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Cyanobacterial phytoplankton blooms are more prevalent in the freshwater Sacramento-San Joaquin Delta (Delta) since the late 1990s, including blooms driven by overgrowths of potentially toxigenic organisms of the genus Microcystis. Data from 2014 to 2021 were used to show how flow dynamics, water temperature, and water clarity drive occurrence of Microcystis. We used a Microcystis bloom in the central Delta from 2021 as a case study for how novel monitoring tools can track blooms in real-time and be used post hoc to evaluate the effects of management actions.Microcystis was detected throughout the Delta in all but the highest-flow years, and bloom incidence and severity increased during drier years. In the South Delta, Franks Tract, lower San Joaquin River, and Old River regions, where blooms are most prevalent, higher water temperatures and clarities combined with lower exports from state and federal water projects were the best explanatory factors for the occurrence of Microcystis blooms. Nutrient concentrations were lower in summer than in winter, but only became limiting at high phytoplankton concentrations.We used satellite data and in situ continuous monitoring of flow, phytoplankton communities, and water quality to track hydro-biogeochemical conditions during the 2021 case study Microcystis bloom in the Central Delta. We did not find evidence that changes to Delta outflow regulatory standards contributed to this bloom, but changes in flow caused by a salinity barrier placed in west False River may have exacerbated the bloom. The frequency and severity of droughts are expected to increase in the future as a result of climate change, and our study demonstrates how continued monitoring of cyanotoxins, water quality, and phytoplankton communities could help improve management of cyanobacterial blooms in the Delta and other estuaries.

Multi-year droughts are ever-present and transformational features of California’s Mediterranean climate and can fundamentally affect the water quality and the ecosystem responses of the San Francisco Estuary and the Sacramento–San Joaquin Delta. This study assessed data collected by long-term monitoring programs over the past 46 water years (1975–2021) to evaluate how water quality in the estuary changes during multi-year droughts. Data were aggregated by region (South-Central Delta, North Delta, confluence, Suisun Bay, and Suisun Marsh) and season, then differences between multi-year drought periods, multi-year wet periods, and neutral periods were compared using generalized linear models. We found that multi-year drought periods altered multiple physical and chemical parameters in the estuary, increasing water temperature, salinity, water clarity, and nutrient levels. This trend was consistent across regions and seasons, with few exceptions. Increases in these parameters during drought periods were likely caused by reduced Delta inflows that intensified in each successive dry year because of reduced precipitation and managed estuarine inflows and outflows. Drought periods did not substantially affect tidal velocities within the estuary, which remained mostly consistent across wet and drought periods. Trends in chlorophyll concentrations during drought periods were more nuanced with higher concentrations occurring in the South-Central Delta region and during the winter and spring. Together, these results characterized drought in the estuary as warm, clear, high in nutrients, with patchy phytoplankton blooms (as indexed by chlorophyll), all of which have implications for higher trophic levels. Considering that droughts are expected to increase in frequency and intensity in California with climate change, understanding the effects of multi-year droughts on the water quality conditions of the estuary can help inform water management decisions.

The viscosity of aerosol particles determines the critical mixing time of gas–particle partitioning of volatile compounds in the atmosphere. The partitioning of the semi-volatile ammonium nitrate (NH4NO3) might alter the viscosity of highly viscous secondary organic aerosol particles during their lifetimes. In contrast to the viscosity of organic particles, data on the viscosity of internally mixed inorganic–organic aerosol particles are scarce. We determined the viscosity of an aqueous ternary inorganic–organic system consisting of NH4NO3 and a proxy compound for a highly viscous organic, sucrose. Three techniques were applied to cover the atmospherically relevant humidity range: viscometry, fluorescence recovery after photobleaching, and the poke-flow technique. We show that the viscosity of NH4NO3–sucrose–H2O with an organic to inorganic dry mass ratio of 4:1 is 4 orders of magnitude lower than the viscosity of the aqueous sucrose under low-humidity conditions (30 % relative humidity (RH), 293 K). By comparing viscosity predictions of mixing rules with those of the Aerosol Inorganic–Organic Mixtures Functional groups Activity Coefficients Viscosity (AIOMFAC-VISC) model, we found that a mixing rule based on mole fractions performs similarly when data from corresponding binary aqueous subsystems are available. Applying this mixing rule, we estimated the characteristic internal mixing time of aerosol particles, indicating significantly faster mixing for inorganic–organic mixtures compared to electrolyte-free particles, especially at lower RH. Hence, the assumption in global atmospheric chemistry models of quasi-instantaneous equilibrium gas–particle partitioning is reasonable for internally mixed single-phase particles containing dissolved electrolytes (but not necessarily for phase-separated particles), for most conditions in the planetary boundary layer. Further data are needed to see whether this assumption holds for the entire troposphere at midlatitudes and at RH > 35 %.

Abstract Background Intimate partner violence (IPV) is widespread in the WHO African region with generalised HIV epidemics and may contribute to ongoing HIV transmission through its associations with behaviours associated with HIV acquisition risk and low use of prevention methods particularly in marital relationships. Methods We conducted a male condom HIV prevention cascade analysis using data from a general-population survey in Manicaland, Zimbabwe (July 2018-December 2019) to develop an understanding of how interventions that reduce IPV might be built upon to also reduce HIV incidence. Multivariable logistic regression was used to measure associations between currently-married HIV-negative women’s experience of IPV and: (1) being in the priority population for HIV prevention methods (i.e. married women engaging in behaviours associated with HIV acquisition risk or with a spouse who engages in similar behaviours or is living with HIV), and (2) male condom use by women in this priority population. Male condom HIV prevention cascades, with explanatory barriers for gaps between successive cascade bars (motivation, access and effective use), were compared for women in the priority population reporting and not reporting IPV. Results We found a positive association between IPV and being in the priority population for HIV prevention methods (72.3% versus 58.5%; AOR = 2.26, 95% CI:1.74–2.93). Condom use was low (

Primary care health checks, screenings and GP consultations are often the gateway for people with intellectual disabilities to access their physical and mental healthcare. For a population who experience greater levels of health difficulties alongside significant health inequality, improving care quality and access is of major importance. This meta-ethnographic, qualitative review aims to explore people with intellectual disabilities experiences of health checks, screenings and GP visits, while assessing the quality of the current literature and synthesising findings to consider clinical and research recommendations based on third order constructs. A systematic search identified 20 studies that met inclusion criteria. Quality assessment of each paper was conducted. Meta-ethnography methods were used to analyse and synthesis findings. One overarching concept was identified: Include Me, along with seven core concepts; Empowerment and Disempowerment, Communication and Interpersonal Factors, Access and Adaptations and Biased Narratives and Shifting Perspectives. Implications for practice and future direction are discussed.

Abstract Background Of the 2 million children living with HIV globally, 90% live in sub-Saharan Africa. Despite antiretroviral therapy, longstanding HIV infection is associated with several chronic complications in children including growth failure, particularly stunting and delayed puberty. Vitamin D deficiency, which is highly prevalent among children living with HIV in sub-Saharan Africa, has further adverse impact on bone health. This trial aims to establish whether supplementation with vitamin D3 and calcium carbonate improves musculoskeletal health among peripubertal children living with HIV. This paper is an update to an already existing protocol that was previously published in Trials in 2022 and details changes in the trial outcomes. Methods/design We will conduct an individually randomised, double-blinded, placebo-controlled trial of weekly high-dose vitamin D3 (20,000 IU) plus daily calcium carbonate (500 mg) supplementation for 48 weeks. Eight hundred and forty children living with HIV aged 11–19 years taking ART for ≥ 6 months will be enrolled and followed up for 96 weeks. The primary outcome is DXA-measured total body less-head bone mineral density Z-score (TBLH-BMD) at 48 weeks and is an update to the previous primary outcome total body less-head bone mineral content adjusted for lean mass (TBLH-BMCLBM) Z-score. The primary outcome was updated to address the substantial differences in distributions of TBLH-BMCLBM Z-score between the two sites as a result of software differences of the DXA machines. Secondary outcomes are DXA-measured TBLH-BMD Z-score adjusted for height at 48 weeks a new secondary outcome, lumbar spine bone mineral apparent density Z-score, number of respiratory infections, lean muscle mass and grip-strength at 48 and 96 weeks, and TBLH-BMD Z-score at 96 weeks. Sub-studies will investigate the effect of the intervention on vitamin D3 pathway metabolites and markers of bone turnover, intestinal microbiota, and innate and acquired immune function. Discussion This is the largest trial to date of vitamin D supplementation in children living with HIV. Intervening to address deficits in bone accrual through childhood is critical for optimising adolescent and early adult bone health, and prevention of later adult osteoporotic fractures. Trial results will draw attention to the need to screen for and treat long-term comorbidities in children living with HIV in resource-limited settings. Trial registration Pan African Clinical Trials Registry PACTR20200989766029. Registered on September 3, 2020. URL of trial registry record: https://pactr.samrc.ac.za Trial status Participant follow-up completed; data analysis ongoing.

Abstract Introduction HIV infection and its treatment compromises skeletal development (growth and maturation). Skeletal maturity is assessed as bone age (BA) on hand and wrist radiographs. BA younger than chronological age (CA) indicates delayed development. We conducted a cross-sectional study to determine differences between BA and CA (i.e., skeletal maturity deviation [SMD]), and risk factors associated with SMD in peripubertal children with and without HIV established on antiretroviral therapy (ART) including use of tenofovir disoproxil fumarate (TDF). Methods Children with HIV taking ART for at least two years and a comparison group of HIV-negative children, aged 8–16 years and frequency-matched by age and sex, were recruited from HIV clinics and local schools in the same catchment area, in Harare, Zimbabwe. BA was assessed from non-dominant hand-wrist radiographs using the Tanner Whitehouse 3 method. Negative SMD values correspond to delayed development, i.e., BA younger than CA. Multivariable linear regression models determined factors associated with SMD overall, and in children with HIV. Results In total, 534 participants (54% males) were included; by design CA was similar in males and females, whether living with or without HIV. Mean (SD) SMD was more negative in CWH than in HIV-negative children in both males [-1.4(1.4) vs. -0.4(1.1) years] and females [-1.1(1.3) vs. -0.0(1.2) years]. HIV infection and weight-for-age Z-score

ABSTRACT This multi-year study (2014–2019) compared identification of rare and unusual Gram-negative organisms (GNOs) by matrix-assisted laser desorption ionization-time of flight mass spectrometry (MALDI-TOF MS) (VITEK MS, bioMérieux, Laval Que.) to 16S rRNA gene sequencing (16S) according to our laboratories routine workflow; 16S is done if initial MALDI-TOF MS gave discordant, wrong, or no results. GNB isolates were first analyzed by standard phenotypic methods and MALDI-TOF MS using direct deposit-full formic acid extraction; proteomics was repeated if no result occurred. Medically approved 16S analyses were done using fast protocols. Isolate sequences were analyzed using the Integrated Database Network System (IDNS3) bacterial database (SmartGene, Lausanne, Switzerland). Three hundred thirty-one GNOs including 251 (76%) aerobic Gram-negative bacilli (GNB), 63 (19%) fastidious Gram-negative coccobacilli (fGNCBs), and 17 (5%) Campylobacterales (CAMPB) isolates were recovered from 304 specimens; >1 isolate was recovered from 19 (6%). GNOs were mainly recovered from blood cultures (31.6%) and lower respiratory specimens (43%) (one-half were isolated from cystic fibrosis patients). Accurate genus vs species identities were obtained for 67.7% and 32.5% aerobic GNBs, 73% and 60% fGNCBs, and 23.5% CAMPB (with no discrepant species), respectively. Wrong or no results were obtained for 81 (32.3%) aerobic GNBs, 17 (27%) fGNCBs, and 13 (72.2%) CAMPB. No results or misidentifications occurred for 33% of aerobic GNBs, 26% of fGNCBs, and 76.5% of CAMPB due to absence of species in the instrument’s database. VITEK MS performance remained stable for aerobic GNBs and fGNCBs but improved for CAMPB with addition of Campylobacter rectus and Campylobacter curvus to the database. 16S remains important for identification of GNOs when proteomics fails.IMPORTANCEMatrix-assisted laser desorption ionization-time of flight mass spectrometry (MALDI-TOF MS) has transformed the identification of commonly encountered Gram-negative organisms (GNOs) in the clinical laboratory, but rare and unusual organisms continue to challenge the technology. This study verified performance of VITEK MS for identification of a broad range of rare and unusual clinical GNO isolates by our large reference laboratory workflow over a multi-year period. Although most GNOs were accurately identified by MALDI-TOF MS, a small number of clinical isolates (~1%–6%) required 16S sequencing for identification depending on the GNO category. Approximately one-third of aerobic Gram-negative bacilli (GNBs) and two-thirds of Campylobacterales could not be accurately identified by proteomics due to lack of an organism in the instrument’s database. MALDI-TOF MS databases should be continuously updated and validated, and laboratories should have a workflow for identification of unusual or rarely encountered aerobic, fastidious, and Campylobacterales GNOs that includes 16S rRNA gene sequencing whenever proteomics cannot give a definitive identification.

BackgroundWith the growing proportion of Canadians aged >65 years, smart home and health monitoring technologies may help older adults manage chronic disease and support aging in place. Localization technologies have been used to support the management of frailty and dementia by detecting activities in the home. ObjectiveThis systematic review aims to summarize the clinical evidence for in-home localization technologies, review the acceptability of monitoring, and summarize the range of technologies being used for in-home localization. MethodsThe PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) methodology was followed. MEDLINE, Embase, CINAHL, and Scopus were searched with 2 reviewers performing screening, extractions, and quality assessments. ResultsA total of 1935 articles were found, with 36 technology-focused articles and 10 articles that reported on patient outcomes being included. From moderate- to high-quality studies, 2 studies reported mixed results on identifying mild cognitive dementia or frailty, while 4 studies reported mixed results on the acceptability of localization technology. Technologies included ambient sensors; Bluetooth- or Wi-Fi–received signal strength; localizer tags using radio frequency identification, ultra-wideband, Zigbee, or GPS; and inertial measurement units with localizer tags. ConclusionsThe clinical utility of localization remains mixed, with in-home sensors not being able to differentiate between older adults with healthy cognition and older adults with mild cognitive impairment. However, frailty was detectable using in-home sensors. Acceptability is moderately positive, particularly with ambient sensors. Localization technologies can achieve room detection accuracies up to 92% and linear accuracies of up to 5-20 cm that may be promising for future clinical applications. Trial RegistrationPROSPERO CRD42022339845; https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=339845

Introduction Organoids have been successfully used in several areas of cancer research and large living biobanks of patient-derived organoids (PDOs) have been developed from various malignancies. The characteristics of the original tumour tissue such as mutation signatures, phenotype and genetic diversity are well preserved in organoids, thus showing promising results for the use of this model in translational research. In this study, we aim to assess whether we can generate PDOs from head and neck squamous cell carcinoma (HNSCC) samples and whether PDOs can be used to predict treatment sensitivity in HNSCC patients as well as to explore potential biomarkers.Methods and analysis This is a prospective observational study at a single centre (Guy’s and St Thomas’ NHS Foundation Trust) to generate PDOs from patients’ samples to assess treatment response and to correlate with patients’ treatment outcomes. Patients will be included if they are diagnosed with HNSCC undergoing curative treatment (primary surgery or radiotherapy) or presenting with recurrent or metastatic cancers and they will be categorised into three groups (cohort 1: primary surgery, cohort 2: primary radiotherapy and cohort 3: recurrent/metastatic disease). Research tumour samples will be collected and processed into PDOs and chemosensitivity/radiosensitivity will be assessed using established methods. Moreover, blood and other biological samples (eg, saliva) will be collected at different time intervals during treatment and will be processed in the laboratory for plasma and peripheral blood mononuclear cell (PBMC) isolation. Plasma and saliva will be used for circulating tumour DNA analysis and PBMC will be stored for assessment of the peripheral immune characteristics of the patients as well as to perform co-culture experiments with PDOs. SOTO study (correlation of the treatment Sensitivity of patient-derived Organoids with Treatment Outcomes in patients with head and neck cancer) uses the collaboration of several specialties in head and neck cancer and has the potential to explore multiple areas of research with the aim of offering a valid and effective approach to personalised medicine for cancer patients.Ethics and dissemination This study was approved by North West-Greater Manchester South Research Ethics Committee (REC Ref: 22/NW/0023) on 21 March 2022. An informed consent will be obtained from all participants prior to inclusion in the study. Results will be disseminated via peer-reviewed publications and presentations at international conferences.Trial registration number NCT05400239.

Abstract People living with HIV (PLHIV) report lower health-related quality-of-life (HRQoL) than HIV-negative people. HIV stigma may contribute to this. We explored the association between HIV stigma and HRQoL among PLHIV. We used cross-sectional data from 3991 randomly selected PLHIV who were surveyed in 2017–2018 for HPTN 071 (PopART), a cluster randomised trial in Zambia and South Africa. Participants were 18–44 years, had laboratory-confirmed HIV infection, and knew their status. HRQoL was measured using the EuroQol-5-dimensions-5-levels (EQ-5D-5L) questionnaire. Stigma outcomes included: internalised stigma, stigma experienced in the community, and stigma experienced in healthcare settings. Associations were examined using logistic regression. Participants who had experienced community stigma (n = 693/3991) had higher odds of reporting problems in at least one HRQoL domain, compared to those who had not (adjusted odds ratio, aOR: 1.51, 95% confidence interval, 95% Cl: 1.16–1.98, p = 0.002). Having experienced internalised stigma was also associated with reporting problems in at least one HRQoL domain (n = 552/3991, aOR: 1.98, 95% CI: 1.54–2.54, p

The diffuse attenuation coefficient of photosynthetically active radiation (KdPAR) is commonly used to predict light attenuation in aquatic productivity models, but obtaining measurements of PAR to compute KdPAR is difficult. In situ calculations of KdPAR require multiple measurements of PAR through the water column, and these measurements are infeasible for real-time recording. Instead, predictive models using surface-water measurements may be used. Traditional KdPAR models are based on open-ocean habitats and rely on chlorophyll—as a proxy measurement for phytoplankton abundance—as the main predictive parameter. However, elevated suspended sediments and dissolved organic materials may also affect KdPAR values of inland water bodies and estuaries. In this study, we leverage KdPAR calculations derived from in situ light measurements collected along with surface-water-quality parameters across the Sacramento-San Joaquin River Delta in California, USA (the Delta). Sampling occurred between January of 2013 and May of 2014. We also explored regional and seasonal effects, but these did not clearly affect the model. Ultimately, the best-performing model included surface-level turbidity only (R2 = 0.91). The simplicity of the model facilitates use of KdPAR estimates for a variety of purposes throughout the Delta, including euphotic depth calculations, and as inputs to primary-productivity and habitat-suitability models. We demonstrate the model’s usability with two open-sources data sets (one spatially dense, and one temporally dense), and estimate KdPAR, euphotic depth, and primary productivity within the Delta. We provide calculations for each estimation, allowing users to easily adopt these models and apply them to their own data or with open-sourced data, which are abundant.

For a positive integer \(n\), the full transformation semigroup \({\mathcal T}_n\) consists of all self maps of the set \(\{1,\ldots,n\}\) under composition. Any finite semigroup \(S\) embeds in some \({\mathcal T}_n\), and the least such \(n\) is called the (minimum transformation) degree of \(S\) and denoted \(\mu(S)\). We find degrees for various classes of finite semigroups, including rectangular bands, rectangular groups and null semigroups. The formulae we give involve natural parameters associated to integer compositions. Our results on rectangular bands answer a question of Easdown from 1992, and our approach utilises some results of independent interest concerning partitions/colourings of hypergraphs.As an application, we prove some results on the degree of a variant \({\mathcal T}_n^a\). (The variant \(S^a=(S,\star)\) of a semigroup \(S\), with respect to a fixed element \(a\in S\), has underlying set \(S\) and operation \(x\star y=xay\).) It has been previously shown that \(n\leq \mu({\mathcal T}_n^a)\leq 2n-r\) if the sandwich element \(a\) has rank \(r\), and the upper bound of \(2n-r\) is known to be sharp if \(r\geq n-1\). Here we show that \(\mu({\mathcal T}_n^a)=2n-r\) for \(r\geq n-6\). In stark contrast to this, when \(r=1\), and the above inequality says \(n\leq\mu({\mathcal T}_n^a)\leq 2n-1\), we show that \(\mu({\mathcal T}_n^a)/n\to1\) and \(\mu({\mathcal T}_n^a)-n\to\infty\) as \(n\to\infty\).Among other results, we also classify the \(3\)-nilpotent subsemigroups of \({\mathcal T}_n\), and calculate the maximum size of such a subsemigroup.Mathematics Subject Classifications: 20M20, 20M15, 20M30, 05E16, 05C65Keywords: Transformation semigroup, transformation representation, semigroup variant, rectangular band, nilpotent semigroup, hypergraph

BackgroundCandidemia is increasing in frequency and is associated with high mortality. We sought to determine the burden of illness, the population it affects and its resistance profile in our region.MethodsThe Calgary Zone (CZ) provides all care for residents of Calgary and surrounding communities (~ 1.69 million) via five tertiary hospitals each served by a common single laboratory for acute care microbiology. All adult patients in the CZ with at least one Candida spp.-positive blood culture between January 1, 2010, and December 31, 2018, were identified using microbiological data from Calgary Lab Services, the laboratory that processes > 95% of all blood culture samples in the CZ, were reviewed for the study.ResultsThe overall annual incidence of candidemia among individuals living in the CZ was 3.8 per 100,000 persons (Median age 61 years (IQR 48-72) and 221/455 (47.4%) were female). C. albicans was the most common species (50.6%), followed by C. glabrata, (24.0%). No other species accounted for more than 7% of cases. Overall mortality at 30, 90, and 365 days was 32.2, 40.1, and 48.1% respectively. Mortality rate did not differ by Candida species. Of individuals who developed candidemia, more than 50% died within the next year. No new resistance pattern has emerged in the most common Candida species in Calgary, Alberta.ConclusionsIn Calgary, Alberta, the incidence of candidemia has not increased in the last decade. C. albicans was the most common species and it remains susceptible to fluconazole.

O estudo descreve a aplicação da Sala de Aula Invertida (SAI) na formação contínua de professores de Matemática, integrando as Tecnologias da Informação e Comunicação (TIC). Dezesseis professores participaram do curso virtual na Regional Centro Sul da Secretaria Estadual de Educação do Rio de Janeiro. O curso, realizado de forma síncrona e assíncrona, envolveu análises de percepções por meio de formulários eletrônicos, entrevistas e atividades práticas. As conclusões destacam o potencial da SAI com suporte de TIC nas práticas pedagógicas. O estudo resultou no livro digital "Guia da Sala de Aula Invertida para Professores de Matemática", desenvolvido com base nos princípios do Design Science Research (DSR). Esse guia não apenas compila boas práticas, mas também incorpora os elementos do DSR para oferecer uma ferramenta prática e eficaz aos professores interessados em implementar a Sala de Aula Invertida.

Objective To estimate the cost-effectiveness of craniotomy, compared with decompressive craniectomy (DC) in UK patients undergoing evacuation of acute subdural haematoma (ASDH).Design Economic evaluation undertaken using health resource use and outcome data from the 12-month multicentre, pragmatic, parallel-group, randomised, Randomised Evaluation of Surgery with Craniectomy for Patients Undergoing Evacuation-ASDH trial.Setting UK secondary care.Participants 248 UK patients undergoing surgery for traumatic ASDH were randomised to craniotomy (N=126) or DC (N=122).Interventions Surgical evacuation via craniotomy (bone flap replaced) or DC (bone flap left out with a view to replace later: cranioplasty surgery).Main outcome measures In the base-case analysis, costs were estimated from a National Health Service and Personal Social Services perspective. Outcomes were assessed via the quality-adjusted life-years (QALY) derived from the EuroQoL 5-Dimension 5-Level questionnaire (cost-utility analysis) and the Extended Glasgow Outcome Scale (GOSE) (cost-effectiveness analysis). Multiple imputation and regression analyses were conducted to estimate the mean incremental cost and effect of craniotomy compared with DC. The most cost-effective option was selected, irrespective of the level of statistical significance as is argued by economists.Results In the cost-utility analysis, the mean incremental cost of craniotomy compared with DC was estimated to be −£5520 (95% CI −£18 060 to £7020) with a mean QALY gain of 0.093 (95% CI 0.029 to 0.156). In the cost-effectiveness analysis, the mean incremental cost was estimated to be −£4536 (95% CI −£17 374 to £8301) with an OR of 1.682 (95% CI 0.995 to 2.842) for a favourable outcome on the GOSE.Conclusions In a UK population with traumatic ASDH, craniotomy was estimated to be cost-effective compared with DC: craniotomy was estimated to have a lower mean cost, higher mean QALY gain and higher probability of a more favourable outcome on the GOSE (though not all estimated differences between the two approaches were statistically significant).Ethics Ethical approval for the trial was obtained from the North West—Haydock Research Ethics Committee in the UK on 17 July 2014 (14/NW/1076).Trial registration number ISRCTN87370545.

Abstract Background Neurological infection is an important cause of critical illness, yet little is known on the epidemiology of neurological infections requiring critical care. Methods We analysed data on all adults with proven or probable neurological infection admitted to UK (NHS) critical care units between 2001 and 2020 reported to the Intensive Care National Audit and Research Centre. Diagnoses, physiological variables, organ support and clinical outcomes were analysed over the whole period, and for consecutive 5-year intervals within it. Predictors of in-hospital mortality were identified using a backward stepwise regression model. Results We identified 20,178 critical care admissions for neurological infection. Encephalitis was the most frequent presentation to critical care, comprising 6725 (33.3%) of 20,178 cases. Meningitis– bacterial, viral or unspecified cases - accounted for 10,056 (49.8%) of cases. In-hospital mortality was high, at 3945/19,765 (20.0%) overall. Over the four consecutive 5-year periods, there were trends towards higher Glasgow Coma Scale scores on admission, longer critical care admissions (from median 4 [IQR 2–8] to 5 days [IQR 2–10]), and reduced in-hospital mortality (from 24.9 to 18.1%). We identified 12 independent predictors of in-hospital death which when used together showed good discrimination between patients who die and those who survive (AUC = 0.79). Conclusions Admissions with neurological infection to UK critical care services are increasing and the mortality, although improving, remains high. To further improve outcomes from severe neurological infection, novel approaches to the evaluation of risk stratification, monitoring and management strategies are required.

Rising to the demands of academic writing, scholarship and research is challenging for many practitioners in post compulsory education. Only a small number manage to see their research through to completion and write-up. Therefore, their work is under-represented in peer-reviewed, published literature in the field of educational research. This article foregrounds the role of stories, storytelling and image in the development of different kinds of language, including scholarship and academic writing. Narrative accounts of experiences of practitioner-researchers beginning to engage in research through intensive residential research development workshops, delivered as part of a national Practitioner Research Programme (PRP), are used to illustrate the power of oracy, imagery and story in extending our ability to develop language; research and represent experience; and portray different forms of understanding in a range of educational contexts. The results indicate that being able to listen, read and 'see' the research stories of more experienced researchers, as well as telling stories of their own experiences of research, enables participants to become more comfortable in using experiences of educational practice as a starting point for research and to regard research and practice not as a dichotomy or as separate activities, but as dynamic and integral aspects of educational improvement.

This article investigates Brown's assertion that students today exhibit an unwillingness/inability to engage in critical thinking (CT). He describes this as a 'critical thinking deficit'. The question of whether CT can be taught or whether we can only create the conditions in which CT can thrive and develop is explored through analysis of data from a pedagogical intervention of a Poetry Group; it aims to develop CT by employing Community of Inquiry as a methodology. This intervention was offered to a group of Further Education (FE) students over a period of six months with the intention of preparing them for progression into Higher Education (HE). Findings from the study lend support to the claim that sharing stories and poems is helpful in developing social and cultural capital across the group and in supporting CT and academic development. Students in the study report that they found the Poetry Group particularly valuable in encouraging both critical engagement with their Arts subject, deeper levels of learning and supporting improvements in attainment.

This article presents the background to and rationale for a practice-focused model of educational change and improvement. In contrast to autocratic top-down models, this democratic and pragmatic approach begins with the educational concerns of teachers. In this model, responsibility and accountability for educational improvement is shared between policy professionals, the university team and sector practitioners. Contributions from the literature explore the question of the nature and purpose of educational practice; how concepts of educational practice influence curriculum design and content in programmes for the initial and continuing professional development for teachers of vocational education; and how these can enhance or inhibit the improvement of educational practice. Drawing upon case study examples from a national programme of university-supported practitioner research in England, results illustrate how this model offers insights into ways of increasing research capacity and achieving sustainable improvements in educational practice. It concludes that programmes of university-supported practitioner research, which encourage and enable teachers to engage in the systematic investigation of educational practice, can realize educational improvements which other approaches to educational evaluation and improvement (including external inspection regimes) struggle to do. It invites politicians and policy professionals to consider potential applications of this approach in other national systems of vocational education.

This article provides an auto-ethnographic narrative to offer insights into my experience as a practitioner-researcher working in widening participation (WP) in post-compulsory education (PCE). It relates how I came to join the Education and Training Foundation (ETF) Practitioner Research Programme (PRP). It provides insights into the role of WP practitioner and manager and offers a reflection upon my experiences as an early practitioner-researcher conducting research in the field of WP. Writing in the first person, I reflect upon the positionality within my professional practice as someone who is immersed in the context that is being researched. I make my story as authentic as possible in order to throw new light upon knowledge in the field of widening participation (WP) practice. This immersion has enabled me to increase my professional knowledge and to establish a stronger voice in and for WP practitioners in the profession and for learners in the WP community. This empowerment has come about as my knowledge of the factors influencing the context of my work has expanded. I hope that it will be of interest to other researchers working in the field of WP and that they will accept my invitation to contribute to this conversation and reflect upon their own journey.

Abstract Background Near-real time surveillance of excess mortality has been an essential tool during the COVID-19 pandemic. It remains critical for monitoring mortality as the pandemic wanes, to detect fluctuations in the death rate associated both with the longer-term impact of the pandemic (e.g. infection, containment measures and reduced service provision by the health and other systems) and the responses that followed (e.g. curtailment of containment measures, vaccination and the response of health and other systems to backlogs). Following the relaxing of social distancing regimes and reduction in the availability of testing, across many countries, it becomes critical to measure the impact of COVID-19 infection. However, prolonged periods of mortality in excess of the expected across entire populations has raised doubts over the validity of using unadjusted historic estimates of mortality to calculate the expected numbers of deaths that form the baseline for computing numbers of excess deaths because many individuals died earlier than they would otherwise have done: i.e. their mortality was displaced earlier in time to occur during the pandemic rather than when historic rates predicted. This is also often termed “harvesting” in the literature. Methods We present a novel Cox-regression-based methodology using time-dependent covariates to estimate the profile of the increased risk of death across time in individuals who contracted COVID-19 among a population of hip fracture patients in England (N = 98,365). We use these hazards to simulate a distribution of survival times, in the presence of a COVID-19 positive test, and then calculate survival times based on hazard rates without a positive test and use the difference between the medians of these distributions to estimate the number of days a death has been displaced. This methodology is applied at the individual level, rather than the population level to provide a better understanding of the impact of a positive COVID-19 test on the mortality of groups with different vulnerabilities conferred by sociodemographic and health characteristics. Finally, we apply the mortality displacement estimates to adjust estimates of excess mortality using a “ball and urn” model. Results Among the exemplar population we present an end-to-end application of our methodology to estimate the extent of mortality displacement. A greater proportion of older, male and frailer individuals were subject to significant displacement while the magnitude of displacement was higher in younger females and in individuals with lower frailty: groups who, in the absence of COVID-19, should have had a substantial life expectancy. Conclusion Our results indicate that calculating the expected number of deaths following the first wave of the pandemic in England based solely on historical trends results in an overestimate, and excess mortality will therefore be underestimated. Our findings, using this exemplar dataset are conditional on having experienced a hip fracture, which is not generalisable to the general population. Fractures that impede mobility in the weeks that follow the accident/surgery considerably shorten life expectancy and are in themselves markers of significant frailty. It is therefore important to apply these novel methods to the general population, among whom we anticipate strong patterns in mortality displacement – both in its length and prevalence – by age, sex, frailty and types of comorbidities. This counterfactual method may also be used to investigate a wider range of disruptive population health events. This has important implications for public health monitoring and the interpretation of public health data in England and globally.

The impacts on global climate of the AD 536 and 541 volcanic eruptions are well attested in palaeoclimatic datasets and in Eurasian historical records. Their effects on farmers in the arid uplands of western North America, however, remain poorly understood. The authors investigate whether extreme cold caused by these eruptions influenced the scale, scope and timing of the Neolithic Transition in the northern US Southwest. Archaeological tree-ring and radiocarbon dates, along with settlement survey data, suggest that extreme cooling generated the physical and social space that enabled early farmers to transition from kin-focused socio-economic strategies to increasingly complex and widely shared forms of social organisation that served as foundational elements of burgeoning Ancestral Pueblo societies.

The relative importance of separation by distance and by environment to population genetic diversity can be conveniently tested in river networks, where these two drivers are often independently distributed over space. To evaluate the importance of dispersal and environmental conditions in shaping microbial population structures, we performed genome-resolved metagenomic analyses of benthic Microcoleus-dominated cyanobacterial mats collected in the Eel and Russian River networks (California, USA). The 64 Microcoleus genomes were clustered into three species that shared >96.5% average nucleotide identity (ANI). Most mats were dominated by one strain, but minor alleles within mats were often shared, even over large spatial distances (>300 km). Within the most common Microcoleus species, the ANI between the dominant strains within mats decreased with increasing spatial separation. However, over shorter spatial distances (tens of kilometres), mats from different subwatersheds had lower ANI than mats from the same subwatershed, suggesting that at shorter spatial distances environmental differences between subwatersheds in factors like canopy cover, conductivity, and mean annual temperature decreases ANI. Since mats in smaller creeks had similar levels of nucleotide diversity (π) as mats in larger downstream subwatersheds, within-mat genetic diversity does not appear to depend on the downstream accumulation of upstream-derived strains. The four-gamete test and sequence length bias suggest recombination occurs between almost all strains within each species, even between populations separated by large distances or living in different habitats. Overall, our results show that, despite some isolation by distance and environmental conditions, sufficient gene-flow occurs among cyanobacterial strains to prevent either driver from producing distinctive population structures across the watershed.

Abstract Background Hip fractures are devastating injuries causing disability, dependence, and institutionalisation, yet hospital care is highly variable. This study aimed to determine hospital organisational factors associated with recovery of mobility and change in patient residence after hip fracture. Methods A cohort of patients aged 60 + years in England and Wales, who sustained a hip fracture from 2016 to 2019 was examined. Patient-level Hospital Episodes Statistics, National Hip Fracture Database, and mortality records were linked to 101 factors derived from 18 hospital-level organisational metrics. After adjustment for patient case-mix, multilevel models were used to identify organisational factors associated with patient residence at discharge, and mobility and residence at 120 days after hip fracture. Results Across 172 hospitals, 165,350 patients survived to discharge, of whom 163,230 (99%) had post-hospital discharge destination recorded. 18,323 (11%) died within 120 days. Among 147,027 survivors, 58,344 (40%) across 143 hospitals had their residence recorded, and 56,959 (39%) across 140 hospitals had their mobility recorded, at 120 days. Nineteen organisational factors independently predicted residence on hospital discharge e.g., return to original residence was 31% (95% confidence interval, CI:17–43%) more likely if the anaesthetic lead for hip fracture had time allocated in their job plan, and 8–13% more likely if hip fracture service clinical governance meetings were attended by an orthopaedic surgeon, physiotherapist or anaesthetist. Seven organisational factors independently predicted residence at 120 days. Patients returning to their pre-fracture residence was 26% (95%CI:4–42%) more likely if hospitals had a dedicated hip fracture ward, and 20% (95%CI:8–30%) more likely if treatment plans were proactively discussed with patients and families on admission. Seventeen organisational factors predicted mobility at 120 days. More patients re-attained their pre-fracture mobility in hospitals where (i) care involved an orthogeriatrician (15% [95%CI:1-28%] improvement), (ii) general anaesthesia was usually accompanied by a nerve block (7% [95%CI:1-12%], and (iii) bedside haemoglobin testing was routine in theatre recovery (13% [95%CI:6-20%]). Conclusions Multiple, potentially modifiable, organisational factors are associated with patient outcomes up to 120 days after a hip fracture, these factors if causal should be targeted by service improvement initiatives to reduce variability, improve hospital hip fracture care, and maximise patient independence.

Objectives Hip fractures are common injuries in older age with high mortality requiring multidisciplinary clinical care. Despite guidance, there is considerable variation in hip fracture services and patient outcomes; furthermore, little is known about how successful multidisciplinary working can be enabled. This study aimed to characterise professionals’ views about the core components of multidisciplinary teamwork in hip fracture care.Design The study comprised qualitative interviews with healthcare professionals delivering hip fracture care. Interviews were audio recorded, transcribed and analysed abductively: material was coded inductively and grouped into higher level concepts informed by theories and frameworks relating to teamwork.Setting Four hospitals in England.Participants Participants were 40 healthcare professionals including orthopaedic surgeons, orthogeriatricians, physiotherapists and service managers.Results Results identified four components of successful multidisciplinary teamwork: (1) defined roles and responsibilities, (2) information transfer processes, (3) shared goals and (4) collaborative leadership. These were underpinned by a single concept: shared responsibility. Defined roles and responsibilities were promoted through formal care pathways, reinforced through induction and training with clear job plans outlining tasks. Information transfer processes facilitated timely information exchange to appropriate individuals. Well-defined common purpose was hindered by complex interdisciplinary professional relationships, particularly between orthogeriatric and orthopaedic staff, and encouraged through multidisciplinary team meetings and training. Clinical service leads were integral to bridging interdisciplinary boundaries. Mutual trust and respect were based on recognition of the value of different professional groups. Teamwork depended on formal clinical leads with facilitative and motivational roles, and on hospital leadership that created an environment supporting collaboration. Shared responsibility for patients was encouraged by joint orthopaedic and orthogeriatric care models. Staff shared responsibility by assisting colleagues when needed.Conclusions Shared responsibility across the multidisciplinary team is fundamental to delivery of hip fracture care. Findings will inform development of clinical practice recommendations and training to build teamworking competencies.

IntroductionAfrica's older population is increasing and this, necessitates the development of interventions to promote healthy ageing. Nutrition is a key determinant of healthy ageing and local contextual evidence is needed to inform nutritional intervention development in Africa. There are already reviews on nutritional status and food insecurity in older adults in Africa. However, a synthesis of nutrition interventions targeting older people specifically, is lacking. Therefore, this protocol describes a scoping review that aims to systematically synthesise current evidence on nutrition interventions for older people in Africa.MethodsThe review will involve: a review of available reviews on nutrition in older people in Africa (Phase 1); a review of nutrition interventions developed or implemented among older people in Africa (Phase 2); and consultation with local nutrition stakeholders in Zimbabwe, and The Gambia to contextualise Phase 1 and 2 findings and solicit insights not in the published literature (Phase 3). Searches for Phases 1 and 2 will include bibliographic databases (MEDLINE, EMBASE, Web of Science, African Journals Online, African Index Medicus) and grey literature sources (i.e. relevant websites). Title, abstract, and full-text screening will be conducted in duplicate, data extracted using piloted tools and findings summarised using descriptive statistics and narrative text. Phase 3 will be conducted using hybrid workshops, audio-recorded, detailed notes taken, and findings combined with those from Phases 1 and 2.ConclusionThe findings of this review will summarise current evidence on nutrition in older people in Africa and inform nutrition intervention development. The findings will be presented in conferences, meetings, and published open access.Trial registrationThis scoping review has been registered in OSF, registration DOI: https://doi.org/10.17605/OSF.IO/FH74T.

Multimorbidity is an emerging challenge for health systems globally. It is commonly defined as the co-occurrence of two or more chronic conditions in one person, but its meaning remains a lively area of academic debate, and the utility of the concept beyond high-income settings is uncertain. This article presents the findings from an interdisciplinary research initiative that drew together 60 academic and applied partners working in 10 African countries to answer the questions: how useful is the concept of multimorbidity within Africa? Can the concept be adapted to context to optimise its transformative potentials? During a three-day concept-building workshop, we investigated how the definition of multimorbidity was understood across diverse disciplinary and regional perspectives, evaluated the utility and limitations of existing concepts and definitions, and considered how to build a more context-sensitive, cross-cutting description of multimorbidity. This iterative process was guided by the principles of grounded theory and involved focus- and whole-group discussions during the workshop, thematic coding of workshop discussions, and further post-workshop development and refinement. Three thematic domains emerged from workshop discussions: the current focus of multimorbidity on constituent diseases; the potential for revised concepts to centre the priorities, needs, and social context of people living with multimorbidity (PLWMM); and the need for revised concepts to respond to varied conceptual priorities amongst stakeholders. These themes fed into the development of an expanded conceptual model that centres the catastrophic impacts multimorbidity can have for PLWMM, families and support structures, service providers, and health systems.