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Fish in the South American genus Arapaima Müller, 1843 (hereafter referred to as arapaimas) have attracted interest for commercial aquaculture development thanks to their rapid growth rate and high market value. However, management agencies in the United States have expressed concerns about importing and culturing arapaimas due to records of non-native establishment in certain other countries where arapaimas were released or escaped from captivity. We used the Freshwater Fish Injurious Species Risk Assessment Model (FISRAM) to estimate the probability that arapaimas would be injurious (able to cause harm) to native ecosystems, humans, or the economy of the contiguous United States. Risk assessment model inputs were elicited from arapaima experts around the world. Model results were sensitive to the estimation of climate suitability for arapaimas within the contiguous United States, with predicted probability of injuriousness ranging from 0.784 down to 0.321 with different climate suitability inputs. Expert assessors predicted that competition and predation on native species would be the most likely mechanism of impact and expressed a high degree of uncertainty about potential for impacts from pathogens and parasites. We concluded that due to the cold sensitivity of these tropically adapted fish, establishment within the contiguous United States would be highly restricted geographically, limiting potential impacts if introduced outside climatically suitable areas. Existing regulations already mitigate risk of escape from aquaculture in areas where establishment is plausible, but further research into arapaima parasites and pathogens would help reduce uncertainties and suggest opportunities to enhance biosecurity measures if needed.

Background: Millennium Development Goal (MDG) 4 set the target of reducing the under-5 mortality rate by two-thirds between 1990 and 2015. MDG 5 set the target of reducing the maternal mortality ratio (MMR) by three-quarters over the same time period, and also achieve universal access to reproductive health. The objective of this study is to analyse the epidemiological transitions in maternal and child health in Peru from 1990 to 2013. Methods: We analysed the risk of child mortality by age, and MMR by cause, stage of pregnancy, and age from 1990–2013 in Peru using data from the Global Burden of Disease Study, 2013. Findings: From 1990 to 2013, child deaths per 1000 livebirths in Peru dropped from 16 to 8·0 during the early neonatal period, 8·3 to 2·7 in the late neonatal period, 29 to 6·5 in the post-neonatal period, and 21 to 4·9 in those aged 1–4 years. MMR for Peru was 130 per 100 000 livebirths in 1990, 76 per 100 000 in 2003, and 64 per 100 000 in 2013. MMR, by cause, from 1990 to 2013 fell from 20 to 9·7 for sepsis, 7·3 to 2·9 for obstructed labour, 20 to 15 for late maternal deaths (up to a year after delivery), 12 to 8·5 for hypertension, 33·2 to 9·4 for haemorrhage, 13 to 6·9 for abortive outcomes, 15 to 7·3 for direct deaths, and 9·5 to 4·3 for indirect deaths (during pregnancy and within 6 weeks of delivery). MMR, by time period of pregnancy, from 1990 to 2013 fell from 17 to 8·5 during the antepartum period, 32 to 16 during the intrapartum period, 62 to 24 during the postpartum period, and 20 to 15 during the late period. MMR, by age, in Peru from 1990 to 2013 changed from 0·8 to 0·2 for ages 10–14 years, 12·0 to 5·7 for ages 15–19 years, 25·0 to 11·0 for ages 20–24 years, 25·0 to 8·0 for ages 25–29 years, 26·0 to 12·0 for ages 30–34 years, 24·0 to 13·0 for ages 35–39 years, 14·0 to 8·6 for ages 40–44 years, and 4·7 to 6·1 for age ≥45 years. Interpretation: Peru has significantly improved child health, with a 70% decline in child mortality with an annualised rate of decline of 5.3% from 1990 to 2013. The ratios of maternal deaths due to haemorrhage and obstructed labour were reduced significantly by 72% and 60%, respectively, from 1990 to 2013. Deaths in pregnant women younger than 35 years dropped by more than 50%, but increased by 30% for women 45 years and older from 1990 to 2013. Postpartum deaths fell by 61% in the study period. The Peruvian government has prioritised access for pregnant women to health facilities and prenatal and postnatal care, including culturally adapted health services. UNICEF and the Ministry of Health in Peru partnered to establish the Mamawasi (mother's home in Quechua local language) project, to encourage women in rural areas who lack transportation to give birth in health centres. Furthermore, economic growth, diminishment of extreme poverty, focus on health initiatives, and political and social support have contributed to improvement of child health and achievement of the MDG 4 target. Although improvements in maternal health have been made, the MDG 5 target is unlikely to be met. Funding: None.

Metal-on-metal hip resurfacing arthroplasty is increasingly popular for younger patients with advanced hip disease. Intra-operative or immediate postoperative femoral neck fracture after metal-on-metal hip resurfacing is a well-described technical complication, ranging from 0% to 1.5%. We report 2 cases of late femoral neck fracture occurring 8 and 15 months following the index operation, with a review of the literature. We recommend that patient selection should be of prime importance before embarking on metal-on-metal surface hip replacement to avoid such complications.

Breaker fluids are designed to dissolve filter cakes by breaking their long-chain molecules, thereby removing solid deposits on the wellbore wall. Although breaker fluids are not intended to infiltrate the hydrocarbon reservoir, they can invade and cause formation damage by altering sandstone reservoirs' wettability and relative permeability. This can lead to a reduction in the overall reservoir performance. This study coupled tripartite methods to investigate the potential impact of breaker invasion and transport in hydrocarbon reservoirs and its multiscale effect on the performances of sandstone reservoirs. We utilized experimental, analytical, and numerical methods to assess and predict the susceptibility of reservoirs to breaker fluid invasion and transportation. Our experimental and empirical investigations considered varying breaker fluid formulations to evaluate the effects of breaker fluid concentration, formation temperature, and solution gas-oil ratio (GOR) on residual-oil saturation (ROS) and oil-water relative permeability. By adopting the ROS and relative permeability associated with the 50% v/v breaker fluid mixture, the performance of the hydrocarbon reservoir was numerically simulated under the limiting scenarios of no-invasion, moderate-invasion, and deep-invasion of breaker fluid. The results indicate a positive correlation between breaker fluid concentration and ROS, highlighting the risks that breaker fluid invasion and deep infiltration pose to hydrocarbon recovery. Further, results show that both live-oil condition (LOC) and dead-oil condition (DOC) reservoirs are susceptible to the detrimental impacts of breaker fluid infiltration, while their invasion can reduce hydrocarbon recovery in both LOC (−6%) and DOC (−28%). The multi-scale effects on reservoir performance are more pronounced at near-wellbore and DOC than at far-field and LOC. Findings from this work provide valuable insights into the complexity of breaker-fluid invasion in sandstone reservoirs and the mitigation of associated risks to reservoir performance.

Abstract Background People with mental illnesses are disproportionately entangled in the criminal legal system. Historically, this involvement has resulted from minor offending, often accompanied by misdemeanor charges. In recent years, policymakers have worked to reduce the footprint of the criminal legal system. This paper seeks to better understand how misdemeanor systems intervene in the lives of people with mental illnesses. Methods System mapping exercises were conducted with misdemeanor system stakeholders from the jurisdictions of Atlanta, Chicago, Manhattan, and Philadelphia. Narrative detail on decision-making and case processing, both generally and in relation to specific types of behavior, including trespassing, retail theft/shoplifting, and simple assault, were coded and analyzed for thematic patterns. Based on the qualitative analysis, this paper offers a conceptual diagram of contexts shaping misdemeanor system interventions among people with mental illnesses. Results All four sites have been engaged in efforts to reduce the use of misdemeanor charges both generally and in relation to people with mental illnesses. Decision-makers across all sites experience contexts that shape how, when, and where they intervene, which are: (1) law and policy environments; (2) location of the behavior; (3) expectations of stakeholders; (4) knowledge of mental illnesses; and (5) access to community resources. Law and policy environments expand or constrain opportunities for diversion. The location of offending is relevant to who has a stake in the behavior, and what demands they have. Clinical, experiential, and system-level knowledge of mental illnesses inform a chain of decisions about what to do. The capacity to address mental health needs is contingent on access to social services, including housing. Conclusion People making decisions along the criminal legal continuum are critical to illuminating the dynamic, inter-related contexts that facilitate and frustrate attempts to address defendants’ mental health needs while balancing considerations of public safety. Multi-sector, scenario-based or case study exercises could help identify concrete ways of improving each of the contexts that surround whole-of-system decisions.

Objectives To explore the views of professional stakeholders on the future of community pharmacy services in England. Specific objectives related to expectations of how community pharmacy services will be provided by 2030 and factors that will influence this.Design Qualitative, using semistructured interviews in person or via telephone/Skype. The topic guide was informed by a recent policy review that used the Walt and Gilson policy framework. Transcripts were analysed using inductive thematic analysis.Setting England.Participants External stakeholders were representatives of non-pharmacy organisations, including policy-makers, commissioners and representatives of healthcare professions. Internal stakeholders were community pharmacists or pharmacy organisation representatives. Interviewees were identified using stakeholder mappingResults In total, 25 interviews were completed (7 external stakeholders and 18 internal stakeholders, of which 10 were community pharmacists). Community pharmacy was recognised as having a key role in expanding health system capacity (‘…pharmacy is the obvious person to take on those roles…’), particularly for long-term condition management (eg, adherence, reducing polypharmacy, monitoring), urgent care (eg, minor illnesses) and public health (including mental health). For these contributions to be developed and optimised, greater integration and collaboration with general practices will be needed (‘…there is no room for isolationism in pharmacy anymore…’), as well as use of technology in a patient-centred way and full access to health records. These changes will require workforce development together with appropriate commissioning and contractual arrangements. Community pharmacy is currently undervalued (‘…the complete misunderstanding by senior Government officials is very scary’) and recent investment in general practice pharmacists rather than community pharmacy was seen as a missed opportunity.Conclusions Community pharmacy as a sector could and should be developed to increase health service capacity to address its current challenges. Numerous modifications are required from a range of stakeholders to create the environment in which these changes can occur.

Relaxing social distancing measures and reduced level of influenza over the last two seasons may lead to a winter 2022 influenza wave in England. We used an established model for influenza transmission and vaccination to evaluate the rolled out influenza immunisation programme over October to December 2022. Specifically, we explored how the interplay between pre-season population susceptibility and influenza vaccine efficacy control the timing and the size of a possible winter influenza wave. Our findings suggest that susceptibility affects the timing and the height of a potential influenza wave, with higher susceptibility leading to an earlier and larger influenza wave while vaccine efficacy controls the size of the peak of the influenza wave. With pre-season susceptibility higher than pre-COVID-19 levels, under the planned vaccine programme an early influenza epidemic wave is possible, its size dependent on vaccine effectiveness against the circulating strain. If pre-season susceptibility is low and similar to pre-COVID levels, the planned influenza vaccine programme with an effective vaccine could largely suppress a winter 2022 influenza outbreak in England.

Background: An increased role for community pharmacy might bring considerable value to healthcare systems, for example by relieving workload elsewhere in primary care through the provision of medicines-related services. This requires support from appropriate policy. Objective(s): To explore the representation of community pharmacy in governmental and professional health policies in England (2008–2017) using the Walt and Gilson policy framework. Methods: Relevant policies were identified using a systematic search. The content of these policies was analysed using thematic analysis. The transparency of evidence use during the policymaking process was scored in four keys areas using a recognised tool: diagnosis; proposal; implementation; testing and evaluation. Key actors involved in the development of each policy were summarised. Results: 18 governmental policies and 7 pharmacy profession policies were included. Convergence between governmental and professional policy content was identified in 6 areas: healthcare workforce; behaviour and collaborations; utilising technology; urgent care; long-term health conditions; service provision. Divergence was identified in 5 areas: enquiry-driven culture; quality in healthcare; cancer care; mental health care; commissioning. Professional policies were less transparent in their use of evidence and had less documentation of the involvement of key actors, such as professionals and the public. Conclusions: The profession has limited influence and/or representation in governmental policies. This may be because professional policies did not reflect concerns expressed in governmental policies and had low credibility due to limited stakeholder involvement and transparency about evidence use.

We describe the clinical course of 4 infants infected with severe acute respiratory syndrome coronavirus 2. All were admitted to our tertiary care neonatal intensive care unit during the Omicron variant wave in our region. All 4 infants, who were less than 3 months of age, including three born prematurely, presented with critical illness. However, their clinical presentation varied considerably. Of them, two infants presented with apnea, one with respiratory distress, and one with gastrointestinal manifestation. Our experience with these four infants provides evidence for a severe form of disease and varied clinical presentation in neonates and young infants speculated to be infected with Omicron variant.

Objectives The aim of this study was to explore the public’s current awareness of the safe use of medicines in general, and over-the-counter (OTC) analgesics (painkillers) in particular, as well as their information-seeking and advice-seeking, medicine use and disposal.Setting General population, Scotland.Participants Adults (aged >16 years) living in Scotland.Interventions A cross-sectional survey was undertaken in collaboration with Ipsos MORI (a market research company). The content was informed by a multi-stakeholder prioritisation event and supplemented with information from earlier studies.Results The survey was completed in March 2020 by 1000 respondents, most of whom had used a pharmacy in the previous 12 months to obtain a medicine. Of the 1000 respondents, 39% (n=389) were 55 years and over; 52% (n=517) were women; and 58% were degree-educated.On receipt of a new prescription, up to 29.8% (95% CI 27.0% to 32.7%) of respondents proactively sought specific information or advice from the pharmacist. Few (5.2% (95% CI 4.0% to 6.8%) respondents ‘always’ discussed their new prescription medicine with pharmacy staff and 28.9% (95% CI 26.2% to 31.8%) reported ‘never’ engaging in this behaviour. Respondents aged >35 years were less likely to engage in this behaviour.Just over half (53% (95% CI 50.5% to 56.7%)) the respondents reported oral OTC analgesic use at least once in the previous month.In terms of medicine disposal, 29.3% (95% CI 26.6% to 32.2%) of respondents considered waste bin disposal to be of low or no harm.Conclusions This study identified low levels of information-seeking and advice-seeking from pharmacy personnel especially on receipt of new prescription medicines. Potentially unsafe behaviours were identified in the use and disposal of medicines. These results will inform the development of interventions to promote advice-seeking and increase awareness regarding safe medicine use.

Abstract Background Mutations in the postsynaptic transmembrane protein neuroligin-3 are highly correlative with autism spectrum disorders (ASDs) and intellectual disabilities (IDs). Fear learning is well studied in models of these disorders, however differences in fear response behaviours are often overlooked. We aim to examine fear behaviour and its cellular underpinnings in a rat model of ASD/ID lacking Nlgn3. Methods This study uses a range of behavioural tests to understand differences in fear response behaviour in Nlgn3 −/y rats. Following this, we examined the physiological underpinnings of this in neurons of the periaqueductal grey (PAG), a midbrain area involved in flight-or-freeze responses. We used whole-cell patch-clamp recordings from ex vivo PAG slices, in addition to in vivo local-field potential recordings and electrical stimulation of the PAG in wildtype and Nlgn3 −/y rats. We analysed behavioural data with two- and three-way ANOVAS and electrophysiological data with generalised linear mixed modelling (GLMM). Results We observed that, unlike the wildtype, Nlgn3 −/y rats are more likely to response with flight rather than freezing in threatening situations. Electrophysiological findings were in agreement with these behavioural outcomes. We found in ex vivo slices from Nlgn3 −/y rats that neurons in dorsal PAG (dPAG) showed intrinsic hyperexcitability compared to wildtype. Similarly, stimulating dPAG in vivo revealed that lower magnitudes sufficed to evoke flight behaviour in Nlgn3 −/y than wildtype rats, indicating the functional impact of the increased cellular excitability. Limitations Our findings do not examine what specific cell type in the PAG is likely responsible for these phenotypes. Furthermore, we have focussed on phenotypes in young adult animals, whilst the human condition associated with NLGN3 mutations appears during the first few years of life. Conclusions We describe altered fear responses in Nlgn3 −/y rats and provide evidence that this is the result of a circuit bias that predisposes flight over freeze responses. Additionally, we demonstrate the first link between PAG dysfunction and ASD/ID. This study provides new insight into potential pathophysiologies leading to anxiety disorders and changes to fear responses in individuals with ASD.

Background: Use of laboratory testing has increased in the UK over the past few decades, with considerable geographical variation. Aim: To evaluate what laboratory tests are used to monitor people with hypertension, type 2 (T2) diabetes, or chronic kidney disease (CKD) and assess variation in test use in UK primary care. Design & setting: Longitudinal cohort study of people registered with UK general practices between June 2013 and May 2018 and previously diagnosed with hypertension, T2 diabetes, or CKD. Method: Clinical Practice Research Datalink (CPRD) primary care data linked to ethnic group and deprivation was used to examine testing rates over time, by GP practice, age, sex, ethnic group, and socioeconomic deprivation, with age–sex standardisation. Results: Nearly 1 million patients were included, and more than 27 million tests. The most ordered tests were for renal function (1463 per 1000 person-years), liver function (1063 per 1000 person-years), and full blood count (FBC; 996 per 1000 person-years). There was evidence of undertesting (compared with current guidelines) for HbA1c and albumin:creatinine ratio (ACR) or microalbumin, and potential overtesting of lipids, FBC, liver function, and thyroid function. Some GP practices had up to 27 times higher testing rates than others (HbA1c testing among patients with CKD). Conclusion: Testing rates are no longer increasing, but they are not always within the guidelines for monitoring long-term conditions (LTCs). There was considerable variation by GP practice, indicating uncertainty over the most appropriate testing frequencies for different conditions. Standardising the monitoring of LTCs based on the latest evidence would provide greater consistency of access to monitoring tests.

Recent studies reveal that lateral mitochondrial transfer, the movement of mitochondria from one cell to another, can affect cellular and tissue homeostasis. Most of what we know about mitochondrial transfer stems from bulk cell studies and have led to the paradigm that functional transferred mitochondria restore bioenergetics and revitalize cellular functions to recipient cells with damaged or non-functional mitochondrial networks. However, we show that mitochondrial transfer also occurs between cells with functioning endogenous mitochondrial networks, but the mechanisms underlying how transferred mitochondria can promote such sustained behavioral reprogramming remain unclear. We report that unexpectedly, transferred macrophage mitochondria are dysfunctional and accumulate reactive oxygen species in recipient cancer cells. We further discovered that reactive oxygen species accumulation activates ERK signaling, promoting cancer cell proliferation. Pro-tumorigenic macrophages exhibit fragmented mitochondrial networks, leading to higher rates of mitochondrial transfer to cancer cells. Finally, we observe that macrophage mitochondrial transfer promotes tumor cell proliferation in vivo. Collectively these results indicate that transferred macrophage mitochondria activate downstream signaling pathways in a ROS-dependent manner in cancer cells, and provide a model of how sustained behavioral reprogramming can be mediated by a relatively small amount of transferred mitochondria in vitro and in vivo.

Sous vide cooking is a method of food preparation in which food is vacuum sealed and cooked in a water bath that is set to a precise temperature and circulated by a sous vide device. Due to ease of use and affordability, this cooking method has grown increasingly popular in food service kitchens and domestic settings. However, low-temperature, long holding time sous vide cooking recommendations from manufacturers and chefs in popular press raise food safety concerns – specifically those for the preparation of nonintact beef products. The objective of this experiment was to address these concerns by validating a 5 log reduction of Salmonella spp. in sous vide cooked, nonintact beef steaks. Beef semitendinosus sliced into 2.54 cm steaks were internally inoculated to 7 log with Salmonella Typhimurium, Enteritidis, and Heidelberg via a needle inoculation pin pad. Steaks were individually vacuum sealed, and sous vide cooked at 46.1, 51.6, and 54.4°C. The minimum time measured for a 5 log reduction at 51.6 and 54.4°C was 150 and 64.5 min, respectively (P

IntroductionBirth defects, particularly those that affect development of the heart, are a leading cause of morbidity and mortality in infants and young children. Babies born with heart hypoplasia (heart hypoplasia) disorders often have a poor prognosis. It remains unclear whether cardiomyocytes from hypoplastic hearts retain the potential to recover growth, although this knowledge would be beneficial for developing therapies for heart hypoplasia disorders. The objective of this study was to determine the proliferation and maturation potential of cardiomyocytes from hypoplastic hearts and whether these behaviors are influenced by biochemical signaling from the extracellular matrix (ECM) and cyclic mechanical stretch.MethodCongenital diaphragmatic hernia (CDH)-associated heart hypoplasia was induced in rat fetuses by maternal exposure to nitrofen. Hearts were isolated from embryonic day 21 nitrofen-treated fetuses positive for CDH (CDH+) and from fetuses without nitrofen administration during gestation.Results and discussionCDH+ hearts were smaller and had decreased myocardial proliferation, along with evidence of decreased maturity compared to healthy hearts. In culture, CDH+ cardiomyocytes remained immature and demonstrated increased proliferative capacity compared to their healthy counterparts. Culture on ECM derived from CDH+ hearts led to a significant reduction in proliferation for both CDH+ and healthy cardiomyocytes. Healthy cardiomyocytes were dosed with exogenous nitrofen to examine whether nitrofen may have an aberrant effect on the proliferative ability of cardiomyocyte, yet no significant change in proliferation was observed. When subjected to stretch, CDH+ cardiomyocytes underwent lengthening of sarcomeres while healthy cardiomyocyte sarcomeres were unaffected. Taken together, our results suggest that alterations to environmental cues such as ECM and stretch may be important factors in the pathological progression of heart hypoplasia.

Abstract Background Anticoagulation for stroke prevention in atrial fibrillation (AF) has, historically, been under-used in older people. The aim of this study was to investigate prescribing of oral anticoagulants (OACs) for people aged ≥ 75 years in the UK before and after direct oral anticoagulants (DOACs) became available. Methods A cohort of patients aged ≥ 75 years with a diagnosis of AF was derived from the Clinical Practice Research Datalink (CPRD) between January 1, 2003, and December 27, 2017. Patients were grouped as no OAC, incident OAC (OAC newly prescribed) or prevalent OAC (entered study on OAC). Incidence and point prevalence of OAC prescribing were calculated yearly. The risk of being prescribed an OAC if a co-morbidity was present was calculated; the risk difference (RD) was reported. Kaplan-Meier curves were used to explore persistence with anticoagulation. A Cox regression was used to model persistence with warfarin and DOACs over time. Results The cohort comprised 165,596 patients (66,859 no OAC; 47,916 incident OAC; 50,821 prevalent OAC). Incidence of OAC prescribing increased from 111 per 1000 person-years in 2003 to 587 per 1000 person-years in 2017. Older patients (≥ 90 years) were 40% less likely to receive an OAC (RD −0.40, 95% CI −0.41 to −0.39) than younger individuals (75–84 years). The likelihood of being prescribed an OAC was lower with a history of dementia (RD −0.34, 95% CI −0.35 to −0.33), falls (RD −0.17, 95% CI −0.18 to −0.16), major bleeds (RD −0.17, 95% CI −0.19 to −0.15) and fractures (RD −0.13, 95% CI −0.14 to −0.12). Persistence with warfarin was higher than DOACs in the first year (0–1 year: HR 1.25, 95% CI 1.17–1.33), but this trend reversed by the third year of therapy (HR 0.75, 95% CI 0.63–0.89). Conclusions OAC prescribing for older people with AF has increased; however, substantial disparities persist with age and co-morbidities. Whilst OACs should not be withheld solely due to the risk of falls, these results do not reflect this national guidance. Furthermore, the under-prescribing of OACs for patients with dementia or advancing age may be due to decisions around risk-benefit management. Trial registration EUPAS29923 . First registered on: 27/06/2019.

Abstract Extracellular vesicles (EVs) large‐scale production is a crucial point for the translation of EVs from discovery to application of EV‐based products. In October 2021, the International Society for Extracellular Vesicles (ISEV), along with support by the FET‐OPEN projects, “The Extracellular Vesicle Foundry” (evFOUNDRY) and “Extracellular vesicles from a natural source for tailor‐made nanomaterials” (VES4US), organized a workshop entitled “massivEVs” to discuss the potential challenges for translation of EV‐based products. This report gives an overview of the topics discussed during “massivEVs”, the most important points raised, and the points of consensus reached after discussion among academia and industry representatives. Overall, the review of the existing EV manufacturing, upscaling challenges and directions for their resolution highlighted in the workshop painted an optimistic future for the expanding EV field.

Background: Coeliac disease is an autoimmune disorder triggered by ingesting gluten. It affects approximately 1% of the UK population, but only one in three people is thought to have a diagnosis. Untreated coeliac disease may lead to malnutrition, anaemia, osteoporosis and lymphoma. Objectives: The objectives were to define at-risk groups and determine the cost-effectiveness of active case-finding strategies in primary care. Design: (1) Systematic review of the accuracy of potential diagnostic indicators for coeliac disease. (2) Routine data analysis to develop prediction models for identification of people who may benefit from testing for coeliac disease. (3) Systematic review of the accuracy of diagnostic tests for coeliac disease. (4) Systematic review of the accuracy of genetic tests for coeliac disease (literature search conducted in April 2021). (5) Online survey to identify diagnostic thresholds for testing, starting treatment and referral for biopsy. (6) Economic modelling to identify the cost-effectiveness of different active case-finding strategies, informed by the findings from previous objectives. Data sources: For the first systematic review, the following databases were searched from 1997 to April 2021: MEDLINE® (National Library of Medicine, Bethesda, MD, USA), Embase® (Elsevier, Amsterdam, the Netherlands), Cochrane Library, Web of Science™ (Clarivate™, Philadelphia, PA, USA), the World Health Organization International Clinical Trials Registry Platform (WHO ICTRP) and the National Institutes of Health Clinical Trials database. For the second systematic review, the following databases were searched from January 1990 to August 2020: MEDLINE, Embase, Cochrane Library, Web of Science, Kleijnen Systematic Reviews (KSR) Evidence, WHO ICTRP and the National Institutes of Health Clinical Trials database. For prediction model development, Clinical Practice Research Datalink GOLD, Clinical Practice Research Datalink Aurum and a subcohort of the Avon Longitudinal Study of Parents and Children were used; for estimates for the economic models, Clinical Practice Research Datalink Aurum was used. Review methods: For review 1, cohort and case–control studies reporting on a diagnostic indicator in a population with and a population without coeliac disease were eligible. For review 2, diagnostic cohort studies including patients presenting with coeliac disease symptoms who were tested with serological tests for coeliac disease and underwent a duodenal biopsy as reference standard were eligible. In both reviews, risk of bias was assessed using the quality assessment of diagnostic accuracy studies 2 tool. Bivariate random-effects meta-analyses were fitted, in which binomial likelihoods for the numbers of true positives and true negatives were assumed. Results: People with dermatitis herpetiformis, a family history of coeliac disease, migraine, anaemia, type 1 diabetes, osteoporosis or chronic liver disease are 1.5–2 times more likely than the general population to have coeliac disease; individual gastrointestinal symptoms were not useful for identifying coeliac disease. For children, women and men, prediction models included 24, 24 and 21 indicators of coeliac disease, respectively. The models showed good discrimination between patients with and patients without coeliac disease, but performed less well when externally validated. Serological tests were found to have good diagnostic accuracy for coeliac disease. Immunoglobulin A tissue transglutaminase had the highest sensitivity and endomysial antibody the highest specificity. There was little improvement when tests were used in combination. Survey respondents (n = 472) wanted to be 66% certain of the diagnosis from a blood test before starting a gluten-free diet if symptomatic, and 90% certain if asymptomatic. Cost-effectiveness analyses found that, among adults, and using serological testing alone, immunoglobulin A tissue transglutaminase was most cost-effective at a 1% pre-test probability (equivalent to population screening). Strategies using immunoglobulin A endomysial antibody plus human leucocyte antigen or human leucocyte antigen plus immunoglobulin A tissue transglutaminase with any pre-test probability had similar cost-effectiveness results, which were also similar to the cost-effectiveness results of immunoglobulin A tissue transglutaminase at a 1% pre-test probability. The most practical alternative for implementation within the NHS is likely to be a combination of human leucocyte antigen and immunoglobulin A tissue transglutaminase testing among those with a pre-test probability above 1.5%. Among children, the most cost-effective strategy was a 10% pre-test probability with human leucocyte antigen plus immunoglobulin A tissue transglutaminase, but there was uncertainty around the most cost-effective pre-test probability. There was substantial uncertainty in economic model results, which means that there would be great value in conducting further research. Limitations: The interpretation of meta-analyses was limited by the substantial heterogeneity between the included studies, and most included studies were judged to be at high risk of bias. The main limitations of the prediction models were that we were restricted to diagnostic indicators that were recorded by general practitioners and that, because coeliac disease is underdiagnosed, it is also under-reported in health-care data. The cost-effectiveness model is a simplification of coeliac disease and modelled an average cohort rather than individuals. Evidence was weak on the probability of routine coeliac disease diagnosis, the accuracy of serological and genetic tests and the utility of a gluten-free diet. Conclusions: Population screening with immunoglobulin A tissue transglutaminase (1% pre-test probability) and of immunoglobulin A endomysial antibody followed by human leucocyte antigen testing or human leucocyte antigen testing followed by immunoglobulin A tissue transglutaminase with any pre-test probability appear to have similar cost-effectiveness results. As decisions to implement population screening cannot be made based on our economic analysis alone, and given the practical challenges of identifying patients with higher pre-test probabilities, we recommend that human leucocyte antigen combined with immunoglobulin A tissue transglutaminase testing should be considered for adults with at least a 1.5% pre-test probability of coeliac disease, equivalent to having at least one predictor. A more targeted strategy of 10% pre-test probability is recommended for children (e.g. children with anaemia). Future work: Future work should consider whether or not population-based screening for coeliac disease could meet the UK National Screening Committee criteria and whether or not it necessitates a long-term randomised controlled trial of screening strategies. Large prospective cohort studies in which all participants receive accurate tests for coeliac disease are needed. Study registration: This study is registered as PROSPERO CRD42019115506 and CRD42020170766. Funding: This project was funded by the National Institute for Health and Care Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 26, No. 44. See the NIHR Journals Library website for further project information.

Abstract Background We have shown previously that current recommendations in UK guidelines for monitoring long-term conditions are largely based on expert opinion. Due to a lack of robust evidence on optimal monitoring strategies and testing intervals, the guidelines are unclear and incomplete. This uncertainty may underly variation in testing that has been observed across the UK between GP practices and regions. Methods Our objective was to audit current testing practices of GPs in the UK; in particular, perspectives on laboratory tests for monitoring long-term conditions, the workload, and how confident GPs are in ordering and interpreting these tests. We designed an online survey consisting of multiple-choice and open-ended questions that was promoted on social media and in newsletters targeting GPs practicing in UK. The survey was live between October–November 2019. The results were analysed using a mixed-methods approach. Results The survey was completed by 550 GPs, of whom 69% had more than 10 years of experience. The majority spent more than 30 min per day on testing (78%), but only half of the respondents felt confident in dealing with abnormal results (53%). There was a high level of disagreement for whether liver function tests and full blood counts should be done ‘routinely’, ‘sometimes’, or ‘never’ in patients with a certain long-term condition. The free text comments revealed three common themes: (1) pressures that promote over-testing, i.e. guidelines or protocols, workload from secondary care, fear of missing something, patient expectations; (2) negative consequences of over-testing, i.e. increased workload and patient harm; and (3) uncertainties due to lack of evidence and unclear guidelines. Conclusion These results confirm the variation that has been observed in test ordering data. The results also show that most GPs spent a significant part of their day ordering and interpreting monitoring tests. The lack of confidence in knowing how to act on abnormal test results underlines the urgent need for robust evidence on optimal testing and the development of clear and unambiguous testing recommendations. Uncertainties surrounding optimal testing has resulted in an over-use of tests, which leads to a waste of resources, increased GP workload and potential patient harm.

Abstract Predators exert strong effects on ecological communities, particularly when they re‐occupy areas after decades of extirpation. Within species, such effects can vary over time and by sex and cascade across trophic levels. We used a space‐for‐time substitution to make foraging observations of sea otters (Enhydra lutris) across a gradient of reoccupation time (1–30 years), and nonmetric multidimensional scaling (nMDS) analysis to ask whether (a) sea otter niche space varies as a function of occupation time and (b) whether niche space varies by sex. We found that niche space varied among areas of different occupation times. Dietary niches at short occupation times were dominated by urchins (Mesocentrotus and Strongylocentrotus spp; >60% of diets) in open habitats at 10–40 m depths. At longer occupation times, niches were dominated by small clams (Veneroida; >30% diet), mussels (Mytilus spp; >20% diet), and crab (Decapoda; >10% diet) in shallow (60%), and urchins (~25%) from deep waters (>40 m), and females and territorial males consuming smaller, varied prey from shallow waters (

The purpose of the study was to investigate the relationship between, neuroticism, emotionality well-being and materialism. A series of mediation analyses were conducted with data obtained from a set of questionnaires completed by University students. The results indicated that neuroticism and emotionality were mediators in the well-being-materialism relationship. However, this relationship is dependent upon whether neuroticism or emotionality is measured as the three neuroticism measures utilized were significant mediators whereas the HEXACO emotionality scale was not. A facet-level analysis was conducted with the IPIP-NEO facets of volatility and withdrawal and with the HEXACO facets of sentimentality/dependence and withdrawal. In either case, withdrawal was a significant mediator in the materialism well-being relationship, whereas volatility or sentimentality/dependence was not. The results highlight the differences between neuroticism and HEXACO emotionality and add additional insight into the relationship between materialism and lower well-being. These findings suggest possible methods of decreasing materialistic tendencies and increasing subjective well-being.

Background: Persistent throat symptoms are commonly attributed to ‘laryngopharyngeal reflux’. Despite a limited evidence base, these symptoms are increasingly being treated in primary care with proton pump inhibitors. Objective: To assess the value of proton pump inhibitor therapy in patients with persistent throat symptoms. Design: This was a double-blind, placebo-controlled, randomised Phase III trial. Setting: This was a multicentre UK trial in eight UK ear, nose and throat departments. Participants: A total of 346 participants aged ≥ 18 years with persistent throat symptoms and a Reflux Symptom Index score of ≥ 10, exclusive of the dyspepsia item, were recruited. Intervention: Random allocation (1 : 1 ratio) to either 30 mg of lansoprazole twice daily or matched placebo for 16 weeks. Main outcome measure: Symptomatic response (i.e. total Reflux Symptom Index score after 16 weeks of therapy). Results: A total of 1427 patients were screened and 346 were randomised. The mean age was 52 years (standard deviation 13.7 years, range 20–84 years); 150 (43%) participants were male and 196 (57%) were female; 184 (53%) participants had a mild Reflux Symptom Index minus the heartburn/dyspepsia item and 162 (47%) had a severe Reflux Symptom Index minus the heartburn/dyspepsia item. A total of 172 patients were randomised to lansoprazole and 174 were randomised to placebo. Main outcomes: A total of 267 participants completed the primary end-point visit (lansoprazole, n = 127; placebo, n = 140), of whom 220 did so between 14 and 20 weeks post randomisation (‘compliant’ group); 102 received lansoprazole and 118 received placebo. The mean Reflux Symptom Index scores at baseline were similar [lansoprazole 22.0 (standard deviation 8.0), placebo 21.7 (standard deviation 7.1), overall 21.9 (standard deviation 7.5)]. The mean Reflux Symptom Index scores at 16 weeks reduced from baseline in both groups [overall 17.4 (standard deviation 9.9), lansoprazole 17.4 (standard deviation 9.9), placebo 15.6 (standard deviation 9.8)]. Lansoprazole participants had estimated Reflux Symptom Index scores at 16 weeks that were 1.9 points higher (worse) than those of placebo participants (95% confidence interval –0.3 to 4.2; padj = 0.096), adjusted for site and baseline severity. Secondary outcomes: Ninety-five (43%) participants achieved a Reflux Symptom Index score in the normal range (

Objectives Despite widespread availability of evidence-based guidelines to inform rational use of medicines, considerable unwarranted variation exists in prescribing. A greater understanding of key determinants of contemporary prescribing in UK general practice could inform strategies to promote evidence-based prescribing. This study explored (1) current influences on prescribing in general practice and (2) the possibility that general practice-based pharmacists (PBPs) may contribute to greater engagement with evidence-based prescribing.Design Semistructured, telephone interviews and a focus group were conducted, audio-recorded and transcribed verbatim. Thematic analysis was undertaken.Participants General practice prescribers: general practitioners (GPs), PBPs, nurses.Key informants: individuals within the National Health Service (NHS) with responsibility for influencing, monitoring and measuring general practice prescribing.Setting General practices and NHS organisations in England.Results Interviews with 17 prescribers (GPs (n=6), PBPs (n=6), nurses (n=5)) and 6 key informants, and one focus group with five key informants were undertaken between November 2018 and April 2019. Determinants operating at individual, practice and societal levels impacted prescribing and guideline use. Prescribers’ professional backgrounds, for example, nursing, pharmacy, patient populations and patient pressure were perceived as substantial influences, as well as media portrayal and public perceptions of medicines.Prescribers identified practice-level determinants of prescribing, including practice culture and shared beliefs. Key informants tended to emphasise higher-level influences, including NHS policies, availability of support and advice from secondary care and generic challenges associated with medicines use, for example, multimorbidity.Participants expressed mixed views about the potential of PBPs to promote evidence-based prescribing in general practice.Conclusion Prescribing in UK general practice is influenced by multiple intersecting factors. Strategies to promote evidence-based prescribing should target modifiable influences at practice and individual levels. Customising strategies for medical and non-medical prescribers may maximise their effectiveness.

Automated flow cytometry (FCM) adapted to real-time quality surveillance provides high-temporal-resolution data about the microbial communities in a water system. The cell concentration calculated from FCM measurements indicates sudden increases in the number of bacteria, but can fluctuate significantly due to man-made and natural dynamics; it can thus obscure the presence of microbial anomalies. Cytometric fingerprinting tools enable a detailed analysis of the aquatic microbial communities, and could distinguish between normal and abnormal community changes. However, the vast majority of current cytometric fingerprinting tools use offline statistical computations which cannot detect anomalies immediately. Here, we present a computational model, entitled Microbial Community Change Detection (MCCD), which transforms microbial community characteristics into an online process control signal (herein called outlier score) that remains close to zero if the microbial community remains stable and increases with fluctuations in the community. The model is based on fingerprints and distance-based outlier calculations. We tested it in silico and in vitro by simulating acute contaminations to real-world water systems with large inherent microbial fluctuations. We showed that the outlier score was robust against these dynamic variations, while reliably detecting intentional contaminations. This model can be used with automated FCM to quickly detect potential microbiological contamination, and this especially when the time between treatment and distribution is very short.

Objectives The aim of this study was to identify which behaviour change techniques (BCTs) were present in intervention and control groups of randomised controlled trials (RCTs) included in a Cochrane systematic review.Setting The RCTs included were conducted in community, primary and/or ambulatory-care settings.Participants The data set was derived from 86 RCTs from an interim update of the Cochrane review of the effectiveness of pharmacist services on non-hospitalised patient outcomes.Primary and secondary outcome measures The primary outcome was the identification of BCTs scheduled for delivery in intervention and control groups of the RCTs. The secondary outcome measure was to identify which BCTs are not being utilised in intervention and control groups of the RCTs.Results The intervention and control groups included 31 and 12 BCTs, respectively. The number of identifiable BCTs/study ranged from 0 to 12 in the intervention groups (mean 3.01 (SD 2.4)) and 0 to 6 in the control groups (mean 0.38 (SD 0.84)). The most commonly identified BCTs in the intervention groups were: instruction on how to perform the behaviour (55%, n=47) (also the most common BCT in control groups); problem solving (29%, n=25); information about health consequences (24%, n=21); social support (practical) (24%, n=21); and social support (unspecified) (23%, n=20) (the second most common BCT in control groups). Thirteen trials had no identifiable BCTs in either group.Conclusion The pharmacist interventions presented in this study did not use the full range of available BCTs. Furthermore, the reporting of BCTs was incomplete for both intervention and control groups, thereby limiting the utility and reproducibility of the interventions. Future interventions should be designed and reported using relevant taxonomies and checklists for example, BCT taxonomy and TIDieR (the template for intervention description and replication).