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While epizootics increasingly affect wildlife, it remains poorly understood how the environment shapes most host-pathogen systems. Here, we employ a three-step framework to study microclimate influence on ectotherm host thermal behaviour, focusing on amphibian chytridiomycosis in fire salamanders (Salamandra salamandra) infected with the fungal pathogen Batrachochytrium salamandrivorans (Bsal). Laboratory trials reveal that innate variation in thermal preference, rather than behavioural fever, can inhibit infection and facilitate salamander recovery under humidity-saturated conditions. Yet, a 3-year field study and a mesocosm experiment close to the invasive Bsal range show that microclimate constraints suppress host thermal behaviour favourable to disease control. A final mechanistic model, that estimates range-wide, year-round host body temperature relative to microclimate, suggests that these constraints are rule rather than exception. Our results demonstrate how innate host defences against epizootics may remain constrained in the wild, which predisposes to range-wide disease outbreaks and population declines.

Wildlife diseases are contributing to the current Earth’s sixth mass extinction; one disease, chytridiomycosis, has caused mass amphibian die-offs. While global spread of a hypervirulent lineage of the fungus Batrachochytrium dendrobatidis (BdGPL) causes unprecedented loss of vertebrate diversity by decimating amphibian populations, its impact on amphibian communities is highly variable across regions. Here, we combine field data with in vitro and in vivo trials that demonstrate the presence of a markedly diverse variety of low virulence isolates of BdGPL in northern European amphibian communities. Pre-exposure to some of these low virulence isolates protects against disease following subsequent exposure to highly virulent BdGPL in midwife toads (Alytes obstetricans) and alters infection dynamics of its sister species B. salamandrivorans in newts (Triturus marmoratus), but not in salamanders (Salamandra salamandra). The key role of pathogen virulence in the complex host-pathogen-environment interaction supports efforts to limit pathogen pollution in a globalized world., The pathogen Batrachochytrium dendrobatidis (BD) associated with widespread amphibian declines is present in Europe but has not consistently caused disease-induced declines in that region. Here, the authors suggest that an endemic strain of BD with low virulence may protect the hosts upon co-infection with more virulent strains.

The chytrid fungal pathogens Batrachochytrium dendrobatidis and Batrachochytrium salamandrivorans cause the skin disease chytridiomycosis in amphibians, which is driving a substantial proportion of an entire vertebrate class to extinction. Mitigation of its impact is largely unsuccessful and requires a thorough understanding of the mechanisms underpinning the disease ecology. By identifying skin factors that mediate key events during the early interaction with B. salamandrivorans zoospores, we discovered a marker for host colonization. Amphibian skin associated beta-galactose mediated fungal chemotaxis and adhesion to the skin and initiated a virulent fungal response. Fungal colonization correlated with the skin glycosylation pattern, with cutaneous galactose content effectively predicting variation in host susceptibility to fungal colonization between amphibian species. Ontogenetic galactose patterns correlated with low level and asymptomatic infections in salamander larvae that were carried over through metamorphosis, resulting in juvenile mortality. Pronounced variation of galactose content within some, but not all species, may promote the selection for more colonization resistant host lineages, opening new avenues for disease mitigation., The skin disease chytridiomycosis is linked to global amphibian declines but effective mitigation measures require improved understanding of the mechanisms underpinning the disease ecology. This study identifies key mediators of interactions between the fungal pathogen and amphibian skin, providing a marker of host colonization that can predict susceptibility between amphibian species.

Funder: MAVA Foundation; Id: http://dx.doi.org/10.13039/100013324, The crisis generated by the emergence and pandemic spread of COVID‐19 has thrown into the global spotlight the dangers associated with novel diseases, as well as the key role of animals, especially wild animals, as potential sources of pathogens to humans. There is a widespread demand for a new relationship with wild and domestic animals, including suggested bans on hunting, wildlife trade, wet markets or consumption of wild animals. However, such policies risk ignoring essential elements of the problem as well as alienating and increasing hardship for local communities across the world, and might be unachievable at scale. There is thus a need for a more complex package of policy and practical responses. We undertook a solution scan to identify and collate 161 possible options for reducing the risks of further epidemic disease transmission from animals to humans, including potential further SARS‐CoV‐2 transmission (original or variants). We include all categories of animals in our responses (i.e. wildlife, captive, unmanaged/feral and domestic livestock and pets) and focus on pathogens (especially viruses) that, once transmitted from animals to humans, could acquire epidemic potential through high rates of human‐to‐human transmission. This excludes measures to prevent well‐known zoonotic diseases, such as rabies, that cannot readily transmit between humans. We focused solutions on societal measures, excluding the development of vaccines and other preventive therapeutic medicine and veterinary medicine options that are discussed elsewhere. We derived our solutions through reading the scientific literature, NGO position papers, and industry guidelines, collating our own experiences, and consulting experts in different fields. Herein, we review the major zoonotic transmission pathways and present an extensive list of options. The potential solutions are organised according to the key stages of the trade chain and encompass solutions that can be applied at the local, regional and international scales. This is a set of options targeted at practitioners and policy makers to encourage careful examination of possible courses of action, validating their impact and documenting outcomes.

Health care encounters are opportunities for primary care practitioners to identify women experiencing domestic violence and abuse (DVA). Increasing DVA support in primary care is a global policy priority but discussion about DVA during consultations remains rare. This article explores how primary care teams in the United Kingdom negotiate the boundaries of their responsibilities for providing DVA support. In-depth interviews were undertaken with 13 general practitioners (GPs) in two urban areas of the United Kingdom. Interviews were analyzed thematically. Analysis focused on the boundary practices participants undertook to establish their professional remit regarding abuse. GPs maintained permeable boundaries with specialist DVA support services. This enabled ongoing negotiation of the role played by clinicians in identifying DVA. This permeability was achieved by limiting the boundaries of the GP role in the care of patients with DVA to identification, with the work of providing support distributed to local specialist DVA agencies.

While emerging fungi threaten global biodiversity, the paucity of fungal genome assemblies impedes thoroughly characterizing epidemics and developing effective mitigation strategies. Here, we generate de novo genomic assemblies for six outbreaks of the emerging pathogen Batrachochytrium salamandrivorans (Bsal). We reveal the European epidemic currently damaging amphibian populations to comprise multiple, highly divergent lineages demonstrating isolate-specific adaptations and metabolic capacities. In particular, we show extensive gene family expansions and acquisitions, through a variety of evolutionary mechanisms, and an isolate-specific saprotrophic lifecycle. This finding both explains the chytrid’s ability to divorce transmission from host density, producing Bsal’s enigmatic host population declines, and is a key consideration in developing successful mitigation measures., M.K. was supported by FWO aspirant grant number 1111119N and would like to thank D. Gullick and JJADMS for their support in computational and practicalities.

BackgroundHealthcare interventions shown to be effective, are commonly then found to be poorly implemented in clinical practice. It is suggested that insufficient attention is given to the implementation process at the developmental phase of intervention. This study outlines a 5 step process for considering both implementation and effectiveness issues from the outset of intervention development. We use the development of a complex intervention Treatment of anxiety and or depression in patients with chronic obstructive disease (TANDEM) to illustrate this process. MethodsIntervention development built upon the Medical Research Council framework for developing complex interventions and the Person Based Approach to development of behavioural interventions. Evidence synthesis, stakeholder engagement, qualitative data collection and pre-piloting were all critical steps in intervention development.ResultsContact with experts in the field ensured efficiency of design. Qualitative work suggested guiding principles for the intervention such as introducing mood in relation to breathlessness, and providing flexible tailoring to patients’ needs, whilst implementation principles focused on training selected respiratory professionals and requiring supervision to ensure standards of care. Subsequent steps of intervention development, pre-piloting and intervention refinement led to an intervention that was deemed acceptable and if successful will be ready for implementation. ConclusionsBy following the 5-step process recommended, both effectiveness and implementation concerns can be addressed in developing health care interventions, with the likelihood that such interventions will have a more rapid translation in to health care benefits, if shown to be effective. Trial RegistrationISRCTN, ID: ISRCTN59537391. Registered on 20 March 2017. Protocol version 6.0, 22 April 2018.

The chytrid fungus Batrachochytrium dendrobatidis has caused the most prominent loss of vertebrate diversity ever recorded, which peaked in the 1980s. Recent incursion by its sister species B. salamandrivorans in Europe raised the alarm for a new wave of declines and extinctions in western Palearctic urodeles. The European Commission has responded by restricting amphibian trade. However, private amphibian collections, the main end consumers, were exempted from the European legislation. Here, we report how invasion by a released, exotic newt coincided with B. salamandrivorans invasion at over 1000 km from the nearest natural outbreak site, causing mass mortality in indigenous marbled newts (Triturus marmoratus), and posing an acute threat to the survival of nearby populations of the most critically endangered European newt species (Montseny brook newt, Calotriton arnoldi). Disease management was initiated shortly after detection in a close collaboration between policy and science and included drastic on site measures and intensive disease surveillance. Despite these efforts, the disease is considered temporarily contained but not eradicated and continued efforts will be necessary to minimize the probability of further pathogen dispersal. This precedent demonstrates the importance of tackling wildlife diseases at an early stage using an integrated approach, involving all stakeholders and closing loopholes in existing regulations., A.M. and F.P. are supported by ENV.B.3/SER/2016/0028. S. Canessa was supported by grant FWO16/PDO/019. M. Kelly was supported by grant 1111119N. S. Carranza was supported by the Ministerio de Ciencia, Innovación y Universidades grant numbers CGL2015‐70390‐P and PGC2018‐098290‐B‐I00 (Co‐funded by FEDER) and Secretaria d'Universitats i Recerca del Departament d'Economia i Coneixement de la Generalitat de Catalunya under Grant number 2017‐SGR‐00991. CRARC pcr analyses were performed by Laboklin (Germany). The captive breeding program of Calotriton arnoldi is supported by LIFE15 NAT/ES/000757.

Understanding the social basis of health and medicine and the contexts of clinical care are essential components of good medical practice. This includes the ways in which social factors such as class, ethnicity and gender influence health outcomes and how people experience health, illness and healthcare. In our Guide we describe what sociology is and what it brings to medicine, beginning with the nature of the ‘sociological imagination’. Sociological theory and methods are reviewed in order to explain and illustrate the role of sociology in the context of undergraduate medical education. Reference is made to A Core Curriculum for Sociology in UK Undergraduate Medical Education by Collett et al. (2016). Teaching and student learning are discussed in terms of organisation and delivery, with an emphasis on practice. Sections are also included on assessment, evaluation, opportunities and challenges and the value of a ‘community of practice’ for sociology teachers in medical education.

Escalating occurrences of emerging infectious diseases underscore the importance of understanding microbiome–pathogen interactions. The amphibian cutaneous microbiome is widely studied for its potential to mitigate disease-mediated amphibian declines. Other microbial interactions in this system, however, have been largely neglected in the context of disease outbreaks. European fire salamanders have suffered dramatic population crashes as a result of the newly emerged Batrachochytrium salamandrivorans ( Bsal ). In this paper, we investigate microbial interactions on multiple fronts within this system. We show that wild, healthy fire salamanders maintain complex skin microbiotas containing Bsal -inhibitory members, but these community are present at a remarkably low abundance. Through experimentation, we show that increasing bacterial densities of Bsal -inhibiting bacteria via daily addition slowed disease progression in fire salamanders. Additionally, we find that experimental- Bsal infection elicited subtle changes in the skin microbiome, with selected opportunistic bacteria increasing in relative abundance resulting in septicemic events that coincide with extensive destruction of the epidermis. These results suggest that fire salamander skin, in natural settings, maintains bacterial communities at numbers too low to confer sufficient protection against Bsal, and, in fact, the native skin microbiota can constitute a source of opportunistic bacterial pathogens that contribute to pathogenesis. By shedding light on the complex interaction between the microbiome and a lethal pathogen, these data put the interplay between skin microbiomes and a wildlife disease into a new perspective.

This paper reports on the moral work done in routine diabetes review consultations in primary care with nurses. Consultations with fluent English speakers are compared with consultations where an interpreter was present, largely involving patients of Bangladeshi origin. The study setting was Tower Hamlets in London, where type 2 diabetes is particularly common. Existing research has shown some dissatisfaction with diabetes care amongst Bangladeshi patients, and studies of care providers in other locations suggest that they at times experience the care of this group as particularly challenging. Through analysis of video-recorded consultations recorded in 2010–2011 we shed light on possible reasons for these difficulties. The 12 non-English speakers often experienced difficulties in raising issues that concerned them, particularly if their interpreter did not translate their utterance because it was deemed to be unrelated to diabetes. These difficulties were not shared by the 24 fluent English speakers, who also found it easier to convey a positive moral reputation and to excuse behaviour that deviated from recommended self-management practices. Interpreters at times also acted as moral mediators. For example, where a participant in the consultation made statements that appeared to convey a negative moral judgement of an other participant, these would often go untranslated. Probably, neither health care providers nor patients are fully aware of the nature of their communication difficulties. Given this, interpreters possess considerable power to influence matters. Understanding the moral work of consultations is important in explaining the findings of other studies showing difficulties in the provision of diabetes care to people with limited English language skills.

This study explores how African, Caribbean and White British women worked to hide psychological partner abuse as they experienced it, “do gender,” and appear competent in social roles. They prioritized negotiated competencies as “good partners,” actively setting socially and culturally embedded boundaries to their abuser’s behaviors: an inner boundary encompassing normal behaviors and an outer one of “acceptable” behaviors projected as normal through remedial work. Behaviors breaching the outer boundary (e.g., if the women narrowed the bounds of the “acceptable”) compromised the women’s competence. This sometimes led them to actively use support services. Appropriate advice and support may change the boundaries.

Background The experience of diabetes care for individuals from minority ethnic groups, particularly individuals of Bangladeshi origin, shows they are at a significant disadvantage. Aim To identify the challenges of interpreted consultations for healthcare providers and to explain the disadvantage experienced by patients from minority groups who have diabetes. Design and setting Comparison of 12 interpreted consultations with 24 consultations involving fluent English speakers in four primary healthcare centres in Tower Hamlets, east London, UK. Method Content analysis of video recordings of routine diabetes review consultations in primary care, involving 36 patients, nine nurses or healthcare assistants, and six interpreters. Result Interpreted consultations were as long as same-language consultations but patients said less. The incidence of misunderstandings was similar but patients in interpreted consultations asked fewer questions. Indicators of social distance in interpreted consultations included less humour and less discussion of the patient’s feelings or personal circumstances. Patients in interpreted consultations were less likely to raise issues unrelated to diabetes, to discuss their own ideas about health, or to talk about clinical parameters. Providers commonly addressed English-speaking patients directly but usually addressed patients through interpreters using the third person. Interpreters sometimes changed the meaning or did not translate speech, and they added their own comments. Conclusion The findings explain some of the known problems of diabetes care for individuals from ethnic minorities. Effective training for interpreters and care providers is needed to reduce social distance and to facilitate patients’ involvement in self-management.

Asthma is still a major cause of morbidity and mortality. Patients who use hospital services frequently tend to have more severe asthma and lack formal support. Attitudes to self-management also tend to differ and qualitative studies of frequent attenders have identified differing views of the appropriateness of service use between patients and their physicians. We undertook a qualitative study of patients with severe asthma admitted and not admitted to hospital in a 12-month period in the UK. The aim of the study was to investigate the relationship between perception of life events, psychosocial factors, coping and asthma admission in these two groups of patients. We interviewed 50 patients (aged 16 and over) admitted to two large teaching hospitals in London with asthma exacerbations, 25 patients with similar levels of asthma severity (step 3 or higher of the British Thoracic Society guidelines) sampled in General Practice and 19 general practitioners (GPs). Data were analysed using an adapted framework analysis. Patients admitted to hospital reported high levels of psychosocial problems and life events but tended to make few connections between these and their asthma attacks or their ability to manage their asthma. Patients reporting frequent hospital use tended to value professionals working in hospitals while reporting poor relationships with GPs; views that appeared related to delays in seeking help from primary care. Among GPs, knowledge of patients having attended hospital was generally poor, although they appeared more aware of those who were high users of General Practice (whether they were high attenders at hospital or not). GPs perceived stressful life events in patients with asthma to compound existing dispositions and be related to poor control and poor adherence. These findings suggest that vulnerable patient groups often face poor material circumstances and chaotic lives, impacting on their capacity to manage their illness and on their ability to derive benefit from primary care. Policy interventions aimed at reducing 'unnecessary' admissions will need to be tailored to the psychosocial circumstances and health beliefs of vulnerable patient groups.

The aim of this Guide is to support teacher with the responsibility of designing, delivering and/or assessing diversity education. Although, the focus is on medical education, the guidance is relevant to all healthcare professionals. The Guide begins by providing an overview of the definitions used and the principles that underpin the teaching of diversity as advocated by Diversity and Medicine in Health (DIMAH). Following an outline of these principles we highlight the difference between equality and diversity education. The Guide then covers diversity education throughout the educational process from the philosophical stance of educators and how this influences the approaches used through to curriculum development, delivery and assessment. Appendices contain practical examples from across the UK, covering lesson plans and specific exercises to deliver teaching. Although, diversity education remains variable and fragmented there is now some momentum to ensure that the principles of good educational practice are applied to diversity education. The nature of this topic means that there are a range of different professions and medical disciplines involved which leads to a great necessity for greater collaboration and sharing of effective practice.

(2002). Who sets the Agenda? Are opportunistic brief interventions for 'excessive drinkers' and patient centred care compatible? Drugs: Education, Prevention and Policy: Vol. 9, No. 1, pp. 1-6.

Teaching ‘cultural diversity’ to medical students in the UK became a priority following the publication of Tomorrow’s Doctors (General Medical Council, [GMC] 1993). This was in the context of incre...

This paper reports the findings of an AUDIT questionnaire administered to a sample of young (16-24-year-old) white males. Of the sample, 65% were drinking at potentially harmful levels. Averaging 45 U/week, 18-21 years was the age of highest alcohol consumption. Compared with 16-17- and 22-24-year-olds, this group recorded the highest proportion of hazardous drinkers and most negative consequences of drinking.

The results from a survey, conducted in February and March 1997, of all Accident and Emergency (A&E) departments in England are presented. The survey examined staff perceptions of the preventive role of A&E departments in screening and intervention in alcohol-related attendances. Perceptions of the prevalence of alcohol-related attendances were also included. Attitudes towards developing a preventive response were positive. Few departments currently screen or offer intervention and considerable barriers to the implementation of a preventive response were reported.

To compare the quality of care for spouses of dying people in St Christopher's Hospice, London and nearby hospitals in 1994 and to make comparisons with earlier studies of the same setting, interviews were undertaken with spouses of people who had died from cancer in these settings, matched by the deceased's age and sex. The subjects comprised 66 people whose spouses had died in 1994, 33 of whom had died in the hospice, 33 in local hospitals. The mean age was 69.3; 61 % were female. No significant differences between groups were found on the outcome measures (adjustment to bereavement, anxiety and psychosomatic symptoms at the time of the final admission), largely replicating earlier studies in the same setting. In various respects hospitals have moved closer to hospice practice: in contrast to earlier studies, there were no differences in visiting patterns or in spouses helping with inpatient care. Bereavement follow-up is now initiated in some cases by hospitals. Liberal visiting hours could be stressful, however, and spouses sometimes helped with care to remedy staff shortcomings. Regret at not being present at the death was more common in the hospital group. Bereavement interventions may have more effect on subsequent adjustment if targeted on high-risk individuals. Other benefits than adjustment, however, may be achievable. Steps to create a calm atmosphere on hospital wards where people can be with their relatives near the time of death are desirable.

To compare the quality of inpatient care for dying people in St Christopher's Hospice, London and nearby hospitals in 1994 and make comparisons with earlier studies of the same setting, interviews were undertaken with spouses of people who had died from cancer in these settings, matched by age and sex. The subjects comprised 66 people who had died in 1994, 33 of whom had died in the hospice, 33 in local hospitals. The mean age was 70.2, 61 % were male. The hospice group were more likely to know that they were dying and less likely to be admitted as emergencies. Treatment for pain, breathlessness and nausea from both sources provided relief in almost all cases. Most information about the illness was given by hospital doctors before hospice care occurred. Where it occurred, communication by hospice staff was judged better than that by hospital doctors. Staff in hospitals were more likely to be judged 'very busy'. Hospice respondents were less likely to want improvements, and more likely to judge the institution as being 'like a family'. Earlier studies had shown a trend for symptom control to have improved in hospitals but for difference in the psychosocial climate to favour the hospice. By 1994, this latter difference was still obtained. We stress the role of hospital staff and general practitioners in helping patients accept a terminal prognosis, so that better-planned care can proceed. The busy public atmosphere of some hospital wards may not be conducive to the good care of dying people.

We outline the emergence of policy in England in the 1970s and 1980s designed to encourage the development of local initiatives for the prevention of alcohol-related harm. Findings from a survey of local initiatives undertaken in 1995–96 are presented and discussed in relation to an earlier overview of prevention activity undertaken in the 1980s. Difficulties in mapping the extent and nature of local preventive activity are discussed. Drawing on the wider literature on community development responses to alcohol and drug problems, some suggestions are advanced for the future of local action on alcohol in the next decade. In particular, multi-component, community-based programmes with a focus on harm reduction are recommended as part of a strategic response to alcohol problems.

The role of theory in qualitative research is often underplayed but it is relevant to the quality of such research in three main ways. Theory influences research design, including decisions about what to research and the development of research questions. Theory underpins methodology and has implications for how data are analyzed and interpreted. Finally, theory about a particular health issue may be developed, contributing to what is already known about the topic that is the focus of the study. This paper will critically consider the role of theory in qualitative primary care research in relation to these three areas. Different approaches to qualitative research will be drawn upon in order to illustrate the ways in which theory might variably inform qualitative research, namely generic qualitative research, grounded theory and discourse analysis. The aim is to describe and discuss key issues and provide practical guidance so that researchers are more aware of the role theory has to play and the importance of being explicit about how theory affects design, analysis and the quality of qualitative research.

Screening of immigrants has been a widespread response to the global resurgence of tuberculosis but has been criticized as discriminatory and stigmatising. Acceptability is an essential but neglected ethical prerequisite of screening programmes, particularly those targeting vulnerable groups such as refugees. No data exist concerning acceptability of tuberculosis screening. We therefore examined the responses of immigrants to screening for tuberculosis in a range of settings.We carried out a qualitative interview study of a maximum diversity sample of 53 immigrants offered screening for tuberculosis in east London. We recruited people screened in three settings: a social service centre for asylum seekers, a hospital clinic for new entrants and primary care. We confirmed validity of our findings at a focus group of asylum seekers.The opportunity to be screened for tuberculosis was valued highly by recipients. Moreover, many saw being screened as a socially responsible activity. Of the minority raising concerns, few mentioned the possibility of discrimination. Acceptability was high irrespective of setting, with respondents expressing preference for their chosen place of screening.Screening for tuberculosis was highly acceptable to recipients in these settings. Screening should be offered in a range of settings.