in the interaction of mycobacterium with host macrophages which provide a niche for the survival of M. tuberculosis, it is important to understand various interactive mechanisms under such conditions. Initial phagocytosis and containment of M. tuberculosis by macrophages, mode of macrophage cell death, respiratory burst responses, Mycobacterium and lysosomal co-localization were studied in M. tuberculosis H37Rv infected cells in the presence of varied concentrations of glucose in order to mimic diabetes like conditions. It was observed that initial attachment, phagocytosis and later containment were less effective under high glucose conditions in comparison to normal glucose. Mycobacterium infected cells showed more necrosis than apoptosis as cell death mechanism during the course of infection under high glucose concentrations. Co-localization and respiratory burst assay also indicated evasion strategies adopted by M. tuberculosis under such conditions. This study by using THP1 macrophage model of tuberculosis and high glucose conditions showed immune evasion strategies adapted during co-pathogenesis of tuberculosis and diabetes., Highlights • Prevailing high glucose environment plays crucial role in the interaction of mycobacterium and host macrophages in the copathogenesis of tuberculosis and diabetes. • In-vitro copathogenensis cell line model depicted that initial attachment; phagocytosis and later containment of Mycobacterium tuberculosis by macrophages were less efficacious under high glucose conditions in comparison to normal glucose conditions. • Mycobacterium infected cells showed more necrosis than apoptosis as cell death mechanism during the course of infection under high glucose concentrations. • Kinetics of co-localization of mycobacterium in phagolysosomes and respiratory burst assay on infected macrophages also indicated evasion strategies adopted by M. tuberculosis under high glucose conditions.

Supplemental Digital Content is available in the text., Objective This systematic review/meta-analysis was conducted to investigate the relationship between rheumatoid arthritis and the incidence of diabetes mellitus. Methods A comprehensive search was conducted up to 10 March 2020 in Medline (via Ovid), Embase (via Ovid) and Web of Science core collection to identify cohort studies comparing the risk of diabetes mellitus incidence in people with rheumatoid arthritis with the general population. The I2 statistic was used to test heterogeneity. Pooled relative risks were calculated using random-effects models. Publication bias was assessed using Egger’s test and Begg’s test. Results The initial search provided 3669 articles. Of those, five journal articles/two conference abstracts comprising 1 629 854 participants were included in this study. The funnel plot showed potential publication bias, proven by Egger’s test (−3.15, P < 0.01), but not Begg’s test (−0.05, P = 1.00). Heterogeneity was observed in I2 test (I2 = 96%, P < 0.01). We found that rheumatoid arthritis was associated with a higher risk of diabetes mellitus incidence (pooled relative risk, 1.23; 95% confidence interval, 1.07–1.40). Exploration of potential sources of heterogeneity found significant heterogeneity in different countries/regions (P = 0.002), but heterogeneity was NS in different study designs (P = 0.30). Sensitivity analyses confirmed that the association between rheumatoid arthritis and diabetes mellitus incidence was robust. Conclusion Rheumatoid arthritis is associated with an increased risk of diabetes mellitus incidence. This finding supports the notion that inflammatory pathways are involved in the pathogenesis of diabetes. More intensive interventions targeting diabetes risk factors should be considered in people with rheumatoid arthritis.

Diabetes affects the presentation of tuberculosis including delayed clearance of the bacteria from host cells, however, the molecular changes which help survival of phagocytosed mycobacterium in the diabetic host are still not clear. The effect of in vitro high glucose concentrations on the proteome of the phagocytosed mycobacterium isolated from the human monocytic THP1 cell line derived macrophages has been investigated in the present study. Concurrent tuberculosis and hyperglycemia conditions were mimicked by growing M. tuberculosis infected THP1 cells under high glucose conditions. Phagocytosed bacilli were isolated 5 days post infection. Proteomics analysis of the isolated bacilli was done by two-dimensional gel electrophoresis followed by mass spectrometry. A total of 224 ± 18 protein spots were obtained out of which 10 were found to be differentially expressed under high glucose concentrations in comparison to normal glucose concentration. Further, identity of all the ten proteins namely Tgs3, Rv0547c, AcrA1, EsxU, Rv2219, Mpa, Rv2308, ORN, LucA, and Rv1414 was elucidated by peptide mass finger printing using Matrix-assisted laser desorption and ionization-mass spectrometry (MALDI/MS) assisted with MASCOT software. Though Tgs3, Rv0547c, AcrA1 and Mpa proteins have been demonstrated to play a major role in lipid metabolism under nitric oxide stress conditions, the functional role of rest of the differentially expressed proteins remains to be elucidated. Under hyperglycemic conditions in the host cells, differential expression of these proteins might help in the better survival of mycobacteria and can further act as suitable targets to design novel drugs for more effective therapy for comorbid tuberculosis and diabetes.

To evaluate specific process components of the Urban Health Centres Europe (UHCE) approach; a coordinated preventive care approach aimed at healthy ageing by decreasing falls, polypharmacy, loneliness and frailty among older persons in community settings of five cities in the United Kingdom, Greece, Croatia, the Netherlands and Spain.Mixed methods evaluation of specific process components of the UHCE approach: reach of the target population, dose of the intervention actually delivered and received by participants and satisfaction and experience of main stakeholders involved in the approach.The UHCE approach intervention consisted of a preventive assessment, shared decision-making on a care plan and enrolment in one or more of four coordinated care-pathways that targeted falls, polypharmacy, loneliness and frailty. Quantitative data from a questionnaire and quantitative/qualitative data from logbooks were collected among older persons involved in the approach. Qualitative data from focus groups were collected among older persons, informal caregivers and professionals involved in the approach. Quantitative data were analysed by means of descriptive statistics and multilevel logistic regression models. Qualitative data were analysed through thematic analysis.Having limited function was associated with non-enrolment in falls and loneliness care-pathways (both p .01). The mean rating of the approach was 8.3/10 (SD 1.9). Feeling supported by a care professional and meeting people were main benefits for older persons. Mistrust towards unfamiliar care providers, lack of confidence to engage in care activities and health constraints were main barriers towards engagement in care.Although the UHCE approach was received generally positively, health constraints and psychosocial barriers prevented older person's engagement in care.Coordinated preventive care approaches for older community-dwelling persons should address health constraints and psychosocial barriers that hinder older person's engagement in care.ISRCTN registry number is ISRCTN52788952. Date of registration is 13/03/2017.目的: 评估欧洲城市保健中心(UHCE)方法具体流程组成部分;采取致力于通过减少英国、希腊、克罗地亚、荷兰和西班牙五个城市的社区中老人跌倒、多重用药、孤独和脆弱的协调预防护理方法。 设计: 对欧洲城市保健中心(UHCE)方法具体流程部分的评估:目标人群范围、实际提供和受试者接收到的干预剂量以及参与方法的主要利益相关者的满意度和体验。 方法: 欧洲城市保健中心(UHCE)方法干预包括预防评估、共享护理计划决策以及以减少跌倒、多重用药、孤独和脆弱为目标的四种协调护理方式之一或其中多个。问卷调查中的定量数据以及日志中的定量或定性数据是从参与该方法的老年人中收集而来。焦点小组的定性数据是从参与该方法的老年人、非正式护理人员以及健康专家中收集而来。采用描述性统计和多层逻辑回归模型对定量数据进行分析。采用专题分析对定性数据进行分析。 结果: 功能受限与跌倒和孤独感护理方法并未注册相关(两者均p.01)。该方法的平均评分为8.3/10(标准差(SD)为1.9)。老年人主要受益在于得到专业人员的护理以及与人见面。不信任不熟悉的护理人员以及缺乏参与护理活动的信心和健康约束是参与护理的主要障碍。 结论: 虽然欧洲城市保健中心(UHCE)方法普遍被积极接受,健康约束和心理障碍阻碍了老年人参与护理。 影响: 针对社区老年人的协调预防护理方法应解决阻碍老年人参与护理的健康约束和心理障碍。 试验注册: ISRCTN注册号是ISRCTN52788952。注册日期为2017年3月13日。.

Background Studies on the association between frailty and health-related quality of life (HRQoL) are scarce and show contradictory results. This study aimed to evaluate the association between physical, psychological and social frailty and HRQoL among community-dwelling older people. Methods A cross-sectional study was performed with baseline data collected in 2015 from the Urban Health Centers Europe (UHCE) project in five European countries, the United Kingdom, Greece, Croatia, The Netherlands and Spain. A total of 2325 participants were included in the baseline measurements of the Urban Health Centers Europe project; 2167 participants (mean age = 79.7; SD=5.6) were included in the analyses after excluding participants with missing data. The Tilburg Frailty Indicator measured overall frailty as well as physical, psychological and social frailty. The 12-Item Short-Form Health Survey was used to measured physical and mental HRQoL. Results Regarding physical HRQoL, a large difference (d=1.29) between physically and not physically frail participants was observed. Regarding mental HRQoL, a large difference (d=1.20) between psychologically and not psychologically frail participants was observed. In the full model with all three domains of frailty and the covariates to explain physical HRQoL, physical (P Conclusion Physical frailty had the strongest association with physical HRQoL, and psychological frailty had the strongest association with mental HRQoL. The associations between social frailty and both physical and mental HRQoL remain significant when controlling for physical and psychological frailty.

BackgroundWorkplace transmission is a significant contributor to severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) outbreaks. Previous studies have found that infectious illness presenteeism could contribute to outbreaks in occupational settings and identified multiple occupational and organisational risk factors. Amid the COVID-19 pandemic, it is imperative to investigate presenteeism particularly in relation to respiratory infectious disease (RID). Hence, this rapid review aims to determine the prevalence of RID-related presenteeism, including COVID-19, and examines the reported reasons and associated risk factors.MethodsThe review followed a Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) search approach and focused on studies published in English and Chinese. Database searches included MEDLINE, EMBASE, Web of Science, China Knowledge Resource Integrated Database (CNKI) and preprint databases MedRxiv and BioRxiv.ResultsThe search yielded 54 studies, of which four investigated COVID-19-related presenteeism. Prevalence of work presenteeism ranged from 14.1% to 55% for confirmed RID, and 6.6% to 100% for those working with suspected or subclinical RID. The included studies demonstrated that RID-related presenteeism is associated with occupation, sick pay policy, age, gender, health behaviour and perception, vaccination, peer pressure and organisational factors such as presenteeism culture.ConclusionsThis review demonstrates that presenteeism or non-adherence to isolation guidance is a real concern and can contribute to workplace transmissions and outbreaks. Policies which would support workers financially and improve productivity, should include a range of effective non-pharmaceutical inventions such as workplace testing, promoting occupational health services, reviewing pay and bonus schemes and clear messaging to encourage workers to stay at home when ill. Future research should focus on the more vulnerable and precarious occupational groups, and their inter-relationships, to develop comprehensive intervention programs to reduce RID-related presenteeism.

Background Inter-urban area (UA) health inequalities can be as dramatic as those between high and low-income countries. Policies need to focus on the determinants of health specific to UAs to effect change. This study therefore aimed to determine the degree to which policymakers from different countries could make autonomous health and wellbeing policy decisions for their urban jurisdiction area. Methods We conducted a cross-sectional, qualitative interview study with policymakers recruited from eight European countries (N = 37). Results The reported autonomy among policymakers varied considerably between countries, from little or no autonomy and strict adherence to national directives (e.g. Slovak Republic) to a high degree of autonomy and ability to interpret national guidelines to local context (e.g. Norway). The main perceived barriers to implementation of local policies were political, and the importance of regular and effective communication with stakeholders, especially politicians, was emphasized. Having qualified health professionals in positions of influence within the UA was cited as a strong driver of the public health (PH) agenda at the UA level. Conclusion Local-level policy development and implementation depends strongly on the degree of autonomy and independence of policymakers, which in turn depends on the organization, structure and financial budget allocation of PH services. While high levels of centralization in small, relatively homogenous countries may enhance efficient use of resources, larger, more diverse countries may benefit from devolution to smaller geographical regions.