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Abstract Background Amyotrophic lateral sclerosis (ALS) is a devastating and incurable neurodegenerative disease. Accumulating evidence strongly suggests that intrinsic muscle defects exist and contribute to disease progression, including imbalances in whole-body metabolic homeostasis. We have previously reported that tumour necrosis factor (TNF)-like weak inducer of apoptosis (TWEAK) and fibroblast growth factor inducible 14 (Fn14) are significantly upregulated in skeletal muscle of the SOD1 G93A ALS mouse model. While antagonising TWEAK did not impact survival, we did observe positive effects in skeletal muscle. Given that Fn14 has been proposed as the main effector of the TWEAK/Fn14 activity and that Fn14 can act independently from TWEAK in muscle, we suggest that manipulating Fn14 instead of TWEAK in the SOD1 G93A ALS mice could lead to differential and potentially improved benefits. Methods We thus investigated the contribution of Fn14 to disease phenotypes in the SOD1 G93A ALS mice. To do so, Fn14 knockout mice (Fn14 −/− ) were crossed onto the SOD1 G93A background to generate SOD1 G93A ;Fn14 −/− mice. Investigations were performed on both unexercised and exercised (rotarod and/or grid test) animals (wild type (WT), Fn14 −/−, SOD1 G93A and SOD1 G93A ;Fn14 −/− ). Results Here, we firstly confirm that the TWEAK/Fn14 pathway is dysregulated in skeletal muscle of SOD1 G93A mice. We then show that Fn14-depleted SOD1 G93A mice display increased lifespan, myofiber size, neuromuscular junction endplate area as well as altered expression of known molecular effectors of the TWEAK/Fn14 pathway, without an impact on motor function. Importantly, we also observe a complex interaction between exercise (rotarod and grid test), genotype, disease state and sex that influences the overall effects of Fn14 deletion on survival, expression of known molecular effectors of the TWEAK/Fn14 pathway, expression of myosin heavy chain isoforms and myofiber size. Conclusions Our study provides further insights on the different roles of the TWEAK/Fn14 pathway in pathological skeletal muscle and how they can be influenced by age, disease, sex and exercise. This is particularly relevant in the ALS field, where combinatorial therapies that include exercise regimens are currently being explored. As such, a better understanding and consideration of the interactions between treatments, muscle metabolism, sex and exercise will be of importance in future studies.

Abstract Introduction Posterior tibial nerve (PTN) cross‐sectional area (CSA) reference values for the diagnosis of tarsal tunnel syndrome (TTS) using ultrasound imaging exist in several countries but not in South Africa (SA). Therefore, the objective was to measure the CSA reference values for PTN in SA. Methods Ultrasound CSA measurements of PTN in both ankles on 112 participants were performed, the mean measurement was recorded, and the effect of race, age, gender, and body mass index (BMI) were recorded. Results In this study, the primary variables age and BMI affect the CSA measurement of the PTN. A positive correlation was found between PTN asymptomatic size and age (r = 0.196, P

Abstract While first-generation, spike (S)-based COVID-19 vaccines were effective against early SARS-CoV-2 strains, the rapid evolution of novel Omicron subvariants have substantially reduced vaccine efficacy. As such, broadly protective vaccines against SARS-CoV-2 are needed to prevent future viral emergence. In addition, it remains less clear whether peripheral immunization, especially with mRNA vaccines, elicits effective respiratory immunity. Our group has developed a nucleoside-modified mRNA vaccine expressing the nucleocapsid (N) protein of the ancestral SARS-CoV-2 virus and has tested its use in combination with the S-based mRNA vaccine (mRNA-S). In this study, we examined efficacy of mRNA-N alone or in combination with mRNA-S (mRNA-S+N) against more immune evasive Omicron variants in hamsters. Our data show that mRNA-N alone induces a modest but significant protection against BA.5 and that dual mRNA-S+N vaccination confers complete protection against both BA.5 and BQ.1, preventing detection of virus in the hamster lungs. Analysis of respiratory immune response in mice shows that intramuscular mRNA-S+N immunization effectively induces respiratory S- and N-specific T cell responses in the lungs and in bronchoalveolar lavage (BAL), as well as antigen-specific binding IgG in BAL. Together, our data further support mRNA-S+N as a potential pan-COVID-19 vaccine for broad protection against current and emerging SARS-CoV-2 variants.

While the exercise-induced responses of circulated biomarkers related to inflammation and brain health are well documented in humans, little is known about the effect of menopausal status on these responses. This study compared the responses of inflammatory cytokines and brain-derived neurotrophic factor (BDNF) to high-intensity exercise between pre- and postmenopausal middle-aged females. Eight premenopausal (44 ± 3 years) and seven postmenopausal (57 ± 2 years) females performed a high-intensity interval training (HIIT) session consisting of 10 × 1 min running intervals (90% maximum heart rate) separated by 1 min passive recovery intervals. Blood samples were collected at baseline (fasted), pre-exercise (postprandial), and at 0, 30, and 90 min post-HIIT and analyzed for interleukin (IL-6) and 10 (IL-10), tumour necrosis factor-alpha (TNF-α), and BDNF. IL-6 significantly increased from pre-exercise to 0 min post-HIIT in postmenopausal (+40%, p = 0.01) and to 30 min post-HIIT in premenopausal females (+60%, p = 0.02). IL-6 remained elevated at 90 min post-HIIT in premenopausal (+104%, p = 0.05) and to a higher degree in postmenopausal females (+385%, p < 0.001). IL-10 showed no response. TNF-α increased from pre- to 0 min post-HIIT (+10%, p = 0.05), then decreased to below pre-exercise at 30 min (−10%, p = 0.02) and 90 min (−5%, p = 0.04) in both groups. BDNF increased immediately post-HIIT in premenopausal (+60%, p < 0.001) but not postmenopausal females. The differences in IL-6 and BDNF responses to HIIT between pre- and postmenopausal females provide evidence of the role of female reproductive hormones in the regulation of these exercise-induced responses.

Abstract Pharmaceutically active compounds have been considered contaminants of emerging concern, in response to evidence that these substances may adversely affect non-target organisms. The pharmaceutical metformin is the most commonly prescribed anti-diabetes medicine throughout the world. Metformin has been detected in numerous freshwater systems as well as in seawater at a number of sites around the world over the last few years, but has never been reported in the Indonesian capital city Jakarta. Several recent studies have highlighted various ecotoxicological effects of this medicine on aquatic organisms. Here we report the first evidence of metformin’s presence in Jakarta waters. Samples from the Angke river, one of the main rivers in Jakarta, were collected from six sites. Metformin was detected at three sites in concentrations ranging from 27 ng/L to 414 ng/L. Metformin is one of the most detected APIs (active pharmaceutical ingredients) in aquatic environments worldwide, and there is increasing concern regarding its impact on the health of wildlife and humans. However, this is the first report of metformin contamination in Jakarta waters, adding to the evidence of potentially increased pollution with pharmaceuticals, as noted in our previous studies. With no natural degradation processes, these chemical compounds can be easily reintroduced to the food chain and impact human health.

Background: Group work is employed in higher education institutions to foster communication, collaborative learning, leadership qualities and teamwork skills. The rationale behind group work as a learning strategy is to ensure that graduates are equipped with teamwork skills. Aim: The aim of this study was to establish whether the final-year radiography students of the National Diploma curriculum in three universities in South Africa were exposed to effective group work. Setting: The study was conducted in three universities in South Africa, all of which offer diagnostic radiography programmes. Methods: This study used a non-experimental descriptive design to collect data. A purposive sampling technique was used to select participants. This was an attempt to conduct a census on 167 students, out of which 124 students responded to the questionnaire, giving a response rate of 74.25%. Results: The findings show that the majority (n = 81; 66.9%) of students did not enjoy group work, as 101 (81.5%) of them preferred less group projects. The results further demonstrated that participants rated factors such as co-operation, leadership, choice, diversity and effectiveness of group work neutral on the Likert scale. Conclusion: The study results imply that factors that contribute towards the effectiveness of group work should be incorporated into group activities in order for student radiographers to be exposed to effective group work. The gaps identified in this study indicate the need for a follow-up study within the current 4-year bachelor’s degree in radiography. Contribution: Identification of a gap in radiography education, which group work needs to be facilitated effectively.

Abstract Objective To investigate the effects of moderate‐intensity aerobic exercise on appetite control parameters, appetite perceptions, and energy intake in sedentary males with obesity. Design Eleven males with obesity (body fat percentage 36.5 ± 2.5%, body mass index 35.3 ± 4.2 kg/m2, V̇O2peak 29 ± 3.1 mL·kg−1·min−1) completed two experimental sessions: (1) no exercise (CTRL) and (2) 60 min of moderate‐intensity cycling exercise at 60% V̇O2peak (MICT) in a crossover design. Blood analysis included growth differentiation factor 15 (GDF‐15), total ghrelin, peptide tyrosine tyrosine3–36 (PYY3–36), total glucagon‐like peptide‐1 (GLP‐1), insulin, and glucose, as well as subjective appetite perceptions were measured in specific intervals. A standard breakfast at 0 h and an ad libitum meal postexercise was provided. Result GDF‐15 (95% confidence interval [CI]: [2.48–27.28] ng/L, p = 0.021) increased immediately following MICT compared to CTRL. However, there were no differences for PYY3–36 (p = 0.480, ηp2=0.025), total ghrelin (p = 0.646, ηp2=0.011), and total GLP‐1 (p = 0.451, ηp2=0.029) between sessions. Appetite perceptions (95% CI: [(−20.38)–(−6.16)] mm, p = 0.001) were suppressed following MICT though energy intake was not different between the sessions (95% CI: [(−1904.9)–928.1] kJ, p = 0.480). Conclusion Sixty minutes of MICT increased GDF‐15 while suppressing appetite perceptions in individuals with obesity. There was no energy compensation postexercise.

Abstract Differentiation of adipose progenitor cells into mature adipocytes entails a dramatic reorganization of the cellular architecture to accommodate lipid storage into cytoplasmic lipid droplets. Lipid droplets occupy most of the adipocyte volume, compressing the nucleus beneath the plasma membrane. How this cellular remodeling affects sub-nuclear structure, including size and number of nucleoli, remains unclear. We describe the morphological remodeling of the nucleus and the nucleolus during in vitro adipogenic differentiation of primary human adipose stem cells. We find that cell cycle arrest elicits a remodeling of nucleolar structure which correlates with a decrease in protein synthesis. Strikingly, triggering cytoskeletal rearrangements mimics the nucleolar remodeling observed during adipogenesis. Our results point to nucleolar remodeling as an active, mechano-regulated mechanism during adipogenic differentiation and demonstrate a key role of the actin cytoskeleton in defining nuclear and nucleolar architecture in differentiating human adipose stem cells.

Abstract Introduction The study explored and described the professional identity of diagnostic radiographers in Johannesburg, Gauteng, South Africa. Methods The methodology employed for the study was qualitative, exploratory and descriptive design. Face‐to‐face interviews were conducted with thirteen diagnostic radiographers from private, public practices and individually owned practices. Semi‐structured interviews were conducted, and the responses underwent thematic analysis and used Braun and Clarke's six steps for analysing qualitative data. Results The thematic analysis revealed three themes and six categories. The three themes identified were: perceptions of identity, environment influences and organisational institutions. Conclusion This study provided an insight into the current perspectives of the professional identity of diagnostic radiographers in Johannesburg, South Africa, which reflected a positive professional identity. The three themes identified could inform guidelines for education in diagnostic radiographers' professional identity in the future.

Background: Management of radiography departments requires skilled and competent managers. This task becomes complex if there is no management development and collaborative performance monitoring. Aim: The study aimed to explore and describe the radiography managers’ perceptions regarding management training and skills required. Setting: The research was conducted in public health institutions of Gauteng, South Africa. Methods: Qualitative, exploratory and descriptive approach was adopted, and a purposive sampling method was used to select twenty-three (23) managers from the radiography departments; however, data saturation guided the sample size. Data were collected through online focus group discussions (FGDs). Ethical approval was obtained through Departmental Research Committee (DRC) of Medical Imaging and Radiation Sciences (MIRS) department, Higher Degrees Committee (HDC), Research Ethics Committee and Gauteng Department of Health Research Committees. Data trustworthiness was obtained through member checking, data verification and an independent coder to verify the accuracy of the data. Thematic data analysis method was used to analyse the data. Results: Five themes emerged from the thematic analysis and centred on: difficulties in transitioning into management, lack of management support, the need for postgraduate management qualification, coaching and mentoring and required skills for radiography managers. Conclusion: Public health institutions continuously face transitions in service delivery frameworks. This requires competent and skilled radiography managers to survive in this environment. The study revealed that new managers experience difficulties and require management support to succeed in their roles. Contribution: Awareness of managers developmental needs relative to the real-life dynamics of radiography management in Gauteng public health environment.

Abstract The first systematic reviews of the effects of exercise on appetite‐regulation and energy intake demonstrated changes in appetite‐regulating hormones consistent with appetite suppression and decreases in subsequent relative energy intake over a decade ago. More recently, an intensity‐dependent effect and several potential mechanisms were proposed, and this review aims to highlight advances in this field. While exercise‐induced appetite suppression clearly involves acylated ghrelin, glucagon‐like peptide‐1 may also be involved, though recent evidence suggests peptide tyrosine tyrosine may not be relevant. Changes in subjective appetite perceptions and energy intake continue to be equivocal, though these results are likely due to small sample sizes and methodological inconsistencies. Of the proposed mechanisms responsible for exercise‐induced appetite suppression, lactate has garnered the most support through in vitro and in vivo rodent studies as well as a growing amount of work in humans. Other potential modulators of exercise‐induced appetite suppression may include sex hormones, growth‐differentiation factor 15, Lac‐Phe, brain‐derived neurotrophic factor, and asprosin. Research should focus on the mechanisms responsible for the changes and consider these other modulators (i.e., myokines/exerkines) of appetite to improve our understanding of the role of exercise on appetite regulation.

Abstract The El Niño 2015 event, most extreme since 1997, led to severe droughts in tropical wet Papua New Guinea (PNG), reducing May to October dry season rainfall by 75% in the lowlands and 25% in the highlands. Such droughts are likely to have significant effects on terrestrial ecosystems, but they have been poorly explored in Papua New Guinea. Here, we report changes in bird community composition prior to, during, and after the 2015 El Niño event along the elevational gradient ranging from 200 m to 2700 m a.s.l. at the Mt. Wilhelm rainforest in PNG. The abundance of birds in the lowlands dropped by 60% but increased by 40% at elevations above 1700 m during El Niño year. In the following year, the individual bird species reached mean population sizes similar to pre‐El Niño years but did not fully recover. Species richness roughly followed the pattern of observed abundance and quickly and fully re‐established after the event to the pre‐ El Niño values. Thus, at least some terrestrial birds seem to react quickly to the extreme droughts in lowlands and shift to less affected mountain habitats. We recorded upper elevational range limits to shifts by more than 500 m a.s.l. in 22 bird species (out of 237 recorded in total) during El Niño year, in contrast to their typical ranges. Our study suggests that a strong El Niño event can have strong but reversible effects on bird communities as long as they have an opportunity to move to more favorable sites through undisturbed habitats.

BackgroundThe beneficial effect of thermogenic adipocytes in maintaining body weight and protecting against metabolic disorders has raised interest in understanding the regulatory mechanisms defining white and beige adipocyte identity. Although alternative splicing has been shown to propagate adipose browning signals in mice, this has yet to be thoroughly investigated in human adipocytes.MethodsWe performed parallel white and beige adipogenic differentiation using primary adipose stem cells from 6 unrelated healthy subjects and assessed differential gene and isoform expression in mature adipocytes by RNA sequencing.ResultsWe find 777 exon junctions with robust differential usage between white and beige adipocytes in all 6 subjects, mapping to 562 genes. Importantly, only 10% of these differentially spliced genes are also differentially expressed, indicating that alternative splicing constitutes an additional layer of gene expression regulation during beige adipocyte differentiation. Functional classification of alternative isoforms points to a gain of function for key thermogenic transcription factors such as PPARG and CITED1, and enzymes such as PEMT, or LPIN1. We find that a large majority of the splice variants arise from differential TSS usage, with beige-specific TSSs being enriched for PPARγ and MED1 binding compared to white-specific TSSs. Finally, we validate beige specific isoform expression at the protein level for two thermogenic regulators, PPARγ and PEMT.DiscussionThese results suggest that differential isoform expression through alternative TSS usage is an important regulatory mechanism for human adipocyte thermogenic specification.

Abstract Any potential positive effects conferred via sunlight exposure have to be carefully balanced against carcinogenic effects. Here we provide evidence UK sunlight exposure upregulates the cardio protectant nitric oxide (NO) within in vitro skin cell lines with negligible increases in DNA damage and cell death at 1 SED, when compared against unexposed samples. The whole of the ultraviolet A (UV-A) spectrum appears to be responsible for NO release, with efficiency higher at exposures closer to shorter UV-A wavelengths and decreasing with wavelength increases. These results support further in vivo work, which could be of benefit for demographics such as the elderly (that exhibit a natural decline in NO bioavailability).

Abstract Background The National Institute for Health and Care Excellence (NICE) recommends that cognitive behaviour therapy (CBT) is offered to all patients with a psychosis diagnosis. However, only a minority of psychosis patients in England and Wales are offered CBT. This is attributable, in part, to the resource-intensive nature of CBT. One response to this problem has been the development of CBT in brief formats that are targeted at a single symptom and are deliverable by briefly trained therapists. We have developed Guided self-help CBT (the GiVE intervention) as a brief form of CBT for distressing voices and reported evidence for the feasibility of a randomised controlled trial (RCT) when the intervention was delivered by briefly trained therapists (assistant psychologists). This study will investigate the clinical and cost-effectiveness of the GiVE intervention when delivered by assistant psychologists following a brief training. Methods This study is a pragmatic, two-arm, parallel group, superiority RCT comparing the GiVE intervention (delivered by assistant psychologists) and treatment as usual to treatment as usual alone, recruiting across three sites, using 1:1 allocation and blind post-treatment and follow-up assessments. A nested qualitative study will develop a model for implementation. Discussion If the GiVE intervention is found to be effective when delivered by assistant psychologists, this intervention could significantly contribute to increasing access to evidence-based psychological interventions for psychosis patients. Furthermore, implementation across secondary care services within the UK’s National Health Service may pave the way for other symptom-specific and less resource-intensive CBT-informed interventions for psychosis patients to be developed and evaluated. Trial registration Current Controlled Trials ISRCTN registration number: 12748453. Registered on 28 September 2022.

Functionally graded materials (FGMs) are promising protective structures for lightweight armor plates because of their features and designability. However, traditional discretely layered FGMs with macroscopic interfaces can generate unfavorable interlaminar stresses under ballistic attacks, eventually leading to delamination or interlayer tearing. Herein, we constructed new B4C/2024Al FGMs without sharp interfaces between layers. The FGM armor systems with varying through-the-thickness distributions were tested against 7.62 mm armor-piercing incendiary projectiles. The effects of compositional gradient exponent on the damage characteristics, stress distribution and energy evolution were numerically and experimentally investigated. The results indicated that the smooth transition within through-the-thickness microstructures effectively avoided the occurrence of interlayer delamination or tearing. The compositional gradient exponent played an essential role in the impact response of the FGM targets. The FGM having a linear composition gradient outperformed other nonlinear types with respect to energy absorption and ballistic properties due to the reduced tensile wave strength and prolonged projectile-target interaction time. Furthermore, the structural optimization problem with the objective of maximizing ballistic efficiency was solved using the conjugate gradient method, and the optimal design of the FGM targets was achieved. The current research provides a promising design guideline for developing and optimizing new advanced lightweight composite armor.

Introduction Adalimumab is an effective treatment for autoimmune non-infectious uveitis (ANIU), but it is currently only funded for a minority of patients with ANIU in the UK as it is restricted by the National Institute for Health and Care Excellence guidance. Ophthalmologists believe that adalimumab may be effective in a wider range of patients. The Adalimumab vs placebo as add-on to Standard Therapy for autoimmune Uveitis: Tolerability, Effectiveness and cost-effectiveness (ASTUTE) trial will recruit patients with ANIU who do and do not meet funding criteria and will evaluate the effectiveness and cost-effectiveness of adalimumab versus placebo as an add-on therapy to standard care.Methods and analysis The ASTUTE trial is a multicentre, parallel-group, placebo-controlled, pragmatic randomised controlled trial with a 16-week treatment run-in (TRI). At the end of the TRI, only responders will be randomised (1:1) to 40 mg adalimumab or placebo (both are the study investigational medicinal product) self-administered fortnightly by subcutaneous injection. The target sample size is 174 randomised participants. The primary outcome is time to treatment failure (TF), a composite of signs indicative of active ANIU. Secondary outcomes include individual TF components, retinal morphology, adverse events, health-related quality of life, patient-reported side effects and visual function, best-corrected visual acuity, employment status and resource use. In the event of TF, open-label drug treatment will be restarted as per TRI for 16 weeks, and if a participant responds again, allocation will be switched without unmasking and treatment with investigational medicinal product restarted.Ethics and dissemination The trial received Research Ethics Committee (REC) approval from South Central – Oxford B REC in June 2020. The findings will be presented at international meetings, by peer-reviewed publications and through patient organisations and newsletters to patients, where available.Trial registration ISRCTN31474800. Registered 14 April 2020.

BackgroundVirtual reality (VR) psychological therapy has the potential to increase access to evidence-based mental health interventions by automating their delivery while maintaining outcomes. However, it is unclear whether these more automated therapies are acceptable to potential users of mental health services. ObjectiveThe main aim of this study was to develop a new, validated questionnaire to measure public perceptions of VR therapy (VRT) guided by a virtual coach. We also aimed to explore these perceptions in depth and test how aspects such as familiarity with VR and mental health are associated with these perceptions, using both quantitative and qualitative approaches. MethodsWe used a cross-sectional mixed methods design and conducted an exploratory factor analysis of a questionnaire that we developed, the Attitudes Towards Virtual Reality Therapy (AVRT) Scale, and a qualitative content analysis of the data collected through free-text responses during completion of the questionnaire. ResultsWe received 295 responses and identified 4 factors within the AVRT Scale, including attitudes toward VRT, expectation of presence, preference for VRT, and cost-effectiveness. We found that being more familiar with VR was correlated with more positive attitudes toward VRT (factor 1), a higher expectation of presence (factor 2), a preference for VRT over face-to-face therapy (factor 3), and a belief that VRT is cost-effective (factor 4). Qualitative data supported the factors we identified and indicated that VRT is acceptable when delivered at home and guided by a virtual coach. ConclusionsThis study is the first to validate a scale to explore attitudes toward VRT guided by a virtual coach. Our findings indicate that people are willing to try VRT, particularly because it offers increased access and choice, and that as VR becomes ubiquitous, they will also have positive attitudes toward VRT. Future research should further validate the AVRT Scale.

Purpose: This study was undertaken to evaluate our 16-year experience with fistulas between the rectum and urethra or urinary bladder, collectively called recto-urinary fistulas (RUFs), and their devastating consequences in patients treated with radiation for prostate cancer. Methods: We downloaded the records of all patients with radiation-related RUFS from 2004 to 2020 at our institution using the electronic medical record system. Details concerning patient demographics, clinical presentation, diagnostic approaches and surgical management were obtained and assessed. Results: We identified a total of seven patients with radiation-induced RUFS: all were male and had an average age of 66 at diagnosis. Each had a history of prostate cancer that was treated with external, internal (i.e.brachytherapy), or combination radiation therapy. No fistulas were noted in patients treated with radiation for another malignancy. Radiation proctitis with rectal ulcer formation occurred in 6 of 7 patients. Common symptoms included fecaluria, pneumaturia, urine leakage via rectum, rectal pain and urinary tract infection. CT scanning was the most useful diagnostic tool. Once confirmed, fistula management included both urinary and fecal diversion in all patients. Only one patient received definitive repair of the fistula. Five others either died before repair could be attempted or had prohibitive co-morbid diseases. One patient declined repair. Conclusions: Although rare, the development of a recto-urinary fistula is a dreaded complication. Our results indicate that radiation proctitis with rectal ulcer formation precedes fistula formation in most patients and must be aggressively managed. While fecal and urinary diversion can manage fistula symptoms in the majority of patients, definitive fistula repair is only possible in selected individuals.

Abstract Background Healthcare systems invest in leadership development of surgeons, surgical trainees, and teams. However, there is no agreement on how interventions should be designed, or what components they must contain to be successful. The objective of this realist review was to generate a programme theory explaining in which context and for whom surgical leadership interventions work and why. Methods Five databases were systematically searched, and articles screened against inclusion considering their relevance. Context-mechanism-outcome configurations (CMOCs) and fragments of CMOCs were identified. Gaps in the CMOCs were filled through deliberation with the research team and stakeholder feedback. We identified patterns between CMOCs and causal relationships to create a programme theory. Results Thirty-three studies were included and 19 CMOCs were developed. Findings suggests that interventions for surgeons and surgical teams improve leadership if timely feedback is delivered on multiple occasions and by trusted and respected people. Negative feedback is best provided privately. Feedback from senior-to-junior or peer-to-peer should be delivered directly, whereas feedback from junior-to-senior is preferred when delivered anonymously. Leadership interventions were shown to be most effective for those with awareness of the importance of leadership, those with confidence in their technical surgical skills, and those with identified leadership deficits. For interventions to improve leadership in surgery, they need to be delivered in an intimate learning environment, consider implementing a speak-up culture, provide a variety of interactive learning activities, show a genuine investment in the intervention, and be customised to the needs of surgeons. Leadership of surgical teams can be best developed by enabling surgical teams to train together. Conclusions The programme theory provides evidence-based guidance for those who are designing, developing and implementing leadership interventions in surgery. Adopting the recommendations will help to ensure interventions are acceptable to the surgical community and successful in improving surgical leadership. Trial registration The review protocol is registered with PROSPERO (CRD42021230709).

Abstract Background Anxiety is a common mental health problem in the general population, and is associated with functional impairment and negative impacts upon quality of life. There has been increased concern about university students’ mental health in recent years, with a wide range of non-specific anxiety rates reported worldwide in undergraduate university students. We aimed to explore prevalence of non-specific anxiety in undergraduate university student populations. Methods Four databases were searched to identify studies published between 1980 and 2020 which investigated prevalence of non-specific anxiety in undergraduate university students. Each study’s quality was appraised using a checklist. Sub-analyses were undertaken reflecting outcome measure utilized, course of study, location of study, and whether study was before or during the COVID-19 pandemic. Results A total of 89 studies – representing approx. 130,090 students—met inclusion criteria. Eighty-three were included in meta-analysis, calculating a weighted mean prevalence of 39.65% (95% CI: 35.72%—43.58%) for non-specific anxiety. Prevalence from diagnostic interview studies ranged from 0.3%-20.8% 12-month prevalence. Prevalence varied by outcome measure used to assess non-specific anxiety, the type of course studied by sample, and by study location. In half the studies, being female was associated with being more likely to have higher non-specific anxiety scores and/or screening above thresholds. Few of the included studies met all quality appraisal criteria. Conclusion The results suggest that approximately a third of undergraduate students are experiencing elevated levels of non-specific anxiety. Results from sub-analyses have identified some methodological issues that need consideration in appraising prevalence in this population.

This case study explores how literature, in particular poetry, can be used as an educational platform within the secondary classroom to explore gender identity. A six-week unit of poetry was created as part of a broader project to enable pupils to reflect on their personal and familial experiences of gender, whilst also utilising creative writing and performance as a tool for self-expression. The all-female class were studied before, during and after the learning process to holistically evaluate their development of gender-consciousness. A key area of focus is the strengths and limitations of the use of performance poetry when developing awareness of gender identity within adolescents.