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Abstract Gestational trophoblastic disease is a process that affects ≈1 of 1000 pregnancies. If left untreated, this can progress to potentially life‐threatening complications with malignancy such as choriocarcinoma. The emergency physician must be aware of the presentation and complications of this disease process, including the difficulties in diagnosis. In this case presentation, the authors discuss the presentation and diagnostic process of a patient in the emergency department as well as the phenomenon known as the hook effect, which may complicate the decision‐making process.

Abstract Community‐engaged learning (CEL) integrates community service with structured learning to strengthen the knowledge and skills of future physicians while still in medical school. A national model forCEL during medical school does not currently exist. Emergency physicians have the opportunity to play a vital role in medical student education using CEL as a platform. This article elucidates the structure of a bystander cardiopulmonary resuscitation (B‐CPR) CEL program developed by emergency physicians that could serve as a national model for community engagement. As B‐CPR is a well‐known evidence‐based community intervention that can be taught by students and implemented by the community, it represents an ideal CEL that can also have a measurable impact on local B‐CPR rates. The development and structure of a B‐CPR CEL program, lessons learned, and impact on B‐CPR in a local area are reported.

Abstract Introduction Complex intervention development has been described as the ‘Cinderella’ black box in health services research. Greater transparency in the intervention development process is urgently needed to help reduce research waste. Methods We applied a new consensus‐based framework for complex intervention development to our programme of research, in which we developed an intervention to improve the safety and experience of care transitions for older people. Through this process, we aimed to reflect on the framework's utility for intervention development and identify any important gaps within it to support its continued development. Findings The framework was a useful tool for transparent reporting of the process of complex intervention development. We identified potential ‘action’ gaps in the framework including ‘consolidation of evidence’ and ‘development of principles’ that could bracket and steer decision‐making in the process. Conclusions We consider that the level of transparency demonstrated in this report, aided through use of the framework, is essential in the quest for reducing research waste. Patient or Public Contribution We have involved our dedicated patient and public involvement group in all work packages of this programme of research. Specifically, they attended and contributed to co‐design workshops and contributed to finalizing the intervention for the pilot evaluation. Staff also participated by attending co‐design workshops, helping us to prioritize content ideas for the intervention and supporting the development of intervention components outside of the workshops.

Abstract Background The current biodiversity crisis underscores the urgent need for sustainable management of the human uses of nature. In the context of sustainability management, adopting the ecosystem service (ES) concept, i.e., the benefits humans obtain from nature, can support decisions aimed at benefiting both nature and people. However, marine ecosystems in particular endure numerous direct drivers of change (i.e., habitat loss and degradation, overexploitation, pollution, climate change, and introduction of non-indigenous species) all of which threaten ecosystem structure, functioning, and the provision of ES. Marine ecosystems have received less attention than terrestrial ecosystems in ES literature, and knowledge on marine ES is hindered by the highly heterogeneous scientific literature with regard to the different types of marine ecosystem, ES, and their correlates. Here, we constructed a systematic map of the existing literature to highlight knowledge clusters and knowledge gaps on how changes in marine ecosystems influence the provision of marine ES. Method We searched for all evidence documenting how changes in structure and functioning of marine ecosystems affect the delivery of ES in academic and grey literature sources. In addition to Scopus, Web of Science, and Google Scholar, we searched 6 online databases from intergovernmental agencies, supranational or national organizations, and NGOs. We screened English-language documents using predefined inclusion criteria on titles, abstracts, and then full texts, without any geographic or temporal limitations. All qualifying literature was coded and metadata were extracted. No formal validity appraisal was undertaken. We identified knowledge clusters and gaps in terms of which ecosystem types, biodiversity components, or ES types have been studied and how these categories are linked. Review findings Our searches identified 41 884 articles published since 1968 of which 12 140 were duplicates; 25 747 articles were excluded at the title-screening stage, then 2774 at the abstract stage. After full-text screening, a total of 653 articles—having met the eligibility criteria—were included in the final database, spanning from 1977 to July 2021. The number of studies was unevenly distributed across geographic boundaries, ecosystem types, ES, and types of pressure. The most studied ecosystems were pelagic ecosystems on continental shelves and intertidal ecosystems, and deep-sea habitats and ice-associated ecosystems were the least studied. Food provision was the major focus of ES articles across all types of marine ecosystem (67%), followed by climate regulation (28%), and recreation (14%). Biophysical values were assessed in 91% of the analysed articles, 30% assessed economic values, but only 3% assessed socio-cultural values. Regarding the type of impact on ecosystems, management effects were the most studied, followed by overexploitation and climate change (with increase in seawater temperature being the most commonly assessed climate change pressure). Lastly, the introduction of non-indigenous species and deoxygenation were the least studied. Conclusions This systematic map provides, in addition to a database, knowledge gaps and clusters on how marine ecosystem changes impact ES provision. The current lack of knowledge is a threat to the sustainability of human actions and knowledge-based nature conservation. The knowledge gaps and clusters highlighted here could guide future research and impact the beneficial development of policy and management practices.

Habitat loss and degradation due to global agriculture land use is a major threat to biodiversity. Identifying agricultural management practices that mitigate these impacts is urgently needed. Thousands of experiments have been conducted worldwide in the last decades to compare the impacts of various agricultural management practices on biodiversity. The magnitudes of difference in biodiversity responses between pairs of agricultural practices, i.e. effect sizes, have now been synthesised in a growing number of meta-analyses. Yet, each meta-analysis generally focuses on a specific type of farming practice and on specific taxonomic groups, or a single region. Meta-analyses could furthermore yield different or sometimes opposite results for the similar research questions. Gathering all the effect sizes in one single dataset helps to critically assess and weigh the available evidence across all studied practices, taxonomic groups and geographical areas, and provide stakeholders a solid base to better inform their decisions. Here, we present a comprehensive dataset of 200 published meta-analyses gathering 1885 effect sizes based on more than 14 000 primary studies. We detail the effect of 8 main individual field practices (e.g. pest and disease management, amendment and fertilisation), 3 agricultural systems (e.g. organic farming, conservation agriculture) and 2 landscape level interventions (i.e. landscape complexity, land-use change). Our dataset covers numerous taxonomic groups over 14 phyla, including animals (e.g. birds, insects), microorganisms (e.g. fungi, bacteria), plants (e.g. trees, weeds). The dataset presented provides a resource to support decision-makers, farmers, and conservation ecologists alike for managing agricultural land for biodiversity.

Abstract Background Climate change and the current phase-out of fossil fuel-fired power generation are currently expanding the market of renewable energy and more especially photovoltaic (PV) panels. Contrary to other types of renewable energies, such as wind and hydroelectricity, evidence on the effects of PV panels on biodiversity has been building up only fairly recently. PV panels have been linked to substantial impacts on species and ecosystems, the first and most obvious one being the degradation of natural habitats but they may also lead to mortality of individuals and displacements of populations. Hence, we propose a systematic map aiming to draw a comprehensive panorama of the available knowledge on the effects of photovoltaic and solar thermal (PVST) installations, whatever their scales (i.e. cells, panels, arrays, utility-scale facilities), on terrestrial and semi-aquatic species and natural/semi-natural habitats and ecosystems. This work aims at providing decision-makers with a better understanding of the effects of PVST installations and, therefore, help them further protect biodiversity while also mitigating anthropogenic climate change. Methods We will follow the collaboration for environmental evidence guidelines and search for relevant peer-reviewed and grey literature in English or French. The search string will combine population (all wild terrestrial and semi-aquatic species—e.g. animals, plants, fungi, microorganisms—as well as natural/semi-natural terrestrial habitats and ecosystems) and exposure/intervention (all technologies of PVST panels at all scales of installations and therefore excluding concentrated solar power) terms. A pre-built test list of relevant articles will be used to assess the comprehensiveness of the search string. Extracted citations will be screened at title and full-text stages thanks to pre-defined inclusion/exclusion criteria. Accepted citations will then be split into studies and observations, from which relevant metadata (e.g. taxon, exposure/intervention, outcome) will be extracted and their internal validity assessed through a critical appraisal. The database will be accessible alongside a map report which will draw a landscape of eligible studies. By describing studied populations, exposures/interventions, outcomes and internal study validity results, the report will identify potential knowledge clusters and gaps regarding the effects of PVST installations on biodiversity and ecosystems.

Abstract Background The current biodiversity crisis calls for an urgent need to sustainably manage human uses of nature. The Ecosystem Services (ES) concept defined as « the benefits humans obtain from nature » support decisions aimed at promoting nature conservation. However, marine ecosystems, in particular, endure numerous direct pressures (e.g., habitat loss and degradation, overexploitation, pollution, climate change, and the introduction of non-indigenous species) all of which threaten ecosystem structure, functioning, and the very provision of ES. While marine ecosystems often receive less attention than terrestrial ecosystems in ES literature, it would also appear that there is a heterogeneity of knowledge within marine ecosystems and within the different ES provided. Hence, a systematic map on the existing literature will aim to highlight knowledge clusters and knowledge gaps on how changes in marine ecosystems influence the provision of marine ecosystem services. This will provide an evidence base for possible future reviews, and may help to inform eventual management and policy decision-making. Methods We will search for all evidence documenting how changes in structure and functioning of marine ecosystems affect the delivery of ES, across scientific and grey literature sources. Two bibliographic databases, Scopus and Web of Science Core Collection, will be used with a supplementary search undertaken in Google scholar. Multiple organisational websites related to intergovernmental agencies, supra-national or national structures, and NGOs will also be searched. Searches will be performed with English terms only without any geographic or temporal limitations. Literature screening, against predefined inclusion criteria, will be undertaken on title, abstract, and then full texts. All qualifying literature will be subjected to coding and meta-data extraction. No formal validity appraisal will be undertaken. Indeed, the map will highlight how marine ecosystem changes impact the ES provided. Knowledge gaps will be identified in terms of which ecosystem types, biodiversity components, or ES types are most or least studied and how these categories are correlated. Finally, a database will be provided, we will narratively describe this evidence base with summary figures and tables of pertinent study characteristics.

Background: Minority children have been shown to receive fewer opioid analgesics for acute pain. Objective: Assess if both White and non-White physicians prescribe fewer opioids to non-White children presenting to the pediatric emergency department (PED) with upper extremity (UE) fractures. Methods: Patients with acute UE fractures were evaluated. Attending physicians provided their self-identified race and consented to analysis of their opioid prescribing practices. Primary outcome was receipt of an opioid prescription at discharge. Bivariate analyses measured the association between patient race and receipt of an opioid prescription; further analysis evaluated the effect of physician race on prescription practices. Generalized linear models measured these associations while controlling for confounders. Results: Thirty-four percent of eligible patients (2754/8155) were discharged with an opioid prescription. There was no statistically significant difference in odds of being discharged with an opioid prescription for non-Hispanic Black (NHB) compared to non-Hispanic White (NHW) patients. There was no statistically significant difference in odds of prescribing opioids by both White physicians and non-White physicians. In patients with the most severe fractures, requiring sedation for reduction, NHB patients had lower odds of receiving an opioid prescription (OR 0.80; 95% CI: 0.65–0.98). Conclusion: Within our institution, NHB patients received fewer opioid prescriptions at discharge for UE fractures. There is no statistically significant association between NHB race and odds of receiving an opioid prescription. In patients sedated for fracture reductions, NHB patients had lower odds of receiving an opioid prescription and non-White physicians had lower odds of prescribing opioids to NHB patients compared to NHW patients.

Abstract Background Ecosystem degradation, mainly through overexploitation and destruction of natural habitats, is a well-known threat to the viability and persistence of many species’ populations worldwide. The use of translocations as a viable conservation tool in conjunction with protected areas has been rapidly increasing over the last few decades. Protected areas such as strict nature reserves, national parks, and species management areas continue to be central tools for biodiversity conservation as they provide vital habitats set aside from various human pressures. Because action consistently runs ahead of policy, the need for a clearer evidence base on the outcomes of wildlife translocations undertaken at a global scale is becoming increasingly urgent for scientific and decision-making communities, in order to build clear strategy frameworks around conservation translocations. We therefore conducted a systematic mapping exercise to provide an overview of the existing evidence on the outcomes of wildlife translocations in protected areas. Methods We searched two bibliographic databases, four web-based search engines with search-by-key-words capacity, 5 specialist websites, and conducted a grey literature call through two project stakeholders. We screened articles by title, abstract, and full text using pre-defined inclusion criteria all the while assessing the consistency of the reviewers. All relevant translocations were coded from retained publications. Key variables of interest were extracted and coded for each translocation event. The quantity and characteristics of the available evidence and knowledge gaps/clusters are summarised. The distribution and frequency of translocations are presented in heat- and geographical maps. Review findings A total of 613 articles were considered eligible for coding bibliometric data. Metapopulation management and review articles were not coded for quantitative and qualitative variables. Linked data (duplicated translocations) were also excluded. Finally, 841 studies of different translocation events were fully coded from 498 articles. Most of these translocations were carried out in North America and Oceania. The most commonly undertaken intervention types were one-off supplementations and “supplemented reintroductions”. Mammals were by far the most transferred group among animals. Magnoliopsida was the most translocated plant group. Survival, space use, and demography metrics were the most studied outcomes on translocated species. Conclusions This systematic map provides an up-to-date global catalogue of the available evidence on wildlife translocations to, from, or within protected areas. It should enable protected area managers to better understand their role in the global network of protected areas, regarding translocation practice, both as suppliers or recipients of translocated species. It may help managers and practitioners make their own choices by comparing previous experiences, regarding both the species concerned and the precise translocation modalities (number of individuals, etc.). Finally, it constitutes a decision-making tool for managers as well as for policy makers for future translocations.

Abstract Background Conversion, fragmentation, and loss of natural habitats are among the main causes of declining species’ populations worldwide. Protected areas are therefore crucial for biodiversity as they provide refuge and ensure key ecological processes. Wildlife translocations, defined as “the deliberate movement of organisms from one site for release in another”, have been used in conjunction as a conservation tool for a number of decades as wild populations become increasingly fragmented and endangered. Not only are translocations used to bolster the viability of imperiled species but are also recommended for improving population resilience and adapting species’ ranges in response to climate change. Despite translocation being a recognised conservation tool, it remains complex with variable results due to the different factors that can determine its success. Accordingly, the Map will investigate the existing evidence on the links between different types of wildlife translocation interventions and factors that may be important to consider for planning. This will provide an overview of relevant studies for possible future syntheses, and may help to inform management decisions. Method We will perform a thorough search of peer-reviewed journal articles and grey literature sources documenting the occurrence of translocations in the context of protected areas. Two databases will be used: Web of science core collection and Scopus, with a supplementary search in Google Scholar. Multiple key specialized websites will also be used. All bibliographic data will be extracted, managed, and screened in Microsoft excel. Three screening stages will be undertaken (title, then abstract, then full texts) against predefined inclusion criteria. The retained relevant literature will be subjected to coding and meta-data extraction. No formal validity appraisal will be undertaken. The Map will particularly highlight translocation operations in terms of origin and destination (i.e. translocating from one protected area to another, within the same area, and from and to non-protected areas) by taxonomic group, among other important factors (e.g. number of individuals, age class, release strategy, distance between capture and release sites etc.). Finally, a database will be provided along with a Map narratively describing the evidence with summary figures and tables of pertinent study characteristics.

Background: As people age and accumulate long-term conditions, their physical activity and physical function declines, resulting in disability and loss of independence. Primary care is well placed to empower individuals and communities to reduce this decline; however, the best approach is uncertain. Objectives: To develop a programme theory to explain the mechanisms through which interventions improve physical activity and physical function in people with long-term conditions in different primary care contexts, and to co-design a prototype intervention. Data sources: Systematic literature searches of relevant databases with forwards and backwards citation tracking, grey literature searches and further purposive searches were conducted. Qualitative data were collected through workshops and interviews. Design: Realist evidence synthesis and co-design for primary care service innovation. Setting: Primary care in Wales and England. Participants: Stakeholders included people with long-term conditions, primary care professionals, people working in relevant community roles and researchers. Methods: The realist evidence synthesis combined evidence from varied sources of literature with the views, experiences and ideas of stakeholders. The resulting context, mechanism and outcome statements informed three co-design workshops and a knowledge mobilisation workshop for primary care service innovation. Results: Five context, mechanism and outcome statements were developed. (1) Improving physical activity and function is not prioritised in primary care (context). If the practice team culture is aligned to the elements of physical literacy (mechanism), then physical activity promotion will become routine and embedded in usual care (outcome). (2) Physical activity promotion is inconsistent and unco-ordinated (context). If specific resources are allocated to physical activity promotion (in combination with a supportive practice culture) (mechanism), then this will improve opportunities to change behaviour (outcome). (3) People with long-term conditions have varying levels of physical function and physical activity, varying attitudes to physical activity and differing access to local resources that enable physical activity (context). If physical activity promotion is adapted to individual needs, preferences and local resources (mechanism), then this will facilitate a sustained improvement in physical activity (outcome). (4) Many primary care practice staff lack the knowledge and confidence to promote physical activity (context). If staff develop an improved sense of capability through education and training (mechanism), then they will increase their engagement with physical activity promotion (outcome). (5) If a programme is credible with patients and professionals (context), then trust and confidence in the programme will develop (mechanism) and more patients and professionals will engage with the programme (outcome). A prototype multicomponent intervention was developed. This consisted of resources to nurture a culture of physical literacy, materials to develop the role of a credible professional who can promote physical activity using a directory of local opportunities and resources to assist with individual behaviour change. Limitations: Realist synthesis and co-design is about what works in which contexts, so these resources and practice implications will need to be modified for different primary care contexts. Conclusions: We developed a programme theory to explain how physical activity could be promoted in primary care in people with long-term conditions, which informed a prototype intervention. Future work: A future research programme could further develop the prototype multicomponent intervention and assess its acceptability in practice alongside existing schemes before it is tested in a feasibility study to inform a future randomised controlled trial. Study registration: This study is registered as PROSPERO CRD42018103027. Funding: This project was funded by the National Institute for Health Research (NIHR) Health Services and Delivery Research programme and will be published in full in Health Services and Delivery Research; Vol. 9, No. 16. See the NIHR Journals Library website for further project information.

Objectives To develop a taxonomy of interventions and a programme theory explaining how interventions improve physical activity and function in people with long-term conditions managed in primary care. To co-design a prototype intervention informed by the programme theory.Design Realist synthesis combining evidence from a wide range of rich and relevant literature with stakeholder views. Resulting context, mechanism and outcome statements informed co-design and knowledge mobilisation workshops with stakeholders to develop a primary care service innovation.Results A taxonomy was produced, including 13 categories of physical activity interventions for people with long-term conditions.Abridged realist programme theory Routinely addressing physical activity within consultations is dependent on a reinforcing practice culture, and targeted resources, with better coordination, will generate more opportunities to address low physical activity. The adaptation of physical activity promotion to individual needs and preferences of people with long-term conditions helps affect positive patient behaviour change. Training can improve knowledge, confidence and capability of practice staff to better promote physical activity. Engagement in any physical activity promotion programme will depend on the degree to which it makes sense to patients and professions, and is seen as trustworthy.Co-design The programme theory informed the co-design of a prototype intervention to: improve physical literacy among practice staff; describe/develop the role of a physical activity advisor who can encourage the use of local opportunities to be more active; and provide materials to support behaviour change.Conclusions Previous physical activity interventions in primary care have had limited effect. This may be because they have only partially addressed factors emerging in our programme theory. The co-designed prototype intervention aims to address all elements of this emergent theory, but needs further development and consideration alongside current schemes and contexts (including implications relevant to COVID-19), and testing in a future study. The integration of realist and co-design methods strengthened this study.

Abstract We revisit the side-channel attacks with brain–computer interfaces (BCIs) first put forward by Martinovic et al. at the USENIX 2012 Security Symposium. For this purpose, we propose a comprehensive investigation of concrete adversaries trying to extract a PIN code from electroencephalogram signals. Overall, our results confirm the possibility of partial PIN recovery with high probability of success in a more quantified manner and at the same time put forward the challenges of full/systematic PIN recovery. They also highlight that the attack complexities can significantly vary in function of the adversarial capabilities (e.g., supervised/profiled vs. unsupervised/non-profiled), hence leading to an interesting trade-off between their efficiency and practical relevance. We then show that similar attack techniques can be used to threat the privacy of BCI users. We finally use our experiments to discuss the impact of such attacks for the security and privacy of BCI applications at large, and the important emerging societal challenges they raise.

Background: Patients are increasingly being asked to provide feedback about their experience of health-care services. Within the NHS, a significant level of resource is now allocated to the collection of this feedback. However, it is not well understood whether or not, or how, health-care staff are able to use these data to make improvements to future care delivery. Objective: To understand and enhance how hospital staff learn from and act on patient experience (PE) feedback in order to co-design, test, refine and evaluate a Patient Experience Toolkit (PET). Design: A predominantly qualitative study with four interlinking work packages. Setting: Three NHS trusts in the north of England, focusing on six ward-based clinical teams (two at each trust). Methods: A scoping review and qualitative exploratory study were conducted between November 2015 and August 2016. The findings of this work fed into a participatory co-design process with ward staff and patient representatives, which led to the production of the PET. This was primarily based on activities undertaken in three workshops (over the winter of 2016/17). Then, the facilitated use of the PET took place across the six wards over a 12-month period (February 2017 to February 2018). This involved testing and refinement through an action research (AR) methodology. A large, mixed-methods, independent process evaluation was conducted over the same 12-month period. Findings: The testing and refinement of the PET during the AR phase, with the mixed-methods evaluation running alongside it, produced noteworthy findings. The idea that current PE data can be effectively triangulated for the purpose of improvement is largely a fallacy. Rather, additional but more relational feedback had to be collected by patient representatives, an unanticipated element of the study, to provide health-care staff with data that they could work with more easily. Multidisciplinary involvement in PE initiatives is difficult to establish unless teams already work in this way. Regardless, there is merit in involving different levels of the nursing hierarchy. Consideration of patient feedback by health-care staff can be an emotive process that may be difficult initially and that needs dedicated time and sensitive management. The six ward teams engaged variably with the AR process over a 12-month period. Some teams implemented far-reaching plans, whereas other teams focused on time-minimising ‘quick wins’. The evaluation found that facilitation of the toolkit was central to its implementation. The most important factors here were the development of relationships between people and the facilitator’s ability to navigate organisational complexity. Limitations: The settings in which the PET was tested were extremely diverse, so the influence of variable context limits hard conclusions about its success. Conclusions: The current manner in which PE feedback is collected and used is generally not fit for the purpose of enabling health-care staff to make meaningful local improvements. The PET was co-designed with health-care staff and patient representatives but it requires skilled facilitation to achieve successful outcomes. Funding: The National Institute for Health Research Health Services and Delivery Research programme.

Nonreligion is often thought to be commensurate with nihilism or fatalism, resulting in the perception that the nonreligious have no source of meaning in life. While views to this effect have been advanced in various arenas, no empirical evaluation of such a view has been conducted. Using data from the 2008 American General Social Survey ( N = ~1,200), we investigated whether atheists, the religiously unaffiliated, and persons raised religiously unaffiliated were more likely than theists, the religiously affiliated, and persons raised with a religious affiliation to report greater levels of fatalism, nihilism, and the perception that meaning in life is self-provided. Results suggested that these groups did not differ with regard to fatalism or nihilism. However, atheists and the religiously unaffiliated (but not persons raised in a religiously unaffiliated household) were more likely to indicate that meaning in life was endogenous—that is, self-produced. While atheists and the nonreligious differed from their counterparts on source of meaning in life, this was not associated with any “penalty” for overall existential meaning.