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Background: The Additional Roles Reimbursement Scheme (ARRS) was introduced by NHS England in 2019 alongside primary care networks (PCNs), with the aims of increasing the workforce and improving patient outcomes., Aim: To describe the uptake of direct patient care (DPC)-ARRS roles and its impact on patients' experiences., Design and Setting: An ecological study using 2020-2023 PCN and practice workforce data, registered patient characteristics, the General Practice Patient Survey, and the Quality and Outcomes Framework (QOF)., Method: Descriptive statistics with associations were examined using quantile and linear regression., Results: By March 2023, 17 588 full-time equivalent (FTE) DPC-ARRS roles were commissioned by 1223 PCNs. PCNs with fewer constituent practices had more DPC-ARRS roles per population ( P <0.001), as did PCNs with more FTE GPs per population ( P = 0.005). DPC-ARRS commissioning did not vary with age, sex, or deprivation characteristics of practice populations. DPC-ARRS roles were associated with small increases in patient satisfaction (0.8 percentage points increase in patients satisfied per one DPC-ARRS FTE) and perceptions of access (0.7 percentage points increase in patients reporting 'good' experience of making an appointment per one DPC-ARRS FTE), but not with overall QOF achievement., Conclusion: The commissioning of DPC-ARRS roles was associated with small increases in patient satisfaction and perceptions of access, but not with QOF achievement. DPC-ARRS roles were employed in areas with more GPs rather than compensating for a shortage of doctors. Single-practice PCNs commissioned more roles per registered population, which may be advantageous to single-practice PCNs. Further evaluation of the scheme is warranted., (© The Authors.)

This scoping review examined grief related to the incarceration of a family member in order to establish a theoretical framework. A comprehensive search of PubMed, Social Sciences Citation Index, Embase, PsycInfo, Psychology & Behavioral Sciences, CINAHL, Cochrane Central Register of Controlled Trials & Cochrane Database of Systematic Reviews, PILOTS, and Psychiatry Online was conducted. We extracted data on sample characteristics, study design, purpose of the study, grief measure used, grief term and definition used, and key qualitative and quantitative findings. Twenty-five studies met inclusion criteria. Most studies used the terms 'ambiguous loss' (n = 15) and 'disenfranchised grief' (n = 12); however, grief terms and their definitions varied. The review identified 14 unique terms and more than 20 definitions. In several cases, the same term was defined and conceptualized differently between studies. This review also revealed shortcomings in existing theoretical frameworks for grief related to incarceration. Grief related to losing a family member to incarceration involves two distinct constructs: non-traditional losses and cascading losses. Non-traditional losses (measured on a continuum) capture elements of a loss to incarceration that are unique (compared to a loss via death) or may not be socially accepted, whereas cascading losses refers to the ongoing losses that one may experience related to the incarceration (e.g., loss of financial stability). This framework provides the field with consistent constructs and definitions that can be used to further advance research in incarceration-related grief and facilitates an improved ability to replicate findings between laboratories., Competing Interests: Declarations. Conflict of interest: The authors report there are no competing interests to declare. Ethical Approval: This article did not require Institutional Review Board approval as the nature of the article is a review and did not require collection of any participant data., (© 2024. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

We monitored leaf production in seedlings, trunkless juvenile, immature, and mature male and female plants of the dioecious palm, Lodoicea maldivica, and studied how internode length changed with trunk height. The fieldwork was conducted in closed forest on Praslin Island and degraded forest on Curieuse Island. Data on numbers of leaves produced and rates of leaf production were used to estimate plant age. On Praslin, the interval between successive leaves increased from 0.47/0.52 years in male/female plants to 4.2 years in seedlings, and on Curieuse from 0.41/0.49 to 2.3 years. Estimated leaf lifespan was 6.4-6.8 years in mature palms and much longer in seedlings and juveniles. On Praslin, internode length increased from the base of the trunk to a mean of 14 cm at leaf 21, before declining to 2.75 cm above leaf 100. Mean internode length of the smaller palms on Curieuse was 1.9 cm and varied little with height. Plants at the same development stage varied widely in age. On Praslin, median time to maturity was 77 (range: 32-209) and on Curieuse 83 (31-191) years. The tallest palms on Praslin (28.4 m trunk height) and Curieuse (8 m) were estimated at 442 and 232 years old, respectively. The ageing method was used to interpret height data of different populations. All showed a marked decline in regeneration in the 19th or early 20th centuries, probably caused by fires. We conclude that slow growth makes this species very vulnerable to disturbance, especially from fire., (© 2024 Wiley‐VCH GmbH. Published by John Wiley & Sons Ltd.)

Background: Plans to phase out fossil fuel-powered internal combustion engine (ICE) vehicles and to replace these with electric and hybrid-electric (E-HE) vehicles represent a historic step to reduce air pollution and address the climate emergency. However, there are concerns that E-HE cars are more hazardous to pedestrians, due to being quieter. We investigated and compared injury risks to pedestrians from E-HE and ICE cars in urban and rural environments., Methods: We conducted a cross-sectional study of pedestrians injured by cars or taxis in Great Britain. We estimated casualty rates per 100 million miles of travel by E-HE and ICE vehicles. Numerators (pedestrians) were extracted from STATS19 datasets. Denominators (car travel) were estimated by multiplying average annual mileage (using National Travel Survey datasets) by numbers of vehicles. We used Poisson regression to investigate modifying effects of environments where collisions occurred., Results: During 2013-2017, casualty rates per 100 million miles were 5.16 (95% CI 4.92 to 5.42) for E-HE vehicles and 2.40 (95%CI 2.38 to 2.41) for ICE vehicles, indicating that collisions were twice as likely (RR 2.15; 95% CI 2.05 to 2.26) with E-HE vehicles. Poisson regression found no evidence that E-HE vehicles were more dangerous in rural environments (RR 0.91; 95% CI 0.74 to 1.11); but strong evidence that E-HE vehicles were three times more dangerous than ICE vehicles in urban environments (RR 2.97; 95% CI 2.41 to 3.7). Sensitivity analyses of missing data support main findings., Conclusion: E-HE cars pose greater risk to pedestrians than ICE cars in urban environments. This risk must be mitigated as governments phase out petrol and diesel cars., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2024. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: Providing safety-netting advice (SNA) in out-of-hours primary care is a recognised standard of safe care but it is not known how frequently this occurs in practice., Aim: Assess the frequency and type of SNA documented in out-of-hours primary care and explore factors associated with its presence., Design and Setting: Retrospective cohort using the Birmingham Out-of-hours General Practice Research Database., Method: A stratified sample of 30 adult consultation records per month from July 2013 to February 2020 were assessed using a safety-netting coding tool. Associations were tested using linear and logistic regression., Results: The overall frequency of SNA per consultation was 78.0%, increasing from 75.7% (2014) to 81.5% (2019). The proportion of specific SNA and the average number of symptoms patients were told to look out for increased with time. The most common symptom to look out for was if the patients' condition worsened followed by if their symptoms persisted, but only one in five consultations included a time-frame to reconsult for persistent symptoms. SNA was more frequently documented in face-to-face treatment-centre encounters compared to telephone-consultations (Odds Ratio [OR]=1.77, p=0.02), for possible infections (OR=1.53, p=0.006), and less frequently for mental (vs. physical) health consultations (OR=0.33, p=0.002) and where follow-up was planned (OR=0.34, p<0.001)., Conclusion: The frequency of SNA documented in OOH was higher than previously reported during in-hours care. Over time, the frequency of SNA and proportion that contained specific advice increased, however this study highlights potential consultations where SNA could be improved, such as mental health and telephone consultations., (Copyright © 2024, The Authors.)

Background: Eliciting patients' ideas, concerns, expectations, and whether a problem has an 'effect' on their life (ICEE), is a widely recommended communication technique. However, it is not known how frequently ICEE components are raised in UK GP consultations., Aim: To assess the frequency of ICEE in routine GP consultations with adult patients and explore variables associated with ICEE., Design & Setting: An observational study was undertaken. It involved secondary analysis of a pre-existing archive of video-recorded, face-to-face GP consultations in the UK., Method: Observational coding of 92 consultations took place. Associations were assessed using binomial and ordered logistic regression., Results: Most consultations included at least one ICEE component (90.2%). The most common ICEE component per consultation was patient ideas (79.3%), followed by concerns (55.4%), expectations (51.1%), and then effects on life (42.4%). For all ICEE components patients more commonly initiated the ICEE dialogue, and in only three consultations (3.3%) did GPs directly ask patients about their expectations. Problems that were acute (odds ratio [OR] 2.98, 95% confidence interval [CI] = 1.36 to 6.53, P = 0.007) or assessed by GPs aged ≥50 years (OR 2.10, 95% CI = 1.07 to 4.13, P = 0.030) were associated with more ICEE components. Problems assessed later in the consultation (OR 0.60 per problem order increase, 95% CI = 0.41 to 0.87, P = 0.007) by patients aged ≥75 years (OR 0.40, 95% CI = 0.16 to 0.98, P = 0.046) and from the most deprived cohort (OR 0.39, 95% CI = 0.17 to 0.92, P = 0.032) were associated with fewer ICEE components. Patient ideas were associated with more patients being 'very satisfied' post-consultation (OR 10.74, 95% CI = 1.60 to 72.0, P = 0.014) and the opposite was true of concerns (OR 0.14, 95% CI = 0.02 to 0.86, P = 0.034)., Conclusion: ICEE components were associated with patient satisfaction and demographic variables. Further research is required to assess if the way ICEE are communicated affects these associations and other potential confounders., (Copyright © 2023, The Authors.)

Background: Self-administered questionnaires are widely used to collect data in epidemiological research, but non-response reduces the effective sample size and can introduce bias. Finding ways to increase response to postal and electronic questionnaires would improve the quality of epidemiological research., Objectives: To identify effective strategies to increase response to postal and electronic questionnaires., Search Methods: We searched 14 electronic databases up to December 2021 and manually searched the reference lists of relevant trials and reviews. We contacted the authors of all trials or reviews to ask about unpublished trials; where necessary, we also contacted authors to confirm the methods of allocation used and to clarify results presented., Selection Criteria: Randomised trials of methods to increase response to postal or electronic questionnaires. We assessed the eligibility of each trial using pre-defined criteria., Data Collection and Analysis: We extracted data on the trial participants, the intervention, the number randomised to intervention and comparison groups and allocation concealment. For each strategy, we estimated pooled odds ratios (OR) and 95% confidence intervals (CI) in a random-effects model. We assessed evidence for selection bias using Egger's weighted regression method and Begg's rank correlation test and funnel plot. We assessed heterogeneity amongst trial odds ratios using a Chi 2 test and quantified the degree of inconsistency between trial results using the I 2 statistic., Main Results: Postal We found 670 eligible trials that evaluated over 100 different strategies of increasing response to postal questionnaires. We found substantial heterogeneity amongst trial results in half of the strategies. The odds of response almost doubled when: using monetary incentives (odds ratio (OR) 1.86; 95% confidence interval (CI) 1.73 to 1.99; heterogeneity I 2 = 85%); using a telephone reminder (OR 1.96; 95% CI 1.03 to 3.74); and when clinical outcome questions were placed last (OR 2.05; 95% CI 1.00 to 4.24). The odds of response increased by about half when: using a shorter questionnaire (OR 1.58; 95% CI 1.40 to 1.78); contacting participants before sending questionnaires (OR 1.36; 95% CI 1.23 to 1.51; I 2 = 87%); incentives were given with questionnaires (i.e. unconditional) rather than when given only after participants had returned their questionnaire (i.e. conditional on response) (OR 1.53; 95% CI 1.35 to 1.74); using personalised SMS reminders (OR 1.53; 95% CI 0.97 to 2.42); using a special (recorded) delivery service (OR 1.68; 95% CI 1.36 to 2.08; I 2 = 87%); using electronic reminders (OR 1.60; 95% CI 1.10 to 2.33); using intensive follow-up (OR 1.69; 95% CI 0.93 to 3.06); using a more interesting/salient questionnaire (OR 1.73; 95% CI 1.12 to 2.66); and when mentioning an obligation to respond (OR 1.61; 95% CI 1.16 to 2.22). The odds of response also increased with: non-monetary incentives (OR 1.16; 95% CI 1.11 to 1.21; I 2 = 80%); a larger monetary incentive (OR 1.24; 95% CI 1.15 to 1.33); a larger non-monetary incentive (OR 1.15; 95% CI 1.00 to 1.33); when a pen was included (OR 1.44; 95% CI 1.38 to 1.50); using personalised materials (OR 1.15; 95% CI 1.09 to 1.21; I 2 = 57%); using a single-sided rather than a double-sided questionnaire (OR 1.13; 95% CI 1.02 to 1.25); using stamped return envelopes rather than franked return envelopes (OR 1.23; 95% CI 1.13 to 1.33; I 2 = 69%), assuring confidentiality (OR 1.33; 95% CI 1.24 to 1.42); using first-class outward mailing (OR 1.11; 95% CI 1.02 to 1.21); and when questionnaires originated from a university (OR 1.32; 95% CI 1.13 to 1.54). The odds of response were reduced when the questionnaire included questions of a sensitive nature (OR 0.94; 95% CI 0.88 to 1.00). Electronic We found 88 eligible trials that evaluated over 30 different ways of increasing response to electronic questionnaires. We found substantial heterogeneity amongst trial results in half of the strategies. The odds of response tripled when: using a brief letter rather than a detailed letter (OR 3.26; 95% CI 1.79 to 5.94); and when a picture was included in an email (OR 3.05; 95% CI 1.84 to 5.06; I 2 = 19%). The odds of response almost doubled when: using monetary incentives (OR 1.88; 95% CI 1.31 to 2.71; I 2 = 79%); and using a more interesting topic (OR 1.85; 95% CI 1.52 to 2.26). The odds of response increased by half when: using non-monetary incentives (OR 1.60; 95% CI 1.25 to 2.05); using shorter e-questionnaires (OR 1.51; 95% CI 1.06 to 2.16; I 2 = 94%); and using a more interesting e-questionnaire (OR 1.85; 95% CI 1.52 to 2.26). The odds of response increased by a third when: offering survey results as an incentive (OR 1.36; 95% CI 1.16 to 1.59); using a white background (OR 1.31; 95% CI 1.10 to 1.56); and when stressing the benefits to society of response (OR 1.38; 95% CI 1.07 to 1.78; I 2 = 41%). The odds of response also increased with: personalised e-questionnaires (OR 1.24; 95% CI 1.17 to 1.32; I 2 = 41%); using a simple header (OR 1.23; 95% CI 1.03 to 1.48); giving a deadline (OR 1.18; 95% CI 1.03 to 1.34); and by giving a longer time estimate for completion (OR 1.25; 95% CI 0.96 to 1.64). The odds of response were reduced when: "Survey" was mentioned in the e-mail subject (OR 0.81; 95% CI 0.67 to 0.97); when the email or the e-questionnaire was from a male investigator, or it included a male signature (OR 0.55; 95% CI 0.38 to 0.80); and by using university sponsorship (OR 0.84; 95%CI 0.69 to 1.01). The odds of response using a postal questionnaire were over twice those using an e-questionnaire (OR 2.33; 95% CI 2.25 to 2.42; I 2 = 98%). Response also increased when: providing a choice of response mode (electronic or postal) rather than electronic only (OR 1.76 95% CI 1.67 to 1.85; I 2 = 97%); and when administering the e-questionnaire by computer rather than by smartphone (OR 1.62 95% CI 1.36 to 1.94)., Authors' Conclusions: Researchers using postal and electronic questionnaires can increase response using the strategies shown to be effective in this Cochrane review., (Copyright © 2023 The Authors. Cochrane Database of Systematic Reviews published by John Wiley & Sons, Ltd. on behalf of The Cochrane Collaboration.)

We studied spatial patterns of kinship in the offspring of the endangered Lodoicea maldivica, a dioecious palm that produces the largest seed of any plant. Previous research has suggested that restricted seed and pollen dispersal in populations resulted in strong spatial genetic structure. We used microsatellites to genotype young plants and their potential parents at four sites across the species' entire natural range. We determined the most likely parents of each young plant based on the spatial separation of each parent pair, their genetic relatedness, and the level of correlated paternity. We identified both parents (43 female, 54 male) for 139 of 493 young plants. Mean distance between parental pairs was 26.8 m. Correlated paternity was low (0.168), indicating that mother trees were often pollinated by several fathers. Parental pairs were more closely related than expected by chance, suggesting outbreeding depression. Our results highlight the apparent strong mate choice for close kin in parent pairs of surviving offspring. We discuss the alternative biological processes that could lead to this, including the potential for break-up of favourable allelic combinations necessary for the development of the palm's very large seed. Management implications include germinating seeds where they naturally fall, using a diverse range of male plants as pollen donors for hand pollination, and protecting the native community of gecko pollinators., (© 2023. Springer Nature Limited.)

Objectives: To describe the population presenting to out-of-hours primary care with insect bites, establish their clinical management and the factors associated with antibiotic prescribing., Design: An observational study using routinely collected data from a large out-of-hours database (BORD, Birmingham Out-of-hours general practice Research Database)., Setting: A large out-of-hour primary care provider in the Midlands region of England., Participants: All patients presenting with insect bites between July 2013 and February 2020 were included comprising 5774 encounters., Outcome Measures: This cohort was described, and a random subcohort was created for more detailed analysis which established the clinical features of the presenting insect bites. Logistic regression was used to model variables associated with antibiotic prescribing., Results: Of the 5641 encounters solely due to insect bites, 67.1% (95% CI 65.8% to 68.3%) were prescribed antibiotics. General practitioners were less likely to prescribe antibiotics than advanced nurse practitioners (60.5% vs 71.1%, p<0.001) and there was a decreasing trend in antibiotic prescribing as patient deprivation increased. Pain (OR 2.13, 95% CI 1.18 to 3.86), swelling (OR 2.88, 95% CI 1.52 to 5.46) and signs of spreading (OR 3.45, 95% CI 1.54 to 7.70) were associated with an increased frequency of antibiotic prescribing. Extrapolation of the findings give an estimated incidence of insect bite consultations in England of 1.5 million annually., Conclusion: Two-thirds of the patients presenting to out-of-hours primary care with insect bites receive antibiotics. While some predictors of prescribing have been found, more research is required to understand the optimal use of antibiotics for this common presentation., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2023. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Nanostructured electronic devices, such as those based on graphene, are typically grown on top of the insulator SiO 2 . Their exposure to a flux of small size-selected silver nanoparticles has revealed remarkably selective adhesion: the graphene channel can be made fully metallized, while the insulating substrate remains coverage-free. This conspicuous contrast derives from the low binding energy between the metal nanoparticles and a contaminant-free passivated silica surface. In addition to providing physical insight into nanoparticle adhesion, this effect may be of value in applications involving deposition of metallic layers on device working surfaces: it eliminates the need for masking the insulating region and the associated extensive and potentially deleterious pre- and postprocessing.

Competing Interests: Competing interests: We have read and understood BMJ policy on declaration of interests and have no relevant interests to declare.

Background: Previous studies have reported how often safety-netting is documented in medical records, but it is not known how this compares with what is verbalised and what factors might influence the consistency of documentation., Aim: To compare spoken and documented safety-netting advice and to explore factors associated with documentation., Design and Setting: A cross-sectional study, using an existing GP consultations archive., Method: Observational coding involving classifying and quantifying medical record entries and comparison with spoken safety-netting advice in 295 video-/audio-recorded consultations. Associations were tested using logistic regression., Results: Two-thirds of consultations (192/295) contained spoken safety-netting advice that applied to less than half of the problems assessed (242/516). Only one-third of consultations (94/295) had documented safety-netting advice, which covered 20.3% of problems (105/516). The practice of GPs varied widely, from those that did not document their safety-netting advice to those that nearly always did so (86.7%). GPs were more likely to document their safety-netting advice for new problems ( P = 0.030), when only a single problem was discussed in a consultation ( P = 0.040), and when they gave specific rather than generic safety-netting advice ( P = 0.007). In consultations where multiple problems were assessed ( n = 139), the frequency of spoken and documented safety-netting advice decreased the later a problem was assessed., Conclusion: GPs frequently do not document the safety-netting advice they have given to patients, which may have medicolegal implications in the event of an untoward incident. GPs should consider how safely they can assess and document more than one problem in a single consultation and this risk should be shared with patients to help manage expectations., (© The Authors.)

Background: The Hajj is one of the world's largest pilgrimage and gathers millions of Muslims from different nationalities every year. Communicable diseases have been reported frequently, during and following the Hajj, and these have been linked to individual behavioural measures. This study aimed to measure the effect of personal preventive measures, such as face mask use, hand hygiene and others, adopted by pilgrims in reducing the acquisition of infectious diseases., Methods: We conducted a cross-sectional study at the Hajj terminal in King Abdulaziz International Airport in Jeddah, Saudi Arabia. Pilgrims were approached in the airport lounges after the 2017 Hajj season and prior to the departure of their flights from Jeddah to their home countries. An electronic data collection tool ('Open Data Kit') was used to gather survey data in regards to health problems and preventive measures during the Hajj., Results: A total of 2973 Hajj pilgrims were surveyed. In all, 38.7% reported symptoms of upper respiratory tract infections (URTIs) and 5.4% reported symptoms of travel diarrhoea. Compliance with face mask use was 50.2%. Changing a face mask every 4 h was found to be significantly associated with lower prevalence of URTIs [adjusted odds ratio 0.56 (95% confidence interval 0.34-0.92), P = 0.02]. There was no statistical difference between overall face mask use and URTI acquisition. The main sources of food, eating raw vegetables/food, frequency of hand washing or use of hand sanitizers were not found to be significantly associated with reported travellers' diarrhoea. Unlicensed barbers were used by 12% of pilgrims and 9.2% of pilgrims reported using blades that were reused by other pilgrims., Conclusion: Preventive measures are the most effective way to prevent infections. Pilgrims can benefit from face masks by changing them frequently. There is still limited information on the effect of the use of face mask in decreasing the risk of URTI in mass gatherings., (© International Society of Travel Medicine 2020. All rights reserved. For Permissions, please e-mail: journals.permissions@oup.com.)

We have investigated the change in mean residence time of gaseous ions adsorbed on the surface of suspended carbon nanotube field-effect transistors (CNT-FETs) with and without native surface water layers that exists in atmospheric conditions. Devices were characterized electrically before and after dehydration by thermal, dry gas, and vacuum desiccation and in each scenario were found to have substantially higher mean ion residence times. It is proposed that water molecules native to the CNT surface in ambient conditions provide a reduction pathway for incoming gaseous ions, yielding hydronium ions (H 3 O + ). This is supported by the appearance of frequent clustered readsorption events in the presence of surface water, caused by the rapid hopping of H + between the device surface and the lowest water layer, which are not present in data collected from desiccated devices. After desiccation of the device, a thermal trial was conducted to determine the adsorption energy of N 2 + ions on the CNT surface. This work has profound implications for our understanding of wetting in one-dimensional systems and the chemistry of ion chemisorption and solvation on the surfaces of materials in general.

Background: Skin complaints are common in primary care, and poor outcomes in long-term conditions are often due to low adherence to treatment. Shared decision making and self-management support may help, yet there is little understanding of patient involvement or the support provided by GPs., Aim: To describe the content of primary care consultations for skin problems, including shared decision making practice, delivery of self-management advice, and follow-up., Design and Setting: Cross-sectional study of video-recorded UK adult GP consultations and linked data., Method: A coding tool was developed and applied to all consultations with skin problems. Shared decision making was assessed using the observer OPTION 5 scale., Results: A total of 45/318 consultations (14.2%) related to one or more skin problems, which were discussed alongside other problems in 71.1% (32/45) of consultations. Of the 100 different problems discussed in these consultations, 51 were dermatological. The mean amount of time spent on skin problems in the consultations was 4 minutes 16 seconds. Medication was recommended for 66.7% (34/51) of skin problems, with low shared decision making (mean OPTION 5 score = 10.7). Self-management advice (verbal only) was given for 47.1% (24/51) of skin problems. Most skin problems (84.3%; 43/51) were not referred to secondary care; 32.6% (14/43) of the skin problems not referred were seen again in primary care within 12 weeks, of which 35.7% (5/14) follow-up appointments were not planned., Conclusion: In this study, skin problems were usually presented alongside other complaints and resulted in a medication recommendation. Shared decision making was uncommon and self-management advice not consistently given, with re-attendance for the same problem common. GPs' training should reflect how frequently skin problems are seen and seek to improve patient involvement in decision making and support self-management., (©The Authors.)

Urban ecosystem service (UES) is becoming an influential concept to guide the planning, design, and management of urban landscapes towards urban sustainability. However, its use is hindered by definitional ambiguity, and the conceptual bases underpinning its application remain weak. This is exemplified by two different but equally valid interpretations of UES: "urban ecosystem services ", referring to ecosystem services from analogs of natural and semi-natural ecosystems within urban boundaries, and " urban ecosystem services", a much broader term that includes the former group as well as urban services in a city. While we recognize that a single definition of UES is not possible nor necessary as its application is context-dependent, it is nevertheless useful to clarify the relationships between these interpretations to promote consistent use, and importantly, explore how a broader interpretation of UES might advance its applications in areas that have been neglected. We developed a conceptual framework that links UES to natural and human-derived capital to explain the relationships between the dual meanings of UES and proposed three normative propositions to guide its application: (1) integrate holistically multiple components of natural capital to provide UES, (2) reduce dependence on non-renewable abiotic resources and human-derived capital, and (3) enhance UES through technology. The framework we developed helps to resolve the current ambiguity in the meanings of UES, highlights the need to recognise neglected aspects of natural capital important for UES, and can be used to clarify relationships with related concepts conveying dependence of human well-being on nature., (© 2020 The Authors.)

Worldwide, alien plant invasions have been intensively studied in the past decades, but mechanisms controlling the invasibility of native communities are not fully understood yet. The stochastic niche hypothesis predicts that species-rich plant communities are less prone to alien plant invasions than species-poor communities, which is supported by some but not all field studies, with some very species-rich communities such as the Brazilian Cerrado becoming heavily invaded. However, species-rich communities potentially contain a greater variety of facilitative interactions in resource exploitation than species-poor communities, from which invasive plants might benefit. This alternative hypothetical mechanism might explain why nutrient-poor, species-rich ecosystems are prone to invasion. Here we show that a high species richness both impedes and promotes invasive plants in the Brazilian Cerrado, using structural equation modelling and data from 38 field sites. We found support for the stochastic niche hypothesis through an observed direct negative influence of species richness on abundance of alien invasive species, but an indirect positive effect of species richness on invasive alien plants through soil phosphatase activity that enhances P availability was also found. These field observations were supported with results from a mesocosm experiment. Root phosphatase activity of plants increased with species richness in the mesocosms, which was associated with greater community P and N uptake. The most prominent alien grass species of the region, Melinis minutiflora, benefited most from the higher N and P availability in the species mixtures. Hence, this study provides a novel explanation of why species-richness may sometimes promote rather than impede invasion, and highlights the need to perform facilitation experiments in multi-species communities.

Urban residents can benefit from spending time in outdoor spaces and engaging with nature-related activities. Such engagement can improve health and well-being, support community cohesion, and improve environmentally-friendly behaviours. However, engagement with nature may not be equal amongst different members of society. We investigated individual variation in engagement with nature in Singapore, a high-density city in tropical Southeast Asia. Through a survey of 1000 residents, we analysed relationships between demographic factors such as age, income, and sex, and the frequency of visitation to different ecosystem types, and the frequency of engagement with different nature-related activities. Parks and neighbourhood open spaces were among the most commonly-visited outdoor spaces, with nature reserves and other natural areas being visited less frequently. Common activities included sitting outdoors, art and photography, and running, while hiking and nature recreation were less frequent. In contrast with previous studies, we found relatively small differences among different groups of the population in their preferred types of outdoor activities. Older people, those with lower incomes, and without degrees were less likely to visit most types of outdoor space and engage with most types of nature-related activities. In the case of nature reserves, the distance from the visitor's home had a significantly negative influence on the frequency of visitation. These findings demonstrate that the benefits of engagement with nature are not equally enjoyed by all demographic groups, and that some groups lack engagement across the board. Strategies to increase nature engagement in tropical cities could include increasing the local availability and accessibility of different types of outdoor space, and education and public outreach programmes to encourage participation., Competing Interests: The authors have declared that no competing interests exist.

Introduction: B-cell malignancies confer an increased risk of infection due to associated immune defects. Conflicting evidence exists on the risk of infection in patients receiving ibrutinib. We conducted a systematic review and meta-analysis to estimate relative risk of infection with ibrutinib in B-cell malignancies., Methods: A systematic search of Embase, Medline, Web of Science, Scopus, Cochrane Database of Systematic Reviews, Cochrane Central Register of Controlled Trials, European Union Clinical Trials Register, and ClinicalTrials.gov was performed through January 15, 2019, to identify randomized controlled trials comparing ibrutinib with other agents or placebo in B-cell malignancies. We pooled point estimates using the Der Simonian and Laird random-effects model. Statistical analyses were performed by Stata/SE 15.1., Results: Seven studies randomizing 2167 patients were included in the final analysis. Treatment duration in studies ranged from 9.4 to 38.7 months. Ibrutinib was associated with a significantly increased risk of infection (any grade and grade 3-5) in patients with B-cell malignancies [pooled risk ratio (RR) = 1.34, 95% confidence interval [CI], 1.06-1.69, P = .015; and RR = 1.35, 95% CI, 1.05-1.74, P = .018, respectively]. In patients with chronic lymphocytic leukemia, a significantly increased risk of grade 3-5 infection was noted in the ibrutinib group [pooled RR = 1.24, 95% CI, 1.02-1.50, P = .028]. Incidences of pneumonia and upper respiratory tract infection were not significantly different between groups., Conclusion: Our meta-analysis found that ibrutinib was associated with significantly higher risk of infections in patients with B-cell malignancies. Occurrence of major individual subtypes was not different between groups, possibly as a result of inconsistent reporting across studies., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Lodoicea maldivica (coco de mer) is a long-lived dioecious palm in which male and female plants are visually indistinguishable when immature, only becoming sexually dimorphic as adults, which in natural forest can take as much as 50 years. Most adult populations in the Seychelles exhibit biased sex ratios, but it is unknown whether this is due to different proportions of male and female plants being produced or to differential mortality. In this study, we developed sex-linked markers in Lodoicea using ddRAD sequencing, enabling us to reliably determine the gender of immature individuals. We screened 589 immature individuals to explore sex ratios across life stages in Lodoicea . The two sex-specific markers resulted in the amplification of male-specific bands (Lm123977 at 405 bp and Lm435135 at 130 bp). Our study of four sub-populations of Lodoicea on the islands of Praslin and Curieuse revealed that the two sexes were produced in approximately equal numbers, with no significant deviation from a 1:1 ratio before the adult stage. We conclude that sex in Lodoicea is genetically determined, suggesting that Lodoicea has a chromosomal sex determination system in which males are the heterogametic sex (XY) and females are homogametic (XX). We discuss the potential causes for observed biased sex ratios in adult populations, and the implications of our results for the life history, ecology and conservation management of Lodoicea ., (© The Author(s) 2019. Published by Oxford University Press on behalf of the Annals of Botany Company.)

Background: Safety-netting advice is information shared with a patient or their carer designed to help them identify the need to seek further medical help if their condition fails to improve, changes, or if they have concerns about their health., Aim: To assess when and how safety-netting advice is delivered in routine GP consultations., Design and Setting: This was an observational study using 318 recorded GP consultations with adult patients in the UK., Method: A safety-netting coding tool was applied to all consultations. Logistic regression for the presence or absence of safety-netting advice was compared between patient, clinician, and problem variables., Results: A total of 390 episodes of safety-netting advice were observed in 205/318 (64.5%) consultations for 257/555 (46.3%) problems. Most advice was initiated by the GP (94.9%) and delivered in the treatment planning (52.1%) or closing (31.5%) consultation phases. Specific advice was delivered in almost half (47.2%) of episodes. Safety-netting advice was more likely to be present for problems that were acute (odds ratio [OR] 2.18, 95% confidence interval [CI] = 1.30 to 3.64), assessed first in the consultation (OR 2.94, 95% CI = 1.85 to 4.68) or assessed by GPs aged ≤49 years (OR 2.56, 95% CI = 1.45 to 4.51). Safety-netting advice was documented for only 109/242 (45.0%) problems., Conclusion: GPs appear to commonly give safety-netting advice, but the contingencies or actions required on the patient's part may not always be specific or documented. The likelihood of safety-netting advice being delivered may vary according to characteristics of the problem or the GP. How to assess safety-netting outcomes in terms of patient benefits and harms does warrant further exploration., (© British Journal of General Practice 2019.)

Background: Safety netting is recommended in a variety of clinical settings, yet there are no tools to record clinician safety-netting communication behaviours., Aim: To develop and assess the inter-rater reliability (IRR) of a coding tool designed to assess safety-netting communication behaviours in primary care consultations., Design and Setting: A mixed-methods study using an existing dataset of video-and audio-recorded UK primary care consultations., Method: Key components that should be assessed in a coding tool were identified using the published literature and relevant guidelines. An iterative approach was utilised to continuously refine and generate new codes based on the application to real-life consultations. After the codebook had been generated, it was applied to 35 problems in 24 consultations independently by two coders. IRR scores were then calculated., Results: The tool allows for the identification and quantification of the key elements of safety-netting advice including: who initiates the advice and at which stage of the consultation; the number of symptoms or conditions the patient is advised to look out for; what action patients should take and how urgently; as well as capturing how patients respond to such advice plus important contextual codes such as the communication of diagnostic uncertainty, the expected time course of an illness, and any follow-up plans. The final tool had substantial levels of IRR with the mean average agreement for the final tool being 88% ( κ = 0.66)., Conclusion: The authors have developed a novel tool that can reliably code the extent of clinician safety-netting communication behaviours., (© British Journal of General Practice 2019.)