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Background The safety, effectiveness, and cost-effectiveness of molnupiravir, an oral antiviral medication for SARS-CoV-2, has not been established in vaccinated patients in the community at increased risk of morbidity and mortality from COVID-19. We aimed to establish whether the addition of molnupiravir to usual care reduced hospital admissions and deaths associated with COVID-19 in this population. Methods PANORAMIC was a UK-based, national, multicentre, open-label, multigroup, prospective, platform adaptive randomised controlled trial. Eligible participants were aged 50 years or older—or aged 18 years or older with relevant comorbidities—and had been unwell with confirmed COVID-19 for 5 days or fewer in the community. Participants were randomly assigned (1:1) to receive 800 mg molnupiravir twice daily for 5 days plus usual care or usual care only. A secure, web-based system (Spinnaker) was used for randomisation, which was stratified by age (vs ≥50 years) and vaccination status (yes vs no). COVID-19 outcomes were tracked via a self-completed online daily diary for 28 days after randomisation. The primary outcome was all-cause hospitalisation or death within 28 days of randomisation, which was analysed using Bayesian models in all eligible participants who were randomly assigned. This trial is registered with ISRCTN, number 30448031. Findings Between Dec 8, 2021, and April 27, 2022, 26 411 participants were randomly assigned, 12 821 to molnupiravir plus usual care, 12 962 to usual care alone, and 628 to other treatment groups (which will be reported separately). 12 529 participants from the molnupiravir plus usual care group, and 12 525 from the usual care group were included in the primary analysis population. The mean age of the population was 56·6 years (SD 12·6), and 24 290 (94%) of 25 708 participants had had at least three doses of a SARS-CoV-2 vaccine. Hospitalisations or deaths were recorded in 105 (1%) of 12 529 participants in the molnupiravir plus usual care group versus 98 (1%) of 12 525 in the usual care group (adjusted odds ratio 1·06 [95% Bayesian credible interval 0·81–1·41]; probability of superiority 0·33). There was no evidence of treatment interaction between subgroups. Serious adverse events were recorded for 50 (0·4%) of 12 774 participants in the molnupiravir plus usual care group and for 45 (0·3%) of 12 934 in the usual care group. None of these events were judged to be related to molnupiravir. Interpretation Molnupiravir did not reduce the frequency of COVID-19-associated hospitalisations or death among high-risk vaccinated adults in the community. Funding UK National Institute for Health and Care Research

Malnutrition and dehydration are strongly associated with increased cognitive and functional decline in people living with dementia (PLWD), as well as an increased rate of hospitalisations in comparison to their healthy counterparts. Extreme changes in eating and drinking behaviours can often lead to malnutrition and dehydration, accelerating the progression of cognitive and functional decline and resulting in a marked reduction in quality of life. Unfortunately, there are currently no established methods by which to objectively detect such changes. Here, we present the findings of a quantitative analysis conducted on in-home monitoring data collected from 73 households of PLWD using Internet of Things technologies. The Coronavirus 2019 (COVID-19) pandemic has previously been shown to have dramatically altered the behavioural habits, particularly the eating and drinking habits, of PLWD. Using the COVID-19 pandemic as a natural experiment, we show that there were significant changes in kitchen activities at the group level within a subset of 21 households of PLWD that were continuously monitored for 499 days, with an overall increase in day-time activities and a decrease in night-time activity observed in both single and multiple occupancy households. We further present preliminary results suggesting it is possible to proactively detect episodic and gradual changes in behaviours using remote monitoring data as a proxy for behaviours that cannot be directly measured. Together, these results pave the way to introduce improvements into the monitoring of PLWD in naturalistic settings and for shifting from reactive to proactive care.

ObjectivesTo understand SARS-Co-V-2 infection and transmission in UK nursing homes in order to develop preventive strategies for protecting the frail elderly residents.DesignAn outbreak investigation.Setting4 nursing homes affected by COVID-19 outbreaks in central London.Participants394 residents and 70 staff in nursing homes.InterventionsTwo point-prevalence surveys one week apart where residents underwent SARS-CoV-2 testing and had relevant symptoms documented. Asymptomatic staff from three of the four homes were also offered SARS-CoV-2 testing.Main outcome measuresAll-cause mortality, and mortality attributed to COVID-19 on death certificates. Prevalence of SARS-CoV-2 infection and symptoms in residents and staff.ResultsOverall, 26% (95% confidence interval 22 to 31) of residents died over the two-month period. All-cause mortality increased by 203% (95% CI 70 to 336). Systematic testing identified 40% (95% CI 35 to 46) of residents, of whom 43% (95% CI 34 to 52) were asymptomatic and 18% (95% CI 11 to 24) had atypical symptoms, as well as 4% (95% CI -1 to 9) of asymptomatic staff who tested positive for SARS-CoV-2.ConclusionsThe SARS-CoV-2 outbreak was associated with a very high mortality rate in residents of nursing homes. Systematic testing of all residents and a representative sample of staff identified high rates of SARS-CoV-2 positivity across the four nursing homes, highlighting a potential for regular screening to prevent future outbreaks.

BackgroundCOVID-19 cases were first detected in the UK in January 2020 and vulnerable patients were asked to shield from March to reduce their risk of COVID-19 infection.AimTo determine the risk and determinants of COVID-19 diagnosis in shielded versus non-shielded groups, adjusted for key comorbidities not explained by shielding.Design & settingRetrospective cohort study of adults with COVID-19 infection between 1 February 2020 and 15 May 2020 in west London.MethodIndividuals diagnosed with COVID-19 were identified in SystmOne records using clinical codes. Infection risks were adjusted for sociodemographic factors, nursing home status, and comorbidities.ResultsOf 57 713 adults, 573 (1%) individuals were identified as shielded and 1074 adults had documented COVID-19 infections (1.9%). COVID-19 infection rate in the shielded group individuals compared with non-shielded adult individuals was 6.5% (n = 37/573) versus 1.8% (n = 1037/57 140), PP = 0.048). Other determinants of COVID-19 infection included nursing home residency (aHR 7.05; 95% CI = 4.22 to 11.77; PP; PP = 0.04), or South Asian ethnic group (aHR 1.46; 95% CI = 1.10 to 1.93; P = 0.01); history of respiratory disease (aHR 1.51; 95% CI = 1.06 to 2.16; P = 0.02); deprivation (third versus least deprived Index of Multiple Deprivation [IMD] quintile) (aHR 1.25 ; 95% CI = 1.01 to 1.56; P = 0.05); obesity (body mass index [BMI] >30 kg/m2) (aHR 1.39; 95% CI = 1.18 to 1.63; PPPConclusionShielded individuals had a higher COVID-19 infection rate compared with non-shielded individuals, after adjusting for sociodemographic factors, nursing home status, and comorbidities.

Wolbachia Hertig and Wolbach (Rickettsiales: Anaplasmataceae) are non-culturable, bacterial endosymbionts that have been found in a broad range of arthropods and other invertebrate species. They have been implicated in human and veterinary pathologies, and may play a major role in embryonic development and evolution of host species. Given the apparent ubiquity of Wolbachia in certain animal taxa suggested by previous studies, there are still many unanswered questions about its biology. Like other obligate intracellular bacteria, they are difficult to cultivate outside of their host and often are analyzed using molecular methods. Polymerase chain reaction (PCR) assays have been developed previously for Wolbachia detection within host species, and several genes have been explored for strain typing and phylogenetic reconstruction. However, given the expansive host range and biological complexity of symbiotic relationships between Wolbachia and its host species, new methods could help accelerate the pace of Wolbachia research. As part of an overarching goal to study the distribution of Wolbachia in local mosquitoes and in the heartworm, Dirofilaria immitis (Leidy) (Rhabditida: Onchocercidae), we aimed to develop cost-effective methods that can be used in strain identification and analysis. We developed a novel PCR assay targeting the gyrA gene of Wolbachia and explored various methods of sample preparation. Presumptive Wolbachia were detected in mosquito specimens from several genera, as well as from D. immitis samples obtained from canine necropsy. DNA sequence analysis of the PCR products confirmed the identity of Wolbachia and revealed variability within some regions of the gyrA gene that correspond to host species. Consequently, this gene could be useful for future phylogenetic and population studies. Resumen Wolbachia Hertig y Wolbach (Rickettsiales: Anaplasmataceae) son endosimbiontes bacterianos no cultivables que se han encontrado en una amplia gama de artropodos y otras especies de invertebrados. Se han implicado en patologias humanas y veterinarias y pueden jugar un papel importante en el desarrollo embrionario y la evolucion de las especies hospederas. Dada la aparente ubicuidad de Wolbachia en ciertos taxones de animales sugerida por estudios previos, indican que quedan muchas preguntas sin respuesta sobre su biologia. Al igual que otras bacterias intracelulares obligadas, son dificiles de cultivar fuera de su hospedero y son a menudo analizadas mediante metodos moleculares. Los ensayos de reaccion en cadena de la polimerasa (PCR) se han desarrollado previamente para la deteccion de Wolbachia dentro de especies hospederas, y se han explorado varios genes para la tipificacion de cepas y la reconstruccion filogenetica. Sin embargo, dada la amplia gama de hospederos y la complejidad biologica de las relaciones simbioticas entre Wolbachia y su especie hospedera, el tener nuevos metodos podrian ayudar a acelerar el paso de la investigacion de Wolbachia. Como parte de un objetivo general para estudiar la distribucion de Wolbachia en mosquitos locales y en el gusano del corazon, Dirofilaria immitis (Leidy) (Rhabditida: Onchocercidae), nuestro objetivo fue el desarrollar metodos rentables que se puedan utilizar en la identificacion y analisis de cepas. Desarrollamos un ensayo de PCR novedoso dirigido al gen gyrA de Wolbachia y exploramos varios metodos de preparacion de muestras. Se detectaron presuntas Wolbachia en muestras de mosquitos de varios generos, asi como en muestras de D. immitis obtenidas de necropsias caninas. El analisis de la secuencia de ADN de los productos de la PCR confirmo la identidad de Wolbachia y revelo variabilidad dentro de algunas regiones del gen gyrA que corresponden a la especie hospedera. En consecuencia, este gen podria ser util para futuros estudios filogeneticos y poblacionales. Key Words: heartworm; symbiosis; Mansonia; evolution; mosquito; parasite View this article in BioOne

The COVID-19 pandemic has abruptly changed healthcare service delivery.1 In a few weeks, clinicians and patients were asked to transition from face-to-face contacts to ‘digital-first’ solutions (that is, telephone, video, online) wherever possible. However, there is a real risk that innovation entrenches inequalities in care access, delivery, and patient safety.2 The adoption of digital technologies is known to happen unevenly …

In 2013, NHS England specified that: ‘... every person with a long-term condition or disability has a personalised care plan supporting them to develop the knowledge, skills and confidence to manage their own health’ .1 Around 40% of the UK population experience a long-term condition while 65% of people aged 65–84 years have two or more.2 This is an all-time high, with figures set to rise. This places significant personal, social, and economic burden on individuals, their families, and the community. The use of care plans to manage multiple long-term conditions — by assessing individual behaviour, setting joint goals, supporting self-management, and ensuring proactive follow-up — is based on Wagner’s Chronic Care Model.3 The model takes into account the need to provide support and structure to patients, and the fact that all long-term conditions have common challenges. Care planning has received extraordinary interest in the NHS. Policymakers endorse care planning as a way of containing high costs, encouraging a more person-centred approach, improving quality of life, and reducing mortality rates and emergency admissions to hospitals. But are care plans effective in this regard and what challenges do GP practices face in implementation? Systematic literature reviews on the impact of care planning show that it leads to only limited reductions in admissions and small improvements in patients’ physical health.4 However, …

During a three-year study of 82 pairs of Moorhens Gallinula chloropus, seasonal reproductive success (SRS) varied greatly between pairs. Pairs on big territories had a higher SRS than pairs on small territories, probably because clutch survival was higher on big territories. Pairs that began breeding early had a higher SRS than pairs that began late because early breeders laid larger clutches and could attempt more broods. Pairs with heavy males had bigger territories and began breeding earlier than pairs with light males. Heavy males therefore had a higher SRS than light males. Female weight did not affect territory size, timing of breeding, or female SRS. Assuming SRS to be a good predictor of lifetime reproductive success, selection should favour heavy males but not heavy females. Male Moorhens are significantly heavier than female Moorhens. Finally, pairs with breeding experience had a higher SRS than pairs without, because they had bigger territories and began breeding earlier. However, males in inexperienced pairs were not lighter than males in experienced pairs, so it is not clear why they defended smaller territories or laid later.

INTRODUCTION: A significant minority of otherwise healthy adults may suffer from disordered breathing during sleep. The commonest problem, known as Obstructive Sleep Apnoea Syndrome (OSAS), results in poor quality sleep, daytime hypersomnolence and excess risk of road traffic crashes. It is also associated with occupational injuries. OSAS can be successfully treated, reducing costs of hospitalisation. There is a gap in the literature regarding the burden of patients with OSAS in primary care, particularly because there is no agreed method for screening. OBJECTIVES: This pilot study was designed to determine the feasibility of screening for OSAS in a UK inner-city multi-ethnic primary care population, to investigate ways in which it might be detected, and to gain an awareness of the potential size of the burden of OSAS METHODS: We tested two methods of screening: firstly, postal questionnaires to a random sample of 240 patients from a subset of the population at highest risk of OSAS (men aged 35-65 years); and secondly, the same questionnaire plus two screening tools for detecting hypersomnolence, given to patients attending the practice for pre-registration health checks. RESULTS: Despite reminders, only 40% of postal questionnaires were returned and there were only 67 (28%) usable responses. The prevalence of snoring was 55%. Almost half of those patients who responded (46%) had a Body Mass Index (BMI) associated with a high risk of OSAS. This was not a positive responder bias because there were no significant differences in BMI between responders and non-responders. 12% had a collar size of greater than 17.5, whilst 34% reported daytime sleepiness, and 24% reported witnessed apnoea. Screening during pre-registration health checks proved both feasible and productive with 38 patients of differing linguistic abilities completing the assessment. CONCLUSION: Screening for OSAS in primary care by means of a postal questionnaire produced a low response. Whilst there was no evidence of a responder bias in terms of BMI, the numbers reporting large collar size, daytime sleepiness and witnessed apnoea suggest that a sizeable proportion of the population is at risk of OSAS. Questionnaires used in this study provide a means of identifying patients with symptoms suggestive of OSAS, although the sensitivity, specificity and positive predictive value of a self-administered instrument needs to be confirmed by a larger study incorporating ventilatory monitoring during sleep. The addition of screening to pre-registration health checks is feasible, but it would take a long time to screen all those at risk for OSAS by this route.

Background: Rounding blood pressure (BP) to the nearest 10 mmHg (terminal digit preference) and selecting for particular values near treatment cut‐offs (number preference) have both been previously described. Both reduce measurement accuracy, and may have consequences for treatment and survival. Aim: To check for number preference in screening for hypertension, and whether this influenced subsequent mortality. Design: Prospective case‐control screening study. Methods: In the General Practice Hypertensive Study Group (GPHSG), prospective case control study patients ( n =23 574) were screened on one occasion for high phase‐IV diastolic BP (DBP4) (≥90 mmHg). Identified cases were matched with normotensive controls for age, sex, date of screen and ethnic group, and were registered for mortality follow‐up ( n =6310). Patients with a high DBP4 had two further readings, and were treated if it remained elevated. Results: For DBP4 terminal digit, ‘0’ was over‐represented (28.2% vs. 20%), and the number ‘88’ was over‐represented in both men and women. There was an excess adjusted death rate for females with DBP4 88–89 mmHg vs. 90–99 mmHg for both cardiovascular (RR 2.56, 95%CI 1.43–4.56, p =0.0015) and all‐cause (1.56, 95%CI 1.06–2.29, p =0.023) mortality. For males, the corresponding rates were non‐significantly reduced: cardiovascular RR 0.69, 95%CI 0.42–1.14, p =0.15; all‐cause RR 0.93, 95%CI 0.68–1.27, p =0.64. Discussion: The quality of BP measurements should be monitored both in research studies and in clinical practice as part of clinical governance procedures.

BACKGROUND: Terminal digit and single-number preference may produce inaccuracy and biased results when measuring blood pressure. We describe these preferences in the Syst-Eur randomized placebo-controlled trial of the treatment of isolated systolic hypertension and describe how we sought to eliminate these problems. METHODS: The Data Monitoring Committee of the trial conducted yearly quality control meetings in Belgium and visited the participating centres to check their adherence to the protocol. These meetings involved identifying terminal digit preference, improving blood pressure control and boosting recruitment. RESULTS: The prevalence of use of terminal digit zero when measuring sitting systolic blood pressure (first readings) reduced from an average of 42.4% in the year prior to the date when a centre first randomized a patient to 31.5, 25, 22.3, 26.3, 23.2 and 22% in the subsequent 6 years. This trend was independent of the calendar year during which a centre entered the trial and supports the hypothesis that data-quality monitoring, including the feedback of digit preference to centres, led to a reduction in terminal digit zero preference. In addition, a higher than expected prevalence of the systolic blood pressure value of 148 mmHg was found in the active treatment groups in the double-blind phase. Selection for 148 mmHg persisted over time and constituted a single-number preference bias. This arose from the instruction to investigators to reduce systolic blood pressure to below 150 mmHg. CONCLUSION: Monitoring and feedback of data quality should be undertaken to minimize digit and number preference. Automatic devices should ideally be employed to help to avoid these problems as long as the devices are fully validated and regularly serviced, and providing that readings are not rejected and repeated. ispartof: Blood pressure monitoring vol:7 issue:3 pages:169-77 ispartof: location:England status: published

By removing males and controlling the rate of water flow past oviposition patches in an experimental area, we showed that female Calopteryx splendens xanthostoma preferred to oviposit in fast flowing water rather than slow flowing water. A series of manipulations revealed the fitness benefits to females for this preference: eggs placed in fast-flowing water developed significantly faster and showed significantly lower mortality than eggs placed in slow-flowing water. A major factor determining this difference was the deposition and growth of encrusting algae which prevented the successful hatching of eggs in slow-flowing water.

Terminal digit preference is a well-known source of error in blood pressure measurements. This was demonstrated in general practice computer databases by conducting a routine search and constructing a frequency distribution of the 20 992 blood pressure readings using mathematical software for a personal computer. The charts produced have a practical application in providing an audit tool whereby nurses and doctors can be made aware of this source of error, providing an opportunity for improving measurement technique and developing more refined and realistic protocols for blood pressure management in general practice. The same principles may be applied to other measurements made in the GP consultation such as peak expiratory flow rate.

evaluation of the 'Keep Well At Home' (KWAH) Project in West London indicated that a programme of screening persons aged 75 and over had not reduced rates of emergency attendances and admissions to hospital. However, coverage of the target population was incomplete. The present analysis addresses 'efficacy'-whether individuals who completed the screening protocol as intended did subsequently use AccidentEmergency (AE) services less often.the target population was divided into five groups, depending on whether an individual had completed none, one or both phases of screening, and whether deviations from the protocol related to incomplete coverage or refusal to participate further. We ascertained use of emergency services before screening and for up to 3 years afterwards by linkage of records from KWAH to those of local AE Departments. Patterns of emergency care were examined as crude rates and, via proportional hazards models, after adjustment for available confounders.there was an increase of 51% (95% CI 22-86%) in the crude rate of emergency admissions in the year after first-phase screening compared with the 12 months before assessment. This was most obvious in individuals deemed at high risk who also underwent the second-phase assessment (adjusted hazard ratio relative to individuals not 'at risk'=2.33; 95% CI 1.59-3.42).the available data do not allow us to distinguish between several possible explanations for the paradoxical increase in use of emergency services. However, what seem to be sensible policies do not necessarily have their intended effects when implemented in practice.

We assessed the morbidity and mortality of subjects with transiently elevated diastolic pressure in the General Practice Hypertension Study Group (GPHSG) population. A total of 23 578 patients (aged 18-65 years) from seven UK general practices were screened in 1974 for a diastolic blood pressure (DBP4) of > or = 90 mmHg. Two further readings of DBP4 determined hypertensive (either DBP4 > or = 90 mmHg) or transient hypertensive (both DBP4 < 90 mmHg) status. Transients (n = 850) were matched with normotensive controls (n = 824) and risk ratios calculated over a mean follow-up of 18.7 years. Rescreening was conducted in six of the practices (n = 20 942) after 7.7 years. Male transients had a higher relative hazard for cardiovascular mortality than controls (11.8%, 8.6%, adjusted relative hazard 1.59, P = 0.056). Female transients had a lower relative hazard for cardiovascular mortality than controls (3.6%, 5.4%, adjusted relative hazard 0.39, P = 0.018). In all, 422 patients with transient hypertension were rescreened along with 367 matched controls. Significantly more transients were on antihypertensive treatment compared with their controls (odds ratio (OR) [95% CI]) for both male (4.2 [1.6-11.1]) and female patients (2.4 [1.0-5.56]) and more untreated female transients developed hypertension. Male transients had a higher rates of diabetes mellitus (adj OR = 5.1, P = 0.04) and stroke (adj OR 15.9, P = 0.03). This study has shown that transiently elevated DBP in GPHSG is associated with a significantly higher risk of later hypertension in men and women and of diabetes, stroke and cardiovascular mortality in men. Women with this condition have a significantly lower cardiovascular mortality.

Background: the National Service Framework for Older People mandates the introduction of 'intermediate care services' to reduce emergency admissions to hospital from the population aged 75 years or more. We evaluated the predictive performance of one of the screening instruments used to identify older people who might most benefit from such services. Methods: using multiple logistic regression, we compared responses to the six-item, self-administered Sherbrooke Questionnaire with subsequent patterns of emergency attendance and admission to hospital among the elderly population of one borough in West London. Results: excess risk of both emergency attendance and admission became significant when two or more risk factors were present, and rose progressively with each additional factor, regardless of their nature. With each additional year of age, risks of emergency attendance and admission to hospital increased by 8% (95% CI = 6-10) and 9% (95% CI = 7-12), respectively. There were also significant independent risks associated with reporting memory problems (typical odds ratio (OR) 1.41, 95% CI = 1.14-1.75) and taking three or more medications (OR 1.65, 95% CI = 1.34-2.02), as well as large risks associated with attendance or admission in the year before screening. Conclusion: the Sherbrooke Questionnaire is a good measure of likely need for emergency visits to hospital among the elderly. However, programmes attempting to reduce such events should also take into account the individual's recent history of emergency attendance at hospital.

Primary and secondary care need to set up a model of combined care E pidemiological studies have shown that renal disease is common. In the United States, the third national health and nutrition survey (Nhanes III) has shown that 4.3% of the population has chronic kidney disease with a glomerular filtration rate of 30-59 ml/min/1.73 m2, and 0.2% has chronic kidney disease with a glomerular filtration rate of less than 15-29 ml/min/1.73 m2.1 In the United Kingdom, screening for renal disease by retrospective surveys of plasma creatinine measurements from chemical pathology laboratories serving defined populations has shown a similar prevalence of more severe chronic kidney disease (0.2-0.5% general population).2 3 In both studies, patients were followed longitudinally; very few developed end stage renal disease, as the major cause of death was cardiovascular disease. So what model of care should we use to look after this large number of patients with varying degrees of chronic kidney disease? Increasing numbers of studies have shown that the presence of …

During a two year study of the moorhen, Gallinula chloropus, a quarter of the nests found had two or more females laying in them. This was the result of two features of the moorhens' breeding biology: (1) Cooperative nesting; two (or more) females were paired to the same male. Both laid in the same nest, the second laid a large clutch synchronously to the first, and both cooperated in parental care. (2) Intraspecific brood parasitism; some females (parasites or dumpers) laid a small number of eggs at random in the nests' of neighbours. Cooperatively nesting females were mother and daughter, while parasite and host were not. Parasitic females laid in their own nest as well, and generally did so after completing a dumping sequence. Parasitic eggs were laid at random during the host's laying and incubation period, and were about a quarter as likely to produce an independent chick as were non-parasitic eggs. Parasitic females would probably have reared more chicks by laying in their own nests straight away, instead of dumping any eggs at all, because there was a strong decline in reproductive success with season. Possible reasons why they did not do so are discussed. Parasitised pairs tended to rear fewer own chicks than non-parasitised pairs. There was no evidence that hosts selectively destroyed parasitic eggs. Four hypotheses that explain why hosts accepted dumped eggs are considered. (1) The host pair were unaware of the dump, (2) the host male had copulated with the dumping female, (3) the dumper was related to one of the host pair, and (4) there was a benefit to the host pair because they gained extra helpers. These hypotheses were not supported by the data, but further tests are needed. As the cost of desertion was greater than the cost of acceptance of parasitic eggs, hosts may have been forced to accept.

In a 3-year study of the moorhen, Gallinula chloropus , some chicks from first broods stayed on their natal territory once they had reached independence, and helped to rear their younger, second brood, siblings. Juvenile dispersal was constrained by habitat saturation, and first brood young were forced to stay on their natal territory. Juveniles that hatched early in the year were forced to stay longer, and helped more than those that hatched late. The total feeding rates to broods with and without juvenile helpers were the same, but parents with helpers reduced their feeding rates relative to parents without helpers. Pairs with helpers (=pairs attempting second broods) reared more chicks per nesting, attempt than pairs rearing chicks at the same time of year without helpers (=pairs attempting first clutch renests). This was true both for all clutches, and for hatched clutches only, even when controlling for parental quality, territory size and scasonal effects.