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Pseudomonas aeruginosa is a highly adaptive opportunistic pathogen that can have serious health consequences in patients with lung disorders. Taxonomic outliers of P. aeruginosa of environmental origin have recently emerged as infectious for humans. Here, we present the first genome-wide analysis of an isolate that caused fatal haemorrhagic pneumonia. In two clones, CLJ1 and CLJ3, sequentially recovered from a patient with chronic pulmonary disease, insertion of a mobile genetic element into the P. aeruginosa chromosome affected major virulence-associated phenotypes and led to increased resistance to the antibiotics used to combat the infection. Comparative genome, proteome and transcriptome analyses revealed that this ISL3-family insertion sequence disrupted the genes for flagellar components, type IV pili, O-specific antigens, translesion polymerase and enzymes producing hydrogen cyanide. Seven-fold more insertions were detected in the later isolate, CLJ3, than in CLJ1, some of which modified strain susceptibility to antibiotics by disrupting the genes for the outer-membrane porin OprD and the regulator of β-lactamase expression AmpD. In the Galleria mellonella larvae model, the two strains displayed different levels of virulence, with CLJ1 being highly pathogenic. This study revealed insertion sequences to be major players in enhancing the pathogenic potential of a P. aeruginosa taxonomic outlier by modulating both its virulence and its resistance to antimicrobials, and explains how this bacterium adapts from the environment to a human host.

Background: First contact physiotherapy practitioners (FCPPs) are embedded within general practice, providing expert assessment, diagnosis, and management plans for patients with musculoskeletal disorders (MSKDs), without the prior need for GP consultation. Aim: To determine the clinical effectiveness and costs of FCPP models compared with GP-led models of care. Design and setting: Multiple site case-study design of general practices in the UK. Method: General practice sites were recruited representing the following three models: 1) GP-led care; 2) FCPPs who could not prescribe or inject (FCPPs-standard [St]); and 3) FCPPs who could prescribe and/or inject (FCPPs-additional qualifications [AQ]). Patient participants from each site completed outcome data at baseline, 3 months, and 6 months. The primary outcome was the SF-36 Physical Component Summary (PCS) score. Healthcare usage was collected for 6 months. Results: In total, 426 adults were recruited from 46 practices across the UK. Non-inferiority analysis showed no significant difference in physical function (SF-36 PCS) across all three arms at 6 months (P = 0.667). At 3 months, a significant difference in numbers improving was seen between arms: 54.7% (n = 47) GP consultees, 72.4% (n = 71) FCPP-St, and 66.4% (n = 101) FCPP-AQ (P = 0.037). No safety issues were identified. Following initial consultation, a greater proportion of patients received medication (including opioids) in the GP-led arm (44.7%, n = 42), compared with FCPP-St (18.4%, n = 21) and FCPP-AQ (24.7%, n = 40) (P<0.001). NHS costs (initial consultation and over 6-month follow-up) were significantly higher in the GP-led model (median £105.5 per patient) versus FCPP-St (£41.0 per patient) and FCPP-AQ (£44.0 per patient) (P<0.001). Conclusion: FCPP-led models of care provide safe, clinically effective patient management, with cost-benefits and reduced opioid use in this cohort. [ABSTRACT FROM AUTHOR]

Background: Digital self‐management platforms have been proposed as a solution to better support people manage their musculoskeletal (MSK) condition. However, research studies often explicitly exclude people who can't access internet connected devices. An important consideration is that digital exclusion (for people without access to an internet connected device) from these new digital options will worsen already existing inequality and inequity in healthcare. Aim: To evaluate the acceptability and potential causes of digital exclusion of the South West London (SWL) MSK self‐management app. Objectives: (1) Explore why some patients are not using the app and any barriers they have. Explore why some clinicians are not prescribing the app. (2) Make recommendations, based on these findings, to improve digital inclusion. Methods/Design: An explanatory sequential mixed method service evaluation that consisted of initial questionnaires to identify suitable collaborators, followed by structured interviews of patients and clinicians. Results: Following a comprehensive data analysis, 10 sub‐themes were grouped into four main themes: (1) Beliefs: Importance of understanding the role of digital; face to face consultation is still valued and needed. (2) Barriers: Lack of digital literacy; lack of physical examination/contact with a clinician. (3) Enablers: Immediate access to advice and information; perceived better control over health; ease of use; no appointment needed. (4) Solutions: Support and training; greater awareness. Conclusions: As digital health technology develops, strategies must change, requiring deliberate work and investments to improve inclusion. Our findings highlight how digital technology design and delivery can be adapted to address the causes of digital exclusion. [ABSTRACT FROM AUTHOR]

We examined the wildlife knowledge of primary (aged 4-12) schoolchildren. In particular, we examined the effects of children's age and gender, as well as the taxonomy and origin (indigenous versus exotic) of wildlife, on the degree of knowledge about different species. We used illustrated "flashcards" of mammals, birds and arthropods, drawn randomly from a species pool. Each indigenous example was paired with an exotic animal. Wildlife knowledge overall increased steadily with age, although the ability to identify species peaked at age 9 then declined slightly. Boys had significantly greater wildlife knowledge than girls, and children of both sexes identified more indigenous than exotic species. Knowledge of mammals was significantly better than that of birds and arthropods. Knowledge of some very common indigenous species, such as sparrow and earwig, was poor. We conclude that the potential for primary school wildlife education using common and easily accessible species of birds and arthropods is not fully realised, and that girls in particular lack knowledge of local species. (Contains 2 online references, 1 table, and 1 figure.)

Introduction: Musculoskeletal (MSK) conditions are the leading cause of disability in the United Kingdom, leading to ever‐growing waiting lists. Clinical guidelines highlight that most musculoskeletal conditions resolve in time and with little clinical input, and so supporting people to self‐manage is recommended to optimise healthcare resources. Despite this, the term self‐management remains ambiguous and to date no systematic review has evaluated if self‐management is a suitable, acceptable, and effective intervention/strategy for managing all MSK conditions. Methods and Analysis: This protocol is informed and reported in line with the Preferred Reporting Items for Systematic Reviews and Meta‐analyses (PRISMA). An advanced convergent qualitative meta‐integration mixed‐studies design will be used. Using a comprehensive predetermined search strategy, databases, key journals and grey literature will be searched independently by two reviewers. The reviewers will independently assess eligibility, complete data extraction, and evaluate for risk of bias using the Mixed Methods Appraisal Tool (MMAT). The overall quality of included studies will be evaluated using Grading of Recommendations, Assessment, Development and Evaluation (GRADE) guidelines. Data from mixed‐methods studies will be transformed using a process of fractionation and analysed alongside the data extracted from the quantitative and qualitative studies, using descriptive analysis and thematic analysis, respectively. Ethics and dissemination: No research ethics are required for this systematic review since patient data will not be collected. The review will help to inform healthcare professionals and researchers on the most suitable, acceptable, and effective intervention/strategy for self‐managing MSK conditions. Results of this review will be submitted for publication in a peer‐reviewed journal and conference presentations. [ABSTRACT FROM AUTHOR]

Rabelais's 'Tiers Livre' contains a misogynistic episode seen in the consultation of Panurge with physician Rondibilis. Rondibilis suggests that a person should marry if he does not get satisfaction from wine, herbs, hard work or serious study. Panurge's desires remain unfulfilled, as is the case with most men and women due to lack of communication. He fails to evoke a dialogue with his prospective wife, but the desire to hear her voice remains.

The spectacle of male pregnancy and childbearing predominates in Rabelais' 'Quart Livre.' Pantagruel and Panurge search for the miracle of rebirth, or Easter and the miracle of birth, or Advent. Their voyage progresses backwards to Spring and Easter, which is also the time of year when women play no major role. The quest for Renaissance is achieved, but a failed sacrament lurks in the background. Panurge gives birth to a cat which he associates with the devil. Thus Advent is depicted in a demonic way. Rabelais could not conceive of the mother as a life-giving force.

Objectives: Osteoarthritis (OA) affects approximately 8.75 million people in the United Kingdom. Physical activity is recommended as a core treatment, yet 44% of people with OA are inactive. Motivation and self‐efficacy for exercise are considered to be key factors contributing to sustained engagement with physical activity. The aim of this study was to explore the beliefs, motives (what an individual aims to attain through participating in physical activity) and gains (what people feel they might get from participation) associated with physical activity engagement in a group of people with OA. Design and method: This study adopted a cross‐sectional survey research design, using two validated questionnaires: the Exercise Motives and Gains Inventory and the Exercise Self‐Efficacy Scale. Results: Data were gathered from 262 people with OA between August 2015 and January 2016. Those who were most active reported higher levels of both motivation and self‐efficacy and were active for enjoyment, to avoid negative health, and for health and fitness reasons. A comparison of motives and gains revealed higher gain scores for social engagement and enjoyment, compared with associated motive scores. Conclusion: This study provides evidence of the central role that motives, gains and self‐efficacy play in facilitating engagement with physical activity in this population. Future interventions should aim to foster increased self‐efficacy for physical activity and promote autonomous forms of motivation by emphasising the importance of choosing activities which are enjoyable, as well as highlighting the value of social engagement. [ABSTRACT FROM AUTHOR]

Introduction: Management of rheumatoid arthritis has changed dramatically over the last decade and is characterised by early start of intensive treatment and tight monitoring of disease activity until remission. The role of nurse‐led care at early stage of disease is not well understood. Aims: To develop an understanding of rheumatology nurse‐led care from the perspective of patients with early rheumatoid arthritis. Methods: A systematic review of qualitative studies, reported in line with PRISMA checklist. In March 2019, the following databases were searched: MEDLINE, EMBASE, CINAHL, PsycINFO and OpenGrey. Studies were included if they: included adults with rheumatoid arthritis; were qualitative studies with data on patients' perspectives of nurse‐led care; and published in peer‐reviewed journals, in English, between 2010–2019. Due to few studies in early rheumatoid arthritis, inclusion was extended to adults with established rheumatoid arthritis. Two reviewers screened abstracts and full texts. Joanna Briggs Institute Critical Appraisal Tool was used for quality assessment. Thematic synthesis was conducted according to the framework of Thomas and Harden (2008). Results: The search identified 1034 records. After screening and assessing for eligibility, eight qualitative studies were included in the review (133 patients). Three themes were identified from the synthesis. Nurse‐led care was seen to provide professional expertise in planning and delivery of care. A person‐centred approach was used combined with good communication skills, thus creating a positive therapeutic environment. Nurse‐led care was described as providing a sense of empowerment and psychological support. Conclusion: Patients with rheumatoid arthritis are supportive of nurse‐led care. They value its professionalism and person‐centred approach which provide a sense of security and confidence. Relevance to Clinical Practice: The findings outline ingredients of nurse‐led care that are important to patients. These can inform nurses' professional development plans, service improvement and the competence framework for rheumatology nursing. [ABSTRACT FROM AUTHOR]