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As elsewhere in the world, academic misconduct is a serious problem in Aotearoa. Yet, beyond the occasional newspaper headline, we know relatively little about the extent of the problem here or the factors associated with it. Consequently, our educational leaders and practitioners are left under-informed as they seek to address the problem and promote academic integrity. To help provide the knowledge and insights needed to craft good policy and best practice, the Research on Academic Integrity in New Zealand (RAINZ) Project--a research collaboration involving eight tertiary institutions--was founded in 2021. In the second semester of 2022, the RAINZ Project launched the first-ever nationwide survey of undergraduate students' perceptions, attitudes, and behaviours related to academic integrity. Results from this survey, which was completed by undergraduates (N = 4493), indicate that most students (approximately two-thirds) reported engaging in at least one form of academic misconduct in the past year. As hypothesised, students' perceptions (of the institutional climate and peer norms) and moral attitudes (related to cheating) were significantly associated with their engagement in academic misconduct. Details of these results as well as their implications for policy and practice are discussed.

Abstract Background Internationally, there has been a move towards fostering diverse healthcare workforces that are representative of the patient populations they serve. Selection criteria for academic-clinicians often aim to capture skills and attributes that demonstrate both clinical and academic excellence. Currently, it is not known whether the selection criteria for early academic-clinical careers advantage or disadvantage certain ethnic or socioeconomic groups. The UK has a structured route of integrated clinical academic training with entry level training for newly qualified doctors administered through the ‘Specialised Foundation Programme’ which provides protected time for research within the first two years of postgraduate clinical training. In this study, we aim to identify what selection criteria are used within the UK Specialised Foundation Programme, and how these relate to demographic factors. Methods We will perform a mixed methods study consisting of a document analysis of person specifications and selection criteria used in the 2024 UK Specialised Foundation Programme, and a national cross-sectional survey of current medical students in the UK. We will obtain the person specifications, selection criteria, white space (open ended questions used during shortlisting) and interview questions and mark schemes from each Specialised Unit of Applications via information available on their websites or through Freedom of Information requests. Our survey will collect information relating to demographic data, selection criteria, and perceptions of specialised foundation programme selection. Discussion International literature has demonstrated inequity in academic markers used in selection of post-graduate clinicians and that disadvantages caused by selection can compound over time. As such it is important to understand what inequity exists within the selection of early academic-clinicians, as this can help inform more equitable selection practices and help nurture a more diverse academic-clinical workforce.

Abstract Background Concerns about mental and cognitive health are common among university students. Engaging in regular physical exercise has been shown to enhance both mental health and cognitive performance, yet most students are not participating in the level of exercise required to obtain these benefits. The Behaviour Change Wheel (BCW) provides a framework for developing behavioural interventions that are informed by theory, evidence, and stakeholder perspectives. The current study aimed to apply the BCW to develop the PEAK Mood, Mind, and Marks program (i.e., PEAK), a behaviour change intervention designed to increase university students’ exercise engagement for the benefit of their mental and cognitive health. Methods PEAK was developed across three stages of the BCW: (1) understand the target behaviour, (2) identify intervention options, and (3) identify intervention content and delivery mode. Development was informed by triangulated data from a systematic literature review, co-design consultations with key stakeholders, and knowledge of relevant experts. Consultations with stakeholders involved focus groups with 25 university students and individual interviews with 10 university leaders and staff to identify barriers and facilitators to students’ exercise engagement and the adoption and implementation of PEAK by universities. Template analysis was used to code transcripts to the capability, opportunity, and motivation (COM-B) model of behaviour. The BCW was applied to identify the most appropriate intervention types and behaviour change techniques (BCTs). Results Thirty-one barriers and facilitators were identified and mapped to seven intervention types (Education; Modelling; Persuasion; Environmental Restructuring; Incentivisation; Training; and Enablement) and 26 BCTs, which were delivered across digital channels and in-person. The final intervention consisted of multiple components targeting students’ capability (e.g., increasing knowledge about the mental and cognitive health benefits of exercise), opportunity (e.g., providing a flexible range of accessible exercise options and social support), and motivation (e.g., increasing the perceived importance of exercise) to exercise. Conclusions University students and staff describe a need and appetite for more empowering, scalable solutions to support students’ mental and cognitive health. Exercise-based approaches that are informed by behaviour change frameworks, evidence, and stakeholder perspectives, such as PEAK, have the potential to address this need. Current findings will inform a pilot of PEAK to evaluate its efficacy and implementation.

Abstract Background Sugammadex is a pharmacologic agent that provides rapid reversal of neuromuscular blockade via encapsulation of the neuromuscular blocking agent (NMBA). The sugammadex-NMBA complex is primarily cleared through glomerular filtration from the kidney, raising the possibility that alterations in renal function could affect its elimination. In pediatric patients, the benefits of sugammadex have led to widespread utilization; however, there is limited information on its application in pediatric renal impairment. This study examined sugammadex use and postoperative outcomes in pediatric patients with severe chronic renal impairment at our quaternary pediatric referral hospital. Methods After IRB approval, we performed a retrospective analysis in pediatric patients with stage IV and V chronic kidney disease who received sugammadex from January 2017 to March 2022. Postoperative outcomes studied included new or increased respiratory requirement, unplanned intensive care unit (ICU) admission, postoperative pneumonia, anaphylaxis, and death within 48 h postoperatively, unplanned deferral of intraoperative extubation, and repeat administrations of NMBA reversal after leaving the operating room. Results The final cohort included 17 patients ranging from 8 months to 16 years old. One patient required new postoperative noninvasive ventilation on postoperative day 2, which was credited to hypervolemia. Another patient had bronchospasm intraoperatively resolving with medication, which could not definitively be associated sugammadex administration. There were no instances of deferred extubation, unplanned ICU or need for supplemental oxygen after tracheal extubation identified. Conclusion No adverse effects directly attributable to sugammadex in pediatric patients with severe renal impairment were detected. There may be a role for utilization of sugammadex for neuromuscular reversal in this population.

Objectives This study addressed two research questions: What factors do doctors in training describe as influencing their choices to apply (or not apply) for specialty training during their Foundation Year 2? Which of these factors are specific to the context of the COVID-19 pandemic, and the unique experiences of the cohort of doctors who qualified early during the pandemic?Design Sequential explanatory mixed methods study: Quantitative survey. Qualitative semistructured interviews. Quantitative data were analysed with logistic regression. Qualitative data were analysed using reflexive thematic analysis.Setting UK-wide.Participants Junior doctors who graduated medical school in 2020. Survey: 320 participants (22% of those contacted). 68% (n=219) were female, 60% (n=192) under 25 and 35% (n=112) 25–30. 72% (n=230) were white, 18% (n=58) Asian and 3% (n=10) black. Interviews: 20 participants, 10 had applied for specialty training, 10 had not.Results A minority of respondents had applied for specialty training to start in 2022 (114, 36%). While burnout varied, with 15% indicating high burnout, this was not associated with the decision to apply. This decision was predicted by having taken time off due to work-related stress. Those who had not taken time off were 2.4 times more likely to have applied for specialty training (OR=2.43, 95% CI 1.20 to 5.34). Interviews found reasons for not applying included wanting to ‘step off the treadmill’ of training; perceptions of training pathways as inflexible, impacting well-being; and disillusionment with the community and vocation of healthcare, based, in part, on their experiences working through COVID-19.Conclusions Participants infrequently cited factors specific to the pandemic had impacted their decision-making but spoke more broadly about challenges associated with increasing pressure on the health service and an eroded sense of vocation and community.

Objective Explore the perceptions of senior medical students on the relationship between gender and pain and examine how formal and hidden curricula in medical education shape their experiences.Design We conducted a cross-sectional qualitative interview study, using individual semistructured interviews and adhering to interpretative description methodology. We used Braun and Clarke’s reflexive approach to thematic analysis to analyse our data.Setting Six medical schools across the UK. Data collection occurred between the autumn of 2022 and the spring of 2023.Participants 14 senior (penultimate or final year) medical students.Results We created three themes, which describe key educational forces shaping students’ experiences of the relationship between gender and pain. These are (1) the sociocultural influencer, (2) the pedagogical influencer and (3) the professorial influencer. Our findings highlight the influence of both wider societal norms and students’ own identities on their experiences. Further, we explore the nature and detrimental role of formal curricular gaps, and negative role modelling as a key mechanism by which a hidden curriculum relating to gender and pain exerts its influence.Conclusions These findings have several educational implications, including the need for a more holistic, person-centred approach to pain management within medical school curricula. Additionally, we recommend the creation of reflective spaces to engage students in critical thinking around bias and advocacy from the early stages of their training. We present actionable insights for medical educators to address issues of gender bias and pain management.

Abstract Background Physical activity is important for all aspects of health, yet most university students are not active enough to reap these benefits. Understanding the factors that influence physical activity in the context of behaviour change theory is valuable to inform the development of effective evidence-based interventions to increase university students’ physical activity. The current systematic review a) identified barriers and facilitators to university students’ physical activity, b) mapped these factors to the Theoretical Domains Framework (TDF) and COM-B model, and c) ranked the relative importance of TDF domains. Methods Data synthesis included qualitative, quantitative, and mixed-methods research published between 01.01.2010—15.03.2023. Four databases (MEDLINE, PsycINFO, SPORTDiscus, and Scopus) were searched to identify publications on the barriers/facilitators to university students' physical activity. Data regarding study design and key findings (i.e., participant quotes, qualitative theme descriptions, and survey results) were extracted. Framework analysis was used to code barriers/facilitators to the TDF and COM-B model. Within each TDF domain, thematic analysis was used to group similar barriers/facilitators into descriptive theme labels. TDF domains were ranked by relative importance based on frequency, elaboration, and evidence of mixed barriers/facilitators. Results Thirty-nine studies involving 17,771 participants met the inclusion criteria. Fifty-six barriers and facilitators mapping to twelve TDF domains and the COM-B model were identified as relevant to students’ physical activity. Three TDF domains, environmental context and resources (e.g., time constraints), social influences (e.g., exercising with others), and goals (e.g., prioritisation of physical activity) were judged to be of greatest relative importance (identified in > 50% of studies). TDF domains of lower relative importance were intentions, reinforcement, emotion, beliefs about consequences, knowledge, physical skills, beliefs about capabilities, cognitive and interpersonal skills, social/professional role and identity, and behavioural regulation. No barriers/facilitators relating to the TDF domains of memory, attention and decision process, or optimism were identified. Conclusions The current findings provide a foundation to enhance the development of theory and evidence informed interventions to support university students’ engagement in physical activity. Interventions that include a focus on the TDF domains 'environmental context and resources,' 'social influences,' and 'goals,' hold particular promise for promoting active student lifestyles. Trial registration Prospero ID—CRD42021242170.

IntroductionRegular exercise has the potential to enhance university students’ mental and cognitive health. The PEAK Mood, Mind and Marks program (i.e., PEAK) is a neuroscience-informed intervention developed using the Behaviour Change Wheel to support students to exercise three or more times per week to benefit their mental and cognitive health. This pilot study assessed the impact of PEAK on exercise, mental and cognitive health, and implementation outcomes.MethodsPEAK was delivered to 115 undergraduate university students throughout a 12-week university semester. The primary outcome was weekly exercise frequency. Secondary outcomes were: time spent engaged in moderate-vigorous exercise, sedentary behaviour and perceived mental health and cognitive health. All were measured via online self-report questionnaires. Qualitative interviews with 15 students investigated influences on engagement, the acceptability and appropriateness of PEAK, and its mechanisms of behaviour change. Paired t-tests, Wilcoxon Signed-Rank tests and template analysis were used to analyse quantitative and qualitative data, respectively.ResultsOn average, 48.4% of students engaged in the recommended frequency of three or more exercise sessions per week. This proportion decreased towards the end of PEAK. Sedentary behaviour significantly decreased from baseline to end-point, and moderate-vigorous exercise significantly increased among students’ who were non-exercisers. Mental wellbeing, stress, loneliness, and sense of belonging to the university significantly improved. There were no significant changes in psychological distress. Concentration, memory, and productivity significantly improved. Sixty-eight percent of students remained engaged in one or more components of PEAK at end-point. Qualitative data indicated students found PEAK to be acceptable and appropriate, and that it improved aspects of their capability, opportunity, and motivation to exercise.ConclusionsStudents are receptive to an exercise-based program to support their mental and cognitive health. Students exercise frequency decreased; however, these figures are likely a conservative estimate of students exercise engagement. Students valued the neuroscience-informed approach to motivational and educational content and that the program’s goals aligned with their academic goals. Students identified numerous areas PEAK’s content and implementation can be optimised, including use of a single digital delivery platform, more opportunities to connect with peers and to expand the content’s cultural inclusivity.

Abstract Background The number of healthcare professionals leaving clinical practice and transitioning to alternative careers in health professions education is increasing. Among these non-practicing healthcare professionals, concerns have been reported regarding tensions in relation to identity, role, and credibility in their new field. There are suggestions that this is a particularly pressing issue for minoritised professionals who make this transition. Support is critical to attract and retain diverse talent within health professions education teaching and research. The purpose of this scoping review is to explore the career experiences of non-practicing healthcare professionals who work in health professions education internationally. Methods Arksey and O’Malley’s framework has been utilised to guide the design of this scoping review process and will be used throughout the course of the review. A comprehensive search of seven electronic databases and limited search of Google Scholar will be conducted, as well as a hand search of eligible article reference lists. Two reviewers will independently screen all articles based on inclusion criteria, with conflicts resolved by a third reviewer. Data from included articles will be charted, collated, and analysed thematically. Meta-data will be summarised quantitatively. Discussion This scoping review aims to explore the role and experiences of non-practicing healthcare professionals working within health professions education. The review will follow established scoping review guidelines and will include studies from various regions and languages, provided an English translation is available. The study remit will be broad, including both quantitative and qualitative studies, as well as reviews and opinion papers. Limitations may include the exclusion of non-English articles and potential difficulty of identifying papers which discuss the experiences of non-practicing clinicians. However, the review will provide insight into the current knowledge on what it is like to be a non-practicing clinician working within health professions education and identify gaps for both future research, and future support for those making this career transition. Systematic review registration Open Science Framework Registration https://doi.org/10.17605/OSF.IO/485Z3

Study Objective. Sugammadex is a widely used neuromuscular blockade reversal agent. Cost concerns limit use in pediatric patients for, whom recommended doses are often far less than vial quantities. Therefore, we undertook a quality improvement initiative at a pediatric hospital in which sugammadex vials were fractionated. We hypothesized we would see a decrease in administered dose and waste and improved adherence with dosing guidelines. Methods. Sugammadex vials were fractionated into 25, 50, or 100 mg aliquots, which would be distributed to anesthesia staff by pharmacy staff in approximate 2 mg/kg of actual body weight doses (±10%). We analyzed changes in sugammadex waste and dosing practices 1/1/2019 to 3/15/2023 pre/postintervention (4/1/2021). We gauged dose appropriateness using last train of four (TOF) prior to sugammadex administration. Results. 7,889 patients 2–17 years (4,771 with documented TOF), ASA 1–4 receiving general anesthesia with a steroidal NMB medication and sugammadex reversal. Pre- and postintervention mean doses were 2.5 mg/kg (SD: 1.2) and 2.4 mg/kg (SD: 0.96), respectively. A smaller proportion of cases received standard 2 or 4 mg/kg doses (pre: 77.6 vs. post: 66.7%). Mean waste per case declined from 4.2 mg/kg (SD: 4.1) to 0.22 mg/kg (SD: 0.38). Among cases with 0 or 1 measured twitches on TOF that should receive at least 4 mg/kg, fewer received at least 3.6 mg/kg (post: 56.7% vs. pre: 66.8%), and a greater proportion received less than 2.2 mg/kg (post: 27.4% vs. pre: 20.7%). Among cases that should have received at least 2 mg/kg by TOF, the proportion of patients receiving more than 3.6 mg/kg declined from 9.5% to 5.2%. Discussion. Fractionating sugammadex vials was associated with decreases in waste, but not dose, and significant underdosing was more likely to occur. While vial fractionation could enable increased access to sugammadex and other costly medications, it may introduce unintended consequences.

Objective To better understand the broader experience of medical students impacted by discrimination and the support systems they engage with.Design Qualitative study using semi-structured interviews.Setting Four medical schools based in the UK.Participants 17 medical students were recruited using volunteer and snowball sampling: all students self-identified as being impacted by discrimination.Results 5 themes were identified: feelings of isolation, imposter syndrome and exclusion; a lack of representation and positive role modelling; the importance of peer support; issues relating to the accessibility of support; building support networks through shared experiences and attempts to foster a sense of inclusion through peer and institutionally led initiatives.Conclusions The findings of this study suggest medical schools could do more to recognise the importance of acknowledging the multiple identities at risk of discrimination held by students, perpetuating feelings of isolation and exclusion. Our research highlights the need for practical systemic initiatives to improve the sense of belonging of medical students who are impacted by discrimination. Medical educators and institutions should consider formal and informal provisions, such as creating time and space for students to meet and share experiences, access support and reporting networks, to foster a greater sense of belonging.

Objective To explore medical student and school pupil experiences of an outreach school teaching project.Setting Community engagement is increasingly commonplace within medical school. Secondary schools offer ample opportunities for community engagement as medical students teach and engage in service learning. There is a lack of research regarding the impact of school community engagement projects and the impact on pupils, as critical stakeholders in the service medical students provide. In this qualitative study, we explore the perspectives of medical students and school pupils involved in a school teaching project.Participants Ten medical students participated in individual interviews, and 17 school pupils across three schools participated in group interviews. Data were analysed using thematic analysis and the concept of service learning.Results For medical students, the project fostered communication and teaching skills, but a lack of reflection hampered further benefit. For school pupils, experiences varied – learning about careers in medicine could be inspiring, but content pitched at the incorrect level disengaged some pupils. The conflict between session timing and medical students’ exams negatively influenced engagement.Conclusions To shift the focus of community engagement projects that promote service-learning towards mutual benefit, designing in partnership with relevant community stakeholders and integrating opportunities to reflect on these experiences are critical.

Abstract Background Lithopedion is a term that refers to a fetus that has calcified or changed to bone. The calcification may involve the fetus, membranes, placenta, or any combination of these structures. It is an extremely rare complication of pregnancy and can remain asymptomatic or present with gastrointestinal and/or genitourinary symptoms. Case presentation A 50-year-old Congolese refugee with a nine-year history of retained fetus after a fetal demise was resettled to the United States (U.S.). She had chronic symptoms of abdominal pain and discomfort, dyspepsia, and gurgling sensation after eating. She experienced stigmatization from healthcare professionals in Tanzania at the time of the fetal demise and subsequently avoided healthcare interaction whenever possible. Upon arrival to the U.S., evaluation of her abdominal mass included abdominopelvic imaging which confirmed the diagnosis of lithopedion. She was referred to gynecologic oncology for surgical consultation given intermittent bowel obstruction from underlying abdominal mass. However, she declined intervention due to fear of surgery and elected for symptom monitoring. Unfortunately, she passed away due to severe malnutrition in the context of recurrent bowel obstruction due to the lithopedion and continued fear of seeking medical care. Conclusion This case demonstrated a rare medical phenomenon and the impact of medical distrust, poor health awareness, and limited access to healthcare among populations most likely to be affected by a lithopedion. This case highlighted the need for a community care model to bridge the gap between the healthcare team and newly resettled refugees.

Objective Longitudinal learning often faces implementation challenges within UK medical schools. Some have suggested that the hidden curriculum may be implicated, but there is little evidence regarding how the hidden curriculum influences student experiences of, and engagement with longitudinal learning. Given this, our objective was to explore the impact of the hidden curriculum on student experiences of a longitudinal curriculum based in primary care at a research-intensive medical school.Design We conducted a longitudinal qualitative study. Students participated in three serial, in-depth semistructured interviews. We conducted a longitudinal thematic analysis.Setting One research-intensive medical school based in the UK. Data collection occurred in 2021–2022.Participants 12 penultimate year medical students taking part in a longitudinal primary care placement for 1 day a week over the course of one academic year.Results We constructed four themes capturing insights on how hidden curricula influenced students’ experiences: (1) A culture which stresses assessment influences student engagement with longitudinal learning; (2) Longitudinal relationships can challenge the hidden curriculum; (3) Support and continuity within primary care improves skills and can influence belonging and (4) Logistical issues influence engagement with longitudinal learning.Conclusions The hidden curriculum, particularly related to assessment, plays a large role in student perceptions of educational value and subsequent engagement with curricula. In a research-intensive institution, longitudinal learning, particularly within primary care, was perceived as at odds with what was important for assessments. Where longitudinal relationships were successfully established, students became more aware of the benefits of person-centred practice. For primary care longitudinal education to succeed in more research-intensive institutions, there must first be advocacy for greater representation of primary care and person-centred values within organisational structures to ensure meaningful curricular alignment.

Historically, ecosystem models have treated rainfall as the primary moisture source driving litter decomposition. In many arid and semi-arid lands, however, non-rainfall moisture (fog, dew, and water vapor) plays a more important role in supporting microbial activity and carbon turnover. To date though, we lack a robust approach for modeling the role of non-rainfall moisture in litter decomposition. We developed a series of simple litter decay models with different moisture sensitivity and temperature sensitivity functions to explicitly represent the role of non-rainfall moisture in the litter decay process. To evaluate model performance, we conducted a 30-month litter decomposition study at 6 sites along a fog and dew gradient in the Namib desert, spanning almost an eightfold difference in non-rainfall moisture frequency. Litter decay rates in the field correlated with fog and dew frequencies but not with rainfall. Including either temperature or non-rainfall moisture sensitivity functions improved model performance, but the combination of temperature and moisture sensitivity together provided more realistic estimates of litter decomposition than relying on either alone. Model performance was similar regardless of whether we used continuous moisture sensitivity functions based on relative humidity or a simple binary function based on the presence of moisture, although a Gaussian temperature sensitivity outperformed a monotonically increasing Q10 temperature function. We demonstrate that explicitly modeling non-rainfall moisture and temperature together is necessary to accurately capture litter decay dynamics in a fog-affected dryland system and provide suggestions for how to incorporate non-rainfall moisture into existing Earth system models.

BackgroundChest drain management has a significant influence on postoperative recovery after robot-assisted minimally invasive esophagectomy (RAMIE). The use of chest drains increases postoperative pain by irritating intercostal nerves and hinders patients from early postoperative mobilization and recovery. To our knowledge, no study has investigated the use of two vs. one intercostal chest drains after RAMIE.MethodsThis retrospective cohort study evaluated patients undergoing elective RAMIE with gastric conduit pull-up and intrathoracic anastomosis. Patients were divided into two groups according to placement of one (11/2020–08/2022) or two (08/2018–11/2020) chest drains. Propensity score matching was performed in a 1:1 ratio, and the incidences of overall and pulmonary complications, drainage-associated re-interventions, radiological diagnostics, analgesic use, and length of hospital stay were compared between single drain and double drain groups.ResultsDuring the study period, 194 patients underwent RAMIE. Twenty-two patients were included after propensity score matching in the single and double chest drain group, respectively. Time until removal of the last chest drain [postoperative day (POD) 6.7 ± 4.4 vs. POD 9.4 ± 2.7, p = 0.004] and intensive care unit stay (4.2 ± 5.1 days vs. 5.3 ± 3.5 days, p = 0.01) were significantly shorter in the single drain group. Overall and pulmonary complications, drainage-associated events, re-interventions, number of diagnostic imaging, analgesic use, and length of hospital stay were comparable between both groups.ConclusionThis study is the first to demonstrate the safety of single intercostal chest drain use and, at least, non-inferiority to double chest drains in terms of perioperative complications after RAMIE.

Abstract Background Empathic erosion and burnout represent crises within medicine. Psychological training has been used to promote empathy and personal resilience, yet some training useful within adjacent fields remain unexplored, e.g., Stoic training. Given recent research within psychology suggesting that Stoic training increases emotional wellbeing, exploring this type of training within health professions education is important. We therefore asked: What impact would a Stoicism informed online training package have on third year medical students’ resilience and empathy? Methods 24 third year medical students took part in 12 days of online training (SeRenE), based on Stoic philosophy, and co-developed with psychotherapists. A mixed-methods study was conducted to evaluate impact. Pre- and post-SeRenE students completed the Stoic Attitudes and Behaviours Scale (SABS), Brief Resilience Scale (BRS) and Jefferson Scale of Empathy (JSE). All students completed semi-structured interviews following training and 2 months post-SeRenE. Thematic analysis was employed to analyse qualitative data, whilst within subjects t-tests and correlational analyses were conducted on quantitative data. Results Quantitatively, stoic ideation, resilience and empathy increased post-training, with correlational analyses suggesting resilience and empathy increase in tandem. Qualitatively, four themes were identified: 1. Negative visualisation aids emotional and practical preparedness; 2. Stoic mindfulness encourages students to think about how they think and feel; 3. Stoic reflection develops the empathic imagination; and 4. Evaluating the accessibility of SeRenE. Conclusions Our data lend support to the ability of Stoic-based psychological training to positively influence resilience and empathy. Although, quantitatively, results were mixed, qualitative data offers rich insight. The practice of negative visualisation, promoted by SeRenE, encourages student self-efficacy and planning, domains of resilience associated with academic success. Further, this study demonstrates a connection between Stoic practice and empathy, which manifests through development of the empathic imagination and a sense of empathic bravery.

Abstract Major depressive disorder (MDD) is a common, disabling, and heterogeneous condition that responds unpredictably to current treatments. We previously showed an association between depressive symptoms and plasma concentrations of two cholesterol precursors, desmosterol and 7-dehydrocholesterol (7DHC). Here, we measured total cholesterol and sterol concentrations with mass spectrometry in postmortem brain samples from depressed and control subjects. Mean (±SEM) desmosterol concentration was 8.9 ± 0.97 ng/mg in the depressed versus 10.7 ± 0.72 ng/mg in the control group. The mean of the posterior probability distribution for the difference in desmosterol concentration between the two groups was 2.36 (95% highest density interval [HDI] 0.59–4.17). Mean 7DHC concentrations, 12.5 ± 4.1 ng/mg in the depressed versus 5.4 ± 0.74 ng/mg in the control group, were unlikely to be different (95% HDI, [−1.37–0.34]). We found that presence of trazodone in the peri-mortem toxicology screen accounted for the observed difference in desmosterol concentrations. We also observed extremely high 7DHC levels in all 4 subjects who had taken trazodone. Trazodone has been recently found to inhibit 7-dehydrocholesterol reductase and alter sterol concentrations in rodents, cell culture, human fibroblasts, and blood. In this study, we demonstrate for the first time that trazodone alters human brain sterol composition. Given congenital deficiency of 7-dehydrocholesterol reductase results in Smith-Lemli-Opitz syndrome, our findings support the hypothesis that this commonly used medication may have previously unappreciated risks.

RNA-based viruses can be engineered to express artificial microRNAs (amiRNAs). Here, the authors identify a candidate amiRNA that confers a replicative advantage to oncolytic viruses, enhancing their anticancer potency, and show that intercellular transfer of extracellular vesicles carrying the amiRNA promotes bystander killing of uninfected cancer cells.

A multiplexed machine-vision-based tracking system enables the high-content analysis of C. elegans behavior in several 96-well plates at a time and shows its utility for comparisons across multiple genotypes and upon drug treatment, tackling the bottlenecks in behavioural quantification.

Abstract Background Lysosomal storage diseases (LSDs) are inherited metabolic disorders that may lead to severe multi-organ disease. Current ERTs are limited by anti-drug antibodies, the blood–brain barrier, and early disease onset and progression before ERT is started. We have opened a phase I clinical trial of enzyme replacement therapy (ERT) for fetuses with LSDs (NCT04532047). We evaluated the attitudes of parents and patients with LSDs towards fetal clinical trials and therapies. Methods A multidisciplinary team designed a survey which was distributed by five international patient advocacy groups. We collected patients’ demographic, diagnostic, and treatment information. Associations between respondent characteristics and attitudes towards fetal therapies/trials were analyzed using multivariate ordinal logistic regression. Results The survey was completed by 181 adults from 19 countries. The majority of respondents were mothers from the United States. The most common diseases were MPS1 (26%), MPS3 (19%), and infantile-onset Pompe (14%). Most patients (88%) were diagnosed after birth, at a median of 21 months. Altogether, 65% of participating patients and children of participants had received ERT, 27% a stem cell transplant, and 4% gene therapy. We found that half (49%) of respondents were unlikely to terminate a future affected pregnancy, 55% would enroll in a phase I clinical trial for fetal ERT, and 46% would enroll in a fetal gene therapy trial. Respondents who received postnatal ERT were significantly more likely enroll in a trial for fetal ERT or gene therapy (ERT OR 4.48, 95% CI 2.13–9.44, p

Abstract Synthesis research in ecology and environmental science improves understanding, advances theory, identifies research priorities, and supports management strategies by linking data, ideas, and tools. Accelerating environmental challenges increases the need to focus synthesis science on the most pressing questions. To leverage input from the broader research community, we convened a virtual workshop with participants from many countries and disciplines to examine how and where synthesis can address key questions and themes in ecology and environmental science in the coming decade. Seven priority research topics emerged: (1) diversity, equity, inclusion, and justice (DEIJ), (2) human and natural systems, (3) actionable and use‐inspired science, (4) scale, (5) generality, (6) complexity and resilience, and (7) predictability. Additionally, two issues regarding the general practice of synthesis emerged: the need for increased participant diversity and inclusive research practices; and increased and improved data flow, access, and skill‐building. These topics and practices provide a strategic vision for future synthesis in ecology and environmental science.

The causal mechanisms and manifestations of psychiatric illness cannot be neatly narrowed down or quantified for diagnosis and treatment. Large-scale genome-wide association studies (GWAS) might renew hope for locating genetic predictors and producing precision medicines, however such hopes can also distract from appreciating social factors and structural injustices that demand more socially inclusive and equitable approaches to mental healthcare. A more comprehensive approach begins with recognizing that there is no one type of contributor to mental illness and its duration that should be prioritized over another. We argue that, if the search for biological specificity is to complement the need to alleviate the social distress that produces mental health inequities, psychiatric genomics must incorporate an intersectional dimension to models of mental illness across research priorities, scientific frameworks, and clinical applications. We outline an intersectional framework that will guide all professionals working in the expanding field of psychiatric genomics to better incorporate issues of social context, racial and cultural diversity, and downstream ethical considerations into their work.

A hexanucleotide repeat expansion of C9orf72 is translated to dipeptide repeat proteins in amyotrophic lateral sclerosis and frontotemporal dementia patients. Here the authors generate a C. elegans model of C9orf72-mediated ALS/FTD and show that translation initiation factor eIF2D regulates the dipeptide repeat protein expression.

Abstract Anaesthesia exposure to the developing nervous system causes neuroapoptosis and behavioural impairment in vertebrate models. Mechanistic understanding is limited, and target-based approaches are challenging. High-throughput methods may be an important parallel approach to drug-discovery and mechanistic research. The nematode worm Caenorhabditis elegans is an ideal candidate model. A rich subset of its behaviour can be studied, and hundreds of behavioural features can be quantified, then aggregated to yield a ‘signature’. Perturbation of this behavioural signature may provide a tool that can be used to quantify the effects of anaesthetic regimes, and act as an outcome marker for drug screening and molecular target research. Larval C. elegans were exposed to: isoflurane, ketamine, morphine, dexmedetomidine, and lithium (and combinations). Behaviour was recorded, and videos analysed with automated algorithms to extract behavioural features. Anaesthetic exposure during early development leads to persisting behavioural variation (in total, 125 features across exposure combinations). Higher concentrations, and combinations of isoflurane with ketamine, lead to persistent change in a greater number of features. Morphine and dexmedetomidine do not appear to lead to behavioural impairment. Lithium rescues the neurotoxic phenotype produced by isoflurane. Findings correlate well with vertebrate research: impairment is dependent on agent, is concentration-specific, is more likely with combination therapies, and can potentially be rescued by lithium. These results suggest that C. elegans may be an appropriate model with which to pursue phenotypic screens for drugs that mitigate the neurobehavioural impairment. Some possibilities are suggested for how high-throughput platforms might be organised in service of this field.

Abstract Novel invertebrate‐killing compounds are required in agriculture and medicine to overcome resistance to existing treatments. Because insecticides and anthelmintics are discovered in phenotypic screens, a crucial step in the discovery process is determining the mode of action of hits. Visible whole‐organism symptoms are combined with molecular and physiological data to determine mode of action. However, manual symptomology is laborious and requires symptoms that are strong enough to see by eye. Here, we use high‐throughput imaging and quantitative phenotyping to measure Caenorhabditiselegans behavioral responses to compounds and train a classifier that predicts mode of action with an accuracy of 88% for a set of ten common modes of action. We also classify compounds within each mode of action to discover substructure that is not captured in broad mode‐of‐action labels. High‐throughput imaging and automated phenotyping could therefore accelerate mode‐of‐action discovery in invertebrate‐targeting compound development and help to refine mode‐of‐action categories.

Abstract Background The coronavirus disease 2019 pandemic has led to global disruption of healthcare. Many students volunteered to provide clinical support. Volunteering to work in a clinical capacity was a unique medical education opportunity; however, it is unknown whether this was a positive learning experience or which volunteering roles were of most benefit to students. Methods The COVIDReady2 study is a national cross-sectional study of all medical students at medical schools in the United Kingdom. The primary outcome is to explore the experiences of medical students who volunteered during the pandemic in comparison to those who did not. We will compare responses to determine the educational benefit and issues they faced. In addition to quantitative analysis, thematic analysis will be used to identify themes in qualitative responses. Discussion There is a growing body of evidence to suggest that service roles have potential to enhance medical education; yet, there is a shortage of studies able to offer practical advice for how these roles may be incorporated in future medical education. We anticipate that this study will help to identify volunteer structures that have been beneficial for students, so that similar infrastructures can be used in the future, and help inform medical education in a non-pandemic setting. Trial registration Not Applicable.

Abstract Although marine subsidies often enrich terrestrial ecosystems, their influence is known to be context‐dependent. Additionally, the multitrophic impact of marine subsidies has not been traced through food webs across physically diverse islands. Here, we test predictions about how island characteristics can affect marine enrichment of food web constituents and how nutrients flow through island food webs. To evaluate enrichment and trace marine nutrients across food webs, we used stable isotopes of soil, flora, and fauna (n = 4752 samples) collected from 97 islands in British Columbia, Canada. Island area was the strongest predictor of enrichment across taxa; we found that samples were more 15N‐rich on smaller islands. Enrichment declined with distance from shore but less so on small islands, implying a higher per‐unit‐area subsidy effect. These area and distance‐to‐shore effects were taxon‐specific, and nearly twice as strong in basal food web groups. We also found that increases in δ15N correlated with increases in %N in basal trophic groups, as well as in songbirds, implying biologically relevant uptake of a potentially limiting nutrient. Path analysis demonstrated that subsidies in soil flow through plants and detritivores, and into upper‐level consumers. Our results reveal an interplay between island biogeography and marine subsidies in shaping island food webs through bottom‐up processes.

Objective: To provide qualitative empirical data on parental expectations of diagnostic prenatal genomic sequencing and the value of the results to families.Methods: We interviewed 15 families—mothers and/or fathers—who had had prenatal genomic sequencing about their expectations and their respective evaluations of the benefits of genomic sequencing.Results: Families’ hopes for genetic sequencing clustered around three themes: hoping to identify the cause of the fetal anomaly in a terminated pregnancy; hopes for guidance as to the likely outcome of current pregnancy; and hopes for information to support future family planning. In addition, hopes were discussed in terms of the potential for results to be beneficial in acquiring greater knowledge, while at the same time recognizing that new knowledge may raise more questions. Assessment of the value of sequencing largely mirrored these expectations when positive results seen. Negative results can also be seen as valuable in ruling out a genetic cause and in providing certainty that families had done everything that they could to know about the cause of fetal demise.Conclusion: It would appear that with guidance from genetic counsellors, families were largely able to navigate the many uncertainties of prenatal genomic sequencing and thus see themselves as benefitting from sequencing. However, support structures are essential to guide them through their expectations and interpretations of results to minimize possible harms. Engaging in the process of genomic sequencing was seen as beneficial in of itself to families who would otherwise be left without any options to seek diagnostic answers.

Genomic sequencing has been increasingly utilized for prenatal diagnosis in recent years and this trend is likely to continue. However, decision-making for parents in the prenatal period is particularly fraught, and prenatal sequencing would significantly expand the complexity of managing health risk information, reproductive options, and healthcare access. This qualitative study investigates decision-making processes amongst parents who enrolled or declined to enroll in the prenatal arm of the California-based Program in Prenatal and Pediatric Genome Sequencing (P3EGS), a study in the Clinical Sequencing Evidence-Generating Research (CSER) consortium that offered whole exome sequencing for fetal anomalies with a focus on underrepresented groups in genomic research. Drawing on the views of 18 prenatal families who agreed to be interviewed after enrolling (n = 15) or declining to enroll (n = 3) in P3EGS, we observed that the timing of sequencing, coupled with unique considerations around experiences of time during pregnancy and prenatal testing, intersect with structural supports beyond the clinic to produce preferences for and against prenatal sequencing and to contain the threat of unwelcome, uncertain knowledge. Particularly for those without structural supports, finding out consequential information may be more palatable after the birth, when the first stage of the uncertain future has been revealed. Future research should examine the role of temporality in decision-making around prenatal genomic sequencing across diverse population cohorts, in order to observe more precisely the role that structural barriers play in patient preferences.

Abstract The 2018 summit and flank eruption of Kīlauea Volcano was one of the largest volcanic events in Hawaiʻi in 200 years. Data suggest that a backup in the magma plumbing system at the long-lived Puʻu ʻŌʻō eruption site caused widespread pressurization in the volcano, driving magma into the lower flank. The eruption evolved, and its impact expanded, as a sequence of cascading events, allowing relatively minor changes at Puʻu ʻŌʻō to cause major destruction and historic changes across the volcano. Eruption forecasting is inherently challenging in cascading scenarios where magmatic systems may prime gradually and trigger on small events.

Cancer is a systemic disease that associates with host metabolic changes. Here, the authors show using Drosophila, that tumours exploit extracellular proline in response to muscle wasting, indicating that tumours induce muscle wasting as a nutrient-scavenging programme to drive tumourigenesis.

The development of reliable measures of health in ageing organisms is a need in ageing research. Using atomic force microscopy, here, the authors assess whole body stiffness of worms and show that it reflects organismal fitness.

The conservation benefits of wildlife rehabilitation are equivocal, but could be substantial for formerly common species that are declining rapidly but are still commonly admitted to wildlife centres. We used a questionnaire survey to estimate the number of practitioners rehabilitating West European hedgehogs (Erinaceus europaeus) in Britain and the numbers entering hospitals/centres in one benchmark year (2016); practitioners were identified using an internet search and snowball sampling. Overall, 304 rehabilitators were identified: 148 supplied data on their structure, and 174 outlined the number of hedgehogs admitted in 2016. The former comprised 62.6% small (≤50 hedgehogs admitted year−1), 16.7% medium-sized (51–250 yr−1), and 20.7% large (>250 yr−1) hospitals; however, these accounted for 4.8%, 12.4%, and 82.8% of hedgehog admissions, respectively. Small hospitals were less likely to be registered as a charity, have paid staff, have a social media account, to record admissions electronically, or to conduct post-release monitoring. However, they were more likely to operate from their home address and to have been established for ≤5 years. Extrapolations indicate that this rehabilitation community admitted >40,000 hedgehogs in 2016, of which approximately 50% could have been released. These figures suggest that wildlife rehabilitation has potentially been an important factor in the dynamics of hedgehog populations in Britain in the last two decades.

The primary scientific objective of MexiDrill, the Basin of Mexico Drilling Program, is development of a continuous, high-resolution ∼400 kyr lacustrine record of tropical North American environmental change. The field location, in the densely populated, water-stressed Mexico City region gives this record particular societal relevance. A detailed paleoclimate reconstruction from central Mexico will enhance our understanding of long-term natural climate variability in the North American tropics and its relationship with changes at higher latitudes. The site lies at the northern margin of the Intertropical Convergence Zone (ITCZ), where modern precipitation amounts are influenced by sea surface temperatures in the Pacific and Atlantic basins. During the Last Glacial Maximum (LGM), more winter precipitation at the site is hypothesized to have been a consequence of a southward displacement of the mid-latitude westerlies. It thus represents a key spatial node for understanding large-scale hydrological variability of tropical and subtropical North America and is at an altitude (2240 m a.s.l.), typical of much of western North America. In addition, its sediments contain a rich record of pre-Holocene volcanic history; knowledge of the magnitude and frequency relationships of the area's explosive volcanic eruptions will improve capacity for risk assessment of future activity. Explosive eruption deposits will also be used to provide the backbone of a robust chronology necessary for full exploitation of the paleoclimate record. Here we report initial results from, and outreach activities of, the 2016 coring campaign.

Ryanodine receptors (RyR) are essential regulators of cellular calcium homeostasis and signaling. Vertebrate genomes contain multiple RyR gene isoforms, expressed in different tissues and executing different functions. In contrast, invertebrate genomes contain a single RyR-encoding gene and it has long been proposed that different transcripts generated by alternative splicing may diversify their functions. Here, we analyze the expression and function of alternative exons in the C. elegans RyR gene unc-68. We show that specific isoform subsets are created via alternative promoters and via alternative splicing in unc-68 Divergent Region 2 (DR2), which actually corresponds to a region of high sequence variability across vertebrate isoforms. The expression of specific unc-68 alternative exons is enriched in different tissues, such as in body wall muscle, neurons and pharyngeal muscle. In order to infer the function of specific alternative promoters and alternative exons of unc-68, we selectively deleted them by CRISPR/Cas9 genome editing. We evaluated pharyngeal function, as well as locomotor function in swimming and crawling with high-content computer-assisted postural and behavioral analysis. Our data provide a comprehensive map of the pleiotropic impact of isoform-specific mutations and highlight that tissue-specific unc-68 isoforms fulfill distinct functions. As a whole, our work clarifies how the C. elegans single RyR gene unc-68 can fulfill multiple tasks through tissue-specific isoforms, and provide a solid foundation to further develop C. elegans as a model to study RyR channel functions and malfunctions.

ABSTRACT Nonalcoholic fatty liver disease (NAFLD), largely studied as a condition of overnutrition, also presents in undernourished populations. Like NAFLD, undernutrition disrupts systemic metabolism and has been linked to gut microbiota dysbiosis. Indeed, chronic exposures to fecal microbes contribute to undernutrition pathology in regions with poor sanitation. Despite a growing prevalence of fatty liver disease, the influence of undernutrition and the gut microbiota remain largely unexplored. Here, we utilize an established murine model (C57BL/6J mice placed on a malnourished diet that received iterative Escherichia coli/Bacteroidales gavage [MBG mice]) that combines a protein/fat-deficient diet and iterative exposure to specific, fecal microbes. Fecal-oral contamination exacerbates triglyceride accumulation in undernourished mice. MBG livers exhibit diffuse lipidosis accompanied by striking shifts in fatty acid, glycerophospholipid, and retinol metabolism. Multiomic analyses revealed metabolomic pathways linked to the undernourished gut microbiome and hepatic steatosis, including phenylacetate metabolism. Intriguingly, fatty liver features were observed only in the early-life, but not adult, MBG model despite similar liver metabolomic profiles. Importantly, we demonstrate that dietary intervention largely mitigates aberrant metabolomic and microbiome features in MBG mice. These findings indicate a crucial window in early-life development that, when disrupted by nutritional deficiency, may significantly influence liver function. Our work provides a multifaceted study of how diet and gut microbes inform fatty liver progression and reversal during undernutrition. IMPORTANCE Nonalcoholic fatty liver disease (NAFLD) remains a global epidemic, but it is often studied in the context of obesity and aging. Nutritional deficits, however, also trigger hepatic steatosis, influencing health trajectories in undernourished pediatric populations. Here, we report that exposure to specific gut microbes impacts fatty liver pathology in mice fed a protein/fat-deficient diet. We utilize a multiomics approach to (i) characterize NAFLD in the context of early undernutrition and (ii) examine the impact of diet and gut microbes in the pathology and reversal of hepatic steatosis. We provide compelling evidence that an early-life, critical development window facilitates undernutrition-induced fatty liver pathology. Moreover, we demonstrate that sustained dietary intervention largely reverses fatty liver features and microbiome shifts observed during early-life malnutrition.

Objectives To evaluate the effectiveness of palliative care teaching for undergraduate medical students.Design A systematic review was prepared according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidance. Screening, data extraction and quality assessment (mixed methods and Cochrane risk of bias tool) were performed in duplicate.Data sources Embase, MEDLINE, PsycINFO, Web of Science, ClinicalTrials.gov, Cochrane and grey literature in August 2019. Studies evaluating palliative care teaching interventions with medical students were included.Results 1446 titles/abstracts and 122 full-text articles were screened. 19 studies were included with 3253 participants. 17 of the varied methods palliative care teaching interventions improved knowledge outcomes. The effect of teaching on clinical practice and patient outcomes was not evaluated in any study.Conclusions The majority of palliative care teaching interventions reviewed improved knowledge of medical students. The studies did not show one type of teaching method to be better than others, and thus no ‘best way’ to provide teaching about palliative care was identified. High quality, comparative research is needed to further understand effectiveness of palliative care teaching on patient care/clinical practice/outcomes in the short-term and longer-term.PROSPERO registration number CRD42018115257.

Abstract In December 2018, Etna volcano experienced one of the largest episodes of unrest since the installation of geophysical monitoring networks in 1970. The unrest culminated in a short eruption with a small volume of lava erupted, a significant seismic crisis and deformation of the entire volcanic edifice of magnitude never recorded before at Mount Etna. Here we describe the evolution of the 2018 eruptive cycle from the analysis of seismic and geodetic data collected in the months preceding, during, and following the intrusion. We model the space‐time evolution of high‐rate deformation data starting from the active source previously identified from deformation data and the propagation of seismicity in a 3‐D velocity model. The intrusion model suggests emplacement of two dikes: a smaller dike located beneath the eruptive fissure and a second, deeper dike between 1 and 5 km below sea level that opened ~2 m. The rise and eruption of magma from the shallower dike did not interrupt the pressurization of a long‐lasting deeper reservoir (~6 km) that induced continuous inflation and intense deformation of the eastern flank. Shortly after the intrusion, on 26 December 2018, a ML4.8 earthquake occurred near Pisano, destroying buildings and roads in two villages. We propose a time‐dependent intrusion model that supports the hypothesis of the inflation inducing flank deformation and that this process has been active since September 2018.