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Abstract This editorial updates the scope and submission expectations of Implementation Science and Implementation Science Communications. We refine our protocol publishing policies and set out new expectations for reporting studies describing determinants and their relationship with implementation outcomes. Our central focus remains on the implementation of evidence-based interventions into healthcare practice and policy. We are most interested in rigorous empirical studies of the implementation of evidence-based healthcare interventions, practices, and policies, and the de-implementation of those that are demonstrated to be of low-value or no benefit. Alongside this, we remain interested in the systematic study of implementation mechanisms and processes and on the influences of patient, professional, and organizational behaviours. Novel theoretical and methodological developments are considered. For all submissions, we expect authors to demonstrate how their work is integrated with existing knowledge in the field and to clearly state the added value of the work to the field broadly.

BackgroundCardiac rehabilitation (CR) services aim to improve heart disease patients’ health and quality of life and reduce the risk of further cardiac events. Depression and anxiety are common among CR patients but psychological treatments have usually had small effects. In contrast, the recent NIHR-funded PATHWAY trial found that group Metacognitive Therapy (MCT) was associated with improvements in anxiety and depression when added to CR and was more effective than usual CR alone. The next stage is to test implementation of MCT within the National Health Service through the creation of a network of CR beacon sites. The study will test the quality of data capture following addition of a new MCT data-field to the national audit of cardiac rehabilitation (NACR), examine level of adoption at sites, examine mental health outcomes benchmarked against usual CR and the PATHWAY data, examine the enablers and barriers to implementation and the expected resource requirements. The study has been registered: NCT05956912 (13th July, 2023).MethodsBeacon sites will be recruited as preliminary adopters of group MCT from NHS CR services in England. A national invitation for expressions of interest from CR services will be issued and those meeting eligibility criteria will be considered for inclusion. Two staff at each site will receive training in MCT, and mixed-methods will be used to address questions concerning the quality of patient data recorded, level of adoption at sites, the characteristics of patients attending MCT, the impact of adding MCT to CR on mental health outcomes, and patient, healthcare staff and commissioner views of barriers/enablers to implementation. Exploration of implementation will be informed by Normalisation Process Theory.DiscussionThe study will support development of an NHS roll-out strategy, assess the mental health outcomes associated with MCT, examine treatment fidelity in real-world settings, and evaluate revised data collection structures that can be used to assess the impact of national-level implementation. Trial RegistrationNCT05956912; 13th July 2023.

The conservation of genetic diversity and connectivity is essential for the long-term persistence and adaptive ability of a species. Recent calls have been made for the inclusion of genetic diversity and differentiation measures in the assessment, management, and conservation of species. However, the literature often lacks direction on how to do so for species with continuous distributions or no distinct breaks in genetic connectivity. There are many considerations to overcome when investigating genetic diversity and connectivity of such species. We combine multiple genetic network methodologies with more traditional population genetic analyses within a single framework to address the challenges of investigating population structure and quantifying variation in genetic diversity and connectivity of wide-ranging species with continuous distributions. We demonstrate the efficacy and applicability of our framework through a study on woodland caribou (Rangifer tarandus) occupying the boreal forest of Canada; a species of significant conservation concern. The dataset consisted of 4911 unique individuals genotyped at 9 microsatellite loci, which were subsequently partitioned into 103 spatial nodes to create a population-based genetic network. The Walktrap community detection algorithm was used to detect hierarchical population genetic structure within the study area and node-based network metrics such as mean inverse edge weight and clustering coefficient were used to quantify the variation in genetic connectivity across the range. Lastly, genetic diversity was assessed by calculating allelic richness and heterozygosity of the nodes making up the network. The community detection analysis identified two communities at the coarsest scale to nine communities at the optimal partition. A strong pattern of Isolation by Distance (IBD) was found across the range at multiple scales. Furthermore, signs of genetic erosion along the study area’s southern boundaries were depicted by nodes presenting low genetic diversity and low centrality values. These results are important to the species status assessments in providing previously unavailable information on connectivity and diversity within and beyond the current local population units used in management. Our approach to quantify the patterns and extent of connectivity across the boreal range is comprehensive and could easily be adapted to other species. The results are robust and provide a solid foundation for the continued monitoring and recovery of the species.

BackgroundApproximately 4.5 million people live with type 2 diabetes mellitus (T2DM) in the United Kingdom. Evidence shows that structured education programs can improve glycemic control and reduce the risk of complications from T2DM, but they have low attendance rates. To widen access to T2DM structured education, National Health Service England commissioned a national rollout of Healthy Living, a digital self-management program. ObjectiveThe objectives were to understand the barriers and enablers to adopting, implementing, and integrating Healthy Living into existing T2DM care pathways across England. MethodsWe undertook a cross-sectional, qualitative telephone semistructured interview study to address the objectives. In total, 17 local National Health Service leads responsible for implementing Healthy Living across their locality were recruited. We conducted 16 one-time interviews across 16 case sites (1 of the interviews was conducted with 2 local leads from the same case site). Interview data were analyzed using thematic analysis. ResultsThree overarching themes were generated: (1) implementation activities, (2) where Healthy Living fits within existing pathways, and (3) contextual factors affecting implementation. Of the 16 sites, 14 (88%) were implementing Healthy Living; the barrier to not implementing it in 2 case sites was not wanting Healthy Living to compete with their current education provision for T2DM. We identified 6 categories of implementation activities across sites: communication strategies to raise awareness of Healthy Living, developing bespoke local resources to support general practices with referrals, providing financial reimbursement or incentives to general practices, promoting Healthy Living via public events, monitoring implementation across their footprint, and widening access across high-need groups. However, outside early engagement sites, most implementation activities were “light touch,” consisting mainly of one-way communications to raise awareness. Local leads were generally positive about Healthy Living as an additional part of their T2DM structured education programs, but some felt it was more suited to specific patient groups. Barriers to undertaking more prolonged, targeted implementation campaigns included implementation not being mandated, sites not receiving data on uptake across their footprint, and confusion in understanding where Healthy Living fit within existing care pathways. ConclusionsA passive process of disseminating information about Healthy Living to general practices rather than an active process of implementation occurred across most sites sampled. This study identified that there is a need for clearer communications regarding the type of patients that may benefit from the Healthy Living program, including when it should be offered and whether it should be offered instead of or in addition to other education programs. No sites other than early engagement sites received data to monitor uptake across their footprint. Understanding variability in uptake across practices may have enabled sites to plan targeted referral campaigns in practices that were not using the service.

Context In the context of iterative feedback loops to support real-time policy decision making, and an emphasis on speeding up adoption of evidence-based interventions, qualitative healthcare researchers are increasingly expected to produce rapid results and products. Traditional qualitative methods have been adapted for this purpose.Objective To develop and apply a rapid analysis framework in a process evaluation for the VICTORION-Spirit study; a ground-breaking hybrid trial examining real-world delivery of inclisiran—a cholesterol-lowering treatment—in primary care.Design We developed a rapid analysis framework, using a summary template, to analyse data from semistructured telephone interviews.Setting Primary care in Greater Manchester, UK.Participants Patients who had received inclisiran as part of the VICTORION-Spirit trial (56), providers delivering inclisiran (28) and representatives from the Academic Health Science Network (8) participated in the original study.Results The rapid analysis framework we developed and applied comprised six steps: (1) creating a summary template based on the five Consolidated Framework for Implementation Research domains; (2) test-driving, refining and finalising the summary template; (3) completing the template soon after each interview using field notes; (4) discussing analysis as a team; (5) transferring summaries to a matrix; and (6) using the summary matrix to inform presentations and interim reports for stakeholders. Our rapid analysis framework saved time and improved efficiency, as we were able to feedback barriers to stakeholders in real time via presentations.Conclusions Rapid analysis in applied healthcare research can produce timely and trustworthy findings. Our rapid analysis framework would be useful within studies where there is a need to feedback to stakeholders and adjust implementation strategies accordingly in real time. Thus, supporting successful implementation efforts and accelerating adoption.Trial registration number NCT04807400, 19/03/2021.

Aims Clinical guidance indicates that methadone doses of 60–120mg are therapeutic as opioid substitution therapy (OST). Audit was completed to understand why patients open to Newcastle Treatment and Recovery (Addictions) are being prescribed doses below 60mg and to identify areas for improvement. Methods 285 patients were identified via prescription software as currently prescribed

The three-dimensional variation inherent to stellarator geometries and fusion sources motivates three-dimensional modeling to obtain accurate results from computational modeling in support of design and analysis of first wall, blanket, and shield (FWBS) systems. Manually constructing stellarator fusion power plant geometries in computer-aided design (CAD) and defining the corresponding fusion source can be cumbersome and challenging. The open-source parametric modeling toolset ParaStell has been developed to automate construction of such geometries in low-fidelity. Low-fidelity modeling is useful during the conceptual phase of engineering design as a means of rapidly exploring the design space of a given device. The modeling capability of ParaStell includes in-vessel components and magnets, for any given stellarator configuration, using a parametric definition and plasma equilibrium data. Furthermore, the toolset automates the generation of detailed, tetrahedral neutron source definitions and DAGMC geometries for use in neutronics modeling. ParaStell assists rapid design iteration, parametric study, and design optimization of stellarator fusion cores. As a demonstration of the design iteration capability, the effect of the three-dimensional parameter space on tritium breeding and magnet shielding is investigated, using the WISTELL-D configuration as a design basis. Blanket and shield thicknesses are varied in three dimensions, using the space available between the plasma edge and magnet coils as a constraint. The corresponding effects on tritium breeding ratio and magnet heating are tallied using the open-source Monte Carlo particle transport code OpenMC. The inclusion of additional and higher-fidelity modeling capabilities is planned for ParaStell’s future, as well as its implementation in machine-driven optimization.

Abstract Background The National Health Service Diabetes Prevention Programme (NHS DPP) was commissioned by NHS England in 2016 and rolled out in three ‘waves’ across the whole of England. It aims to help people with raised blood glucose levels reduce their risk of developing type 2 diabetes through behaviour change techniques (e.g., weight loss, dietary changes and exercise). An independent, longitudinal, mixed methods evaluation of the NHS DPP was undertaken. We report the findings from the implementation work package: a qualitative interview study with designated local leads, responsible for the local commissioning and implementation of the programme. The aim of the study was to explore how local implementation processes were enacted and adapted over time. Methods We conducted a telephone interview study across two time-points. Twenty-four semi-structured interviews with local leads across 19 sampled case sites were undertaken between October 2019 and January 2020 and 13 interviews with local leads across 13 sampled case sites were conducted between July 2020 and August 2020. Interviews aimed to reflect on the experience of implementation and explore how things changed over time. Results We identified four overarching themes to show how implementation was locally enacted and adapted across the sampled case sites: 1. Adapting to provider change; 2. Identification and referral; 3. Enhancing uptake in underserved populations; and 4. Digital and remote service options. Conclusion This paper reports how designated local leads, responsible for local implementation of the NHS DPP, adapted implementation efforts over the course of a changing national diabetes prevention programme, including how local leads adapted implementation during the COVID-19 pandemic. This paper highlights three main factors that influence implementation: the importance of facilitation, the ability (or not) to tailor interventions to local needs and the role of context in implementation.

Abstract Implementation researchers often find themselves as research partners in practice improvement projects, clinical trials or other applied health studies. The implementation science component in these projects can be described as supportive, descriptive or explanatory. This commentary reflects on the potential contributions of such projects to implementation science. They may provide evidence on implementation strategies, so it is essential to identify and evaluate these separately from the clinical and preventive interventions of interest. The use of theory on implementation processes and associated factors can contribute to knowledge accumulation, particularly if the focus is on what actually gets implemented when, why and how. The development and validation of relevant measures is a third potential contribution to implementation science. Although not all issues in implementation science can be addressed in this way, capitalization on the opportunities beyond the field can contribute to implementation science.

Abstract Grasslands (natural, semi-natural and improved) occupy approximately one-third of the terrestrial biosphere and are key for global ecosystem service provision, storing up to 30% of soil organic carbon (SOC). To date, most research on soil carbon (C) sequestration has focused on croplands where the levels of native soil organic matter (SOM) are typically low and significant potential exists to replenish SOM stocks. However, with the renewed push to achieve “net zero” C emissions by 2050, grasslands may offer an additional C store, utilising tools such as biochar. Here, we critically evaluate the potential for biochar as a technology for increasing grassland C stocks, identifying a number of practical, economic, social and legislative challenges that need to be addressed before the widescale adoption of biochar may be achieved. We critically assess the current knowledge within the field of grassland biochar research in the context of ecosystem service provision and provide opinions on the applicability of biochar as an amendment to different types of grassland (improved, semi-improved and unimproved) and the potential effect on ecosystem provision using a range of application techniques in the topsoil and subsoil. We concluded that the key question remains, is it possible for managed grasslands to store more C, without causing a loss in additional ecosystem services? To address this question future research must take a more multidisciplinary and holistic approach when evaluating the potential role of biochar at sequestering C in grasslands to mitigate climate change. Graphical Abstract

Narcissism is a part of the Dark Triad that consists also of the traits of Machiavellianism and psychopathy. Two main types of narcissism exist: grandiose and vulnerable narcissism. Being a Dark Triad trait, narcissism is typically associated with negative outcomes. However, recent research suggests that at least the grandiose type may be linked (directly or indirectly) to positive outcomes including lower levels of psychopathology, higher school grades in adolescents, deeper and more strategic learning in university students and higher cognitive performance in experimental settings. The current pre-registered, quasi-experimental study implemented eye-tracking to assess whether grandiose narcissism indirectly predicts cognitive performance through wider distribution of attention on the Raven's Progressive Matrices task. Fifty-four adults completed measures of the Dark Triad, self-esteem and psychopathology. Eight months to one year later, participants completed the Raven's, while their eye-movements were monitored during high stress conditions. When controlling for previous levels of psychopathology, grandiose narcissism predicted higher Raven's scores indirectly, through increased variability in the number of fixations across trials. These findings suggest that grandiose narcissism predicts higher cognitive performance, at least in experimental settings, and call for further research to understand the implications of this seemingly dark trait for performance across various settings.

Abstract Growing recognition of the potential vulnerabilities of major crop systems has spurred a growing interest in the potential of alternative crops which may be resilient to climate change and also help mitigate its effects. In Indonesia, such issues are particularly pertinent given that country's particular vulnerability to climate change impacts high dependence on agricultural livelihoods and varied topographies and growing conditions. Cyrtosperma merkusii (giant swamp taro) is a wetland plant which has historically formed part of food systems in the eastern Pacific. The plant has the potential to be cultivated as a source of starch on marginal coastal land and on peatlands with high water tables. The aim of this paper was therefore to determine site conditions that promote growth of C. merkusii and the macro and micronutrient status of the corms. Naturally, the size of the plants varied substantially among sites, with a neutral pH, and low redox and conductivity being strong edaphic predictors of corm size. Despite substantial differences in the soil properties of the different study sites, there were no significant differences in the macro and micronutrient content of the corms. Field trials showed that although the plants grew under dry land conditions, the plants grew bigger and yielded corms with greater concentrations of Fe, Mn and K under waterlogged conditions, indicating that a high‐water table is the best cultivation environment for C. merkusii. The nutrient content of the corms suggests that, although primarily a starch crop, C. merkusii could also increase the intake of Fe in populations where Fe deficiency is pervasive. We conclude that the wetland plant C. merkusii has considerable potential as a paludiculture crop in low‐lying areas of SE Asia as it was tolerant of a wide range of soil conditions and performed well when cultivated under waterlogged conditions without additional fertilisation.

Abstract Background COVID-19 spread rapidly in UK care homes for older people in the early pandemic. National infection control recommendations included remote resident assessment. A region in North-West England introduced a digital COVID-19 symptom tracker for homes to identify early signs of resident deterioration to facilitate care responses. We examined the implementation, uptake and use of the tracker in care homes across four geographical case study localities in the first year of the pandemic. Methods This was a rapid, mixed-methods, multi-locality case study. Tracker uptake was calculated using the number of care homes taking up the tracker as a proportion of the total number of care homes in a locality. Mean tracker use was summarised at locality level and compared. Semi-structured interviews were conducted with professionals involved in tracker implementation and used to explore implementation factors across localities. Template Analysis with the Consolidated Framework for Implementation Research (CFIR) guided the interpretation of qualitative data. Results Uptake varied across the four case study localities ranging between 13.8 and 77.8%. Tracker use decreased in all localities over time at different rates, with average use ranging between 18 and 58%. The implementation context differed between localities and the process of implementation deviated over time from the initially planned strategy, for stakeholder engagement and care homes’ training. Four interpretative themes reflected the most influential factors appearing to affect tracker uptake and use: (1) the process of implementation, (2) implementation readiness, (3) clarity of purpose/perceived value and (4) relative priority in the context of wider system pressures. Conclusions Our study findings resonate with the digital solutions evidence base prior to the COVID-19 pandemic, suggesting three key factors that can inform future development and implementation of rapid digital responses in care home settings even in times of crisis: an incremental approach to implementation with testing of organisational readiness and attention to implementation climate, particularly the innovation’s fit with local contexts (i.e. systems, infrastructure, work processes and practices); involvement of end-users in innovation design and development; and enabling users’ easy access to sustained, high-quality, appropriate training and support to enable staff to adapt to digital solutions.

Abstract The journals Implementation Science and Implementation Science Communications are focused on the implementation of evidence into healthcare practice and policy. This editorial offers reflections on how we handle this as editors. Studies that focus on the simultaneous implementation of implementation objects and (technological or other) structures to enable their implementation are considered on a case-by-case basis regarding their contribution to implementation science. Studies on implementation objects with limited, mixed, or of out-of-context evidence are considered if the evidence for key components of the object of interest is sufficiently robust. We follow GRADE principles in our assessment of the certainty of research findings for health-related interventions in individuals. Adapted thresholds apply to evidence for population health interventions, organizational changes, health reforms, health policy innovations, and medical devices. The added value of a study to the field of implementation science remains of central interest for our journals.

Abstract Background The rapid identification and adoption of effective innovations in healthcare is a known challenge. The strongest evidence base for innovations can be provided by evidence synthesis, but this is frequently a lengthy process and even rapid versions of this can be time-consuming and complex. In the UK, the Accelerated Access Review and Academic Health Science Network (AHSN) have provided the impetus to develop a consistently rapid process to support the identification and adoption of high-value innovations in the English NHS. Methods The Greater Manchester Applied Research Collaboration (ARC-GM) developed a framework for a rapid evidence synthesis (RES) approach, which is highly integrated within the innovation process of the Greater Manchester AHSN and the associated healthcare and research ecosystem. The RES uses evidence synthesis approaches and draws on the GRADE Evidence to Decision framework to provide rapid assessments of the existing evidence and its relevance to specific decision problems. We implemented this in a real-time context of decision-making around adoption of innovative health technologies. Results Key stakeholders in the Greater Manchester decision-making process for healthcare innovations have found that our approach is both timely and flexible; it is valued for its combination of rigour and speed. Our RES approach rapidly and systematically identifies, appraises and contextualises relevant evidence, which can then be transparently incorporated into decisions about the wider adoption of innovations. The RES also identifies limitations in existing evidence for innovations and this can inform subsequent evaluations. There is substantial interest from other ARCs and AHSNs in implementing a similar process. We are currently exploring methods to make completed RES publicly available. We are also exploring methods to evaluate the impact of using RES as more implementation decisions are made. Conclusions The RES framework we have implemented combines transparency and consistency with flexibility and rapidity. It therefore maximises utility in a real-time decision-making context for healthcare innovations.

The paper focuses on the effect of the scanning strategies on the microstructural evolution, defect formation, and macro-hardness performance of laser-powder bed fusion (L-PBF) produced samples of low alloy 20MnCr5 steel. Respect to the scanning strategies, advanced characterization techniques were employed to study (i) as-built microstructure, (ii) inclusion size and distribution, and (iii) details of compositional variation around porosity and within the build. Microstructural characterization shows that the chessboard scanning strategy can provide a favorable microstructure for the improvement of mechanical performance. However, macro-hardness results show a lower mechanical performance compared to the linear scanning strategy samples, which is contradicted by the improved microstructure. Experimental results reveal that the chessboard scanning strategy promotes the oxidation reaction and in-situ oxide (SiO2) formation in L-PBF, which leads to significant defect formation due to the excessive thermal profile from the overlap of the laser. This has been validated through finite element analysis and thermodynamic computation. The advantages of microstructural improvement using the chessboard strategy can only be realized with strict control of the metallurgical quality during the L-PBF process. Thermal profile optimization and oxygen elimination during the L-PBF process could be critical for the improved metallurgical quality and superior mechanical performance of the as-built components.

BackgroundIncreased maximal oxygen uptake (V̇O2max) is beneficial in children with cystic fibrosis (CF) but remains lower compared to healthy peers. Intrinsic metabolic deficiencies within skeletal muscle (muscle “quality”) and skeletal muscle size (muscle “quantity”) are both proposed as potential causes for the lower V̇O2max, although exact mechanisms remain unknown. This study utilises gold-standard methodologies to control for the residual effects of muscle size from V̇O2max to address this “quality” vs. “quantity” debate.MethodsFourteen children (7 CF vs. 7 age- and sex-matched controls) were recruited. Parameters of muscle size – muscle cross-sectional area (mCSA) and thigh muscle volume (TMV) were derived from magnetic resonance imaging, and V̇O2max obtained via cardiopulmonary exercise testing. Allometric scaling removed residual effects of muscle size, and independent samples t-tests and effect sizes (ES) identified differences between groups in V̇O2max, once mCSA and TMV were controlled for.ResultsV̇O2max was shown to be lower in the CF group, relative to controls, with large ES being identified when allometrically scaled to mCSA (ES = 1.76) and TMV (ES = 0.92). Reduced peak work rate was also identified in the CF group when allometrically controlled for mCSA (ES = 1.18) and TMV (ES = 0.45).ConclusionsA lower V̇O2max was still observed in children with CF after allometrically scaling for muscle size, suggesting reduced muscle “quality” in CF (as muscle “quantity” is fully controlled for). This observation likely reflects intrinsic metabolic defects within CF skeletal muscle.

Abstract “No regrets” buying – using Advance Purchase Agreements (APAs) – has characterized the response to recent pandemics such as Avian flu, Zika Virus, and now COVID-19. APAs are used to reduce demand uncertainty for product developers and manufacturers; to hedge against R&D and manufacturing risks; and to secure availability of products in the face of spiking demand. Evidence on the use of APAs to buy vaccines, medicines, diagnostics, and personal protective equipment during recent pandemics illustrates how these contracts can achieve their intended objectives for buyers. But, transferring risk from suppliers to buyers - as APAs do - can have consequences, including overbuying and overpaying. Furthermore, the widespread use of APAs by high-income countries has contributed to the striking inequities that have characterized the Swine flu and COVID-19 responses, delaying access to vaccines and other supplies for low- and middle-income countries (L&MICs). We identify seven ways to address some of the risks and disadvantages of APAs, including adoption of a global framework governing how countries enter into APAs and share any resulting supplies; voluntary pooling through joint or coordinated APAs; a concessional-capital-backed facility to allow international buyers and L&MICs to place options on products as an alternative to full purchase commitments; greater collection and sharing of market information to help buyers place smarter APAs; support for a resale market; building in mechanisms for donation from the outset; and transitioning away from APAs as markets mature. While a binding global framework could in theory prevent the competitive buying and hoarding that have characterized country/state responses to pandemics, it will be very challenging to put in place. The other solutions, while less sweeping, can nonetheless mitigate both the inequities associated with the current uncoordinated use of APAs and also some of the risks to individual buyers. Analysis of recent experiences can provide useful lessons on APAs for the next pandemic. It will be important to keep in mind, however, that these contractual instruments work by transferring risk to the buyer, and that buyers must therefore accept the consequences. In the spirit of “no regrets” purchasing, having bought what hindsight suggests was too much is generally preferable to having bought not enough.

This work presents X-ray computed tomography (XCT) as a dimensional quality assurance technique for micro-injection moulded polymeric test objects for the establishment of predictive quality models and quantifying soft-tool deformation. The results are compared against an industry standard laser-scanning-confocal microscope (LSCM) for the evaluation of XCT’s capability. The work demonstrates; (i) the exploitation of a XCT equipment for dimensional characterisation of micro-injection moulded products made out of polymers with adequate acquisition times, (ii) that acquired XCT data from the 3D visualisation of the micromouldings perform on par with a laser-scanning-confocal microscope in a quality prediction model, (iii) that the deformation occurring in an additively manufactured soft-tool can be quantified using XCT. The technique was particularly superior in volumetric data acquisition compared to LSCM in the filling prediction of the micromouldings. Better accuracy and repeatability in predicting the quality of the mouldings up to 92% achieved with XCT, in conjunction with an in-line collected soft-tool surface temperature data as an indirect quality assurance method. Given the capability of the XCT for the 3D data acquisition of polymeric miniature components, the approach described here has great potential in high-value micro-manufacturing process quality modelling for in-line quality assessment of miniature and added value products in data-rich contexts.Rendered 3D animation of the X-ray CT data: https://youtu.be/KwZty_yoDfs.

Abstract Background There is increasing awareness among researchers and policymakers of the potential for healthcare interventions to have consequences beyond those initially intended. These unintended consequences or “spillover effects” result from the complex features of healthcare organisation and delivery and can either increase or decrease overall effectiveness. Their potential influence has important consequences for the design and evaluation of implementation strategies and for decision-making. However, consideration of spillovers remains partial and unsystematic. We develop a comprehensive framework for the identification and measurement of spillover effects resulting from changes to the way in which healthcare services are organised and delivered. Methods We conducted a scoping review to map the existing literature on spillover effects in health and healthcare interventions and used the findings of this review to develop a comprehensive framework to identify and measure spillover effects. Results The scoping review identified a wide range of different spillover effects, either experienced by agents not intentionally targeted by an intervention or representing unintended effects for targeted agents. Our scoping review revealed that spillover effects tend to be discussed in papers only when they are found to be statistically significant or might account for unexpected findings, rather than as a pre-specified feature of evaluation studies. This hinders the ability to assess all potential implications of a given policy or intervention. We propose a taxonomy of spillover effects, classified based on the outcome and the unit experiencing the effect: within-unit, between-unit, and diagonal spillover effects. We then present the INTENTS framework: Intended Non-intended TargEted Non-Targeted Spillovers. The INTENTS framework considers the units and outcomes which may be affected by an intervention and the mechanisms by which spillover effects are generated. Conclusions The INTENTS framework provides a structured guide for researchers and policymakers when considering the potential effects that implementation strategies may generate, and the steps to take when designing and evaluating such interventions. Application of the INTENTS framework will enable spillover effects to be addressed appropriately in future evaluations and decision-making, ensuring that the full range of costs and benefits of interventions are correctly identified.

Global environmental sustainability and food security are fundamental societal issues, and most crop production relies upon inputs from organic or inorganic nitrogen sources. Previous research in the Global North has demonstrated a typical over application of nitrogen across global agriculture with substantial negative impacts on the environment. The objective of this work was to draw on English Farm Business Survey (FBS) data of non-organic General Cropping and Cereal farms to explore the relationship between farm gate nitrogen balance, fertilizer application advice and farm business performance. A mixed effects generalized modeling approach was used to partition the variance into random (such as year, or farm ID) and fixed effects (those of interest). Whilst the financial performance of farm businesses is subject to high variance and multiple drivers, a negative relationship was detected between business performance and farm gate nitrogen balance, we demonstrate that nitrogen lost to the environment of >60 kg per hectare is associated with a significant negative impact on farm performance. Supplier-provided fertilizer advice was also associated with reduced farm performance. These results imply a positive effect on farm performance of enhancing on-farm understanding of crop nutrient requirements through the provision of accredited fertilizer advice. Within the stated bounds our model demonstrates good predictivity on randomly subsetted data, and is presented as a tool for use in scenario modeling of interventions such as agri-environment schemes, Natural Capital and Ecosystems Assessment, and the UN Sustainable Development Goals.

Abstract This editorial provides a comprehensive consolidated overview of the scope and expectations of Implementation Science and Implementation Science Communications. We remain most interested in rigorous empirical studies of the implementation of evidence-based healthcare practices (including interventions, technologies, and policies) and the de-implementation of practices that are demonstrated to be of low or no benefit. Implementation strategies (e.g., continuing professional education, organizational changes, and financial incentives to enhance the uptake of evidence-based practices) are of central interest to the journals. We see the field as large and complex, with a wide literature that is published in many venues. We urge people for whom it is new to spend some time reading the existing literature, and learning the scope of the work that has already been done, and published, in our journals and in an increasing number of other journals in the field.

Abstract Background In malignancy, eosinophils have been shown to play an important role in the tumour micro‐environment. Increasingly, development of eosinophilia with immune checkpoint inhibitor (ICI) use is thought to be predictive of prognosis and development of immune‐related adverse events. However, there are many other causes for developing eosinophilia which can contribute to the difficulties in diagnosis and management. Case Here, we present a case of Strongyloides parasitic infection as an uncommon differential for eosinophilia in a patient with lung cancer receiving a PDL‐1 ICI, durvalumab, in Australia. Conclusion This case highlights the complexities exploring the multiple potential causes of eosinophilia and the subsequent management, to allow safe continuation of ICI.

Several healthcare organizations have developed pre-emptive pharmacogenetic testing programs, where testing is undertaken prior to the prescription of a medicine. This review characterizes the barriers and facilitators which influenced the development of these programs. A bidirectional citation searching strategy identified relevant publications before a standardized data extraction approach was applied. Publications were grouped by program and data synthesis was undertaken using the Consolidated Framework for Implementation Research (CFIR). 104 publications were identified from 40 programs and 4 multi-center initiatives. 26 (66%) of the programs were based in the United States and 95% in high-income countries. The programs were heterogeneous in their design and scale. The Characteristics of the Intervention, Inner Setting, and Process domains were referenced by 92.5, 80, and 77.5% of programs, respectively. A positive institutional culture, leadership engagement, engaging stakeholders, and the use of clinical champions were frequently described as facilitators to implementation. Clinician self-efficacy, lack of stakeholder knowledge, and the cost of the intervention were commonly cited barriers. Despite variation between the programs, there were several similarities in approach which could be categorized via the CFIR. These form a resource for organizations planning the development of pharmacogenetic programs, highlighting key facilitators which can be leveraged to promote successful implementation.

Abstract Background With innovation in service delivery increasingly viewed as crucial to the long-term sustainability of health systems, NHS England launched an ambitious new model of care (Vanguard) programme in 2015. Supported by a £350 million transformation fund, 50 Vanguard sites were to act as pilots for innovation in service delivery, to move quickly to change the way that services were delivered, breaking down barriers between sectors and improving the coordination and delivery of care. Methods As part of a national evaluation of the Vanguard programme, we conducted an evidence synthesis to assess the nature and quality of locally commissioned evaluations. With access to a secure, online hub used by the Vanguard and other integrated care initiatives, two researchers retrieved any documents from a locally commissioned evaluation for inclusion. All identified documents were downloaded and logged, and details of the evaluators, questions, methodological approaches and limitations in design and/or reporting were extracted. As included evaluations varied in nature and type, a narrative synthesis was undertaken. Results We identified a total of 115 separate reports relating to the locally commissioned evaluations. Five prominent issues relating to evaluation conduct were identified across included reports: use of logic models, number and type of evaluation questions posed, data sharing and information governance, methodological challenges and evaluation reporting in general. A combination of resource, data and time constraints means that evaluations often attempted to but did not fully address the wide range of questions posed by individual Vanguards. Conclusions Significant investment was made in independent local evaluations of the Vanguard programme by NHS England. This synthesis represents the only comprehensive attempt to capture methodological learning and may serve as a key resource for researchers and policy-makers seeking to understand investigating large-scale system change, both within the NHS and internationally. PROSPERO (Registration number: CRD42017069282).

Recently, it has been shown that the long penetrating polarimetric L-band ALOS is very promising for boreal and subarctic peatland mapping and monitoring. The unique information provided by the Touzi decomposition, and the dominant-scattering-type phase in particular, on peatland subsurface water flow permits an enhanced discrimination of bogs from fens, two peatland classes that can hardly be discriminated using conventional optical remote sensing sensors and C-band polarimetric SAR. In this study, the dominant and medium-scattering phases generated by the Touzi decomposition are investigated for discontinuous permafrost mapping in peatland regions. Polarimetric ALOS2, LiDAR, and field data were collected in the middle of August 2014, at the maximum permafrost thaw conditions, over discontinuous permafrost distributed within wooded palsa bogs and peat plateaus near the Namur Lake (Northern Alberta). The ALOS2 image, which was miscellaneously calibrated with antenna cross talk (−33 dB) much higher than the actual ones, was recalibrated. This led to a reduction of the residual calibration error (down to −43 dB) and permitted a significant improvement of the dominant and medium-scattering-type phase (20∘ to −30∘) over peatlands underlain by discontinuous permafrost. The Touzi decomposition, Cloude–Pottier α-H incoherent target scattering decomposition, and the HH-VV phase difference were investigated, in addition to the conventional multipolarization (HH, HV, and VV) channels, for discontinuous permafrost mapping using the recalibrated ALOS2 image. A LiDAR-based permafrost classification developed by the Alberta Geological Survey (AGS) was used in conjunction with the field data collected during the ALOS2 image acquisition for the validation of the results. It is shown that the dominant- and scattering-type phases are the only polarimetric parameters which can detect peatland subsurface discontinuous permafrost. The medium-scattering-type phase, ϕs2, performs better than the dominant-scattering-type phase, ϕs1, and permits a better detection of subsurface discontinuous permafrost in peatland regions. ϕs2 also allows for a better discrimination of areas underlain by permafrost from the nonpermafrost areas. The medium Huynen maximum polarization return (m2) and the minimum degree of polarization (DoP), pmin, can be used to remove the scattering-type phase ambiguities that might occur in areas with deep permafrost (more than 50 cm in depth). The excellent performance of polarimetric PALSAR2 in term of NESZ (−37 dB) permits the demonstration of the very promising L-band long-penetration SAR capabilities for enhanced detection and mapping of relatively deep (up to 50 cm) discontinuous permafrost in peatland regions.

AbstractQuantile regression presents a complete picture of the effects on the location, scale, and shape of the dependent variable at all points, not just the mean. We focus on two challenges for citation count analysis by quantile regression: discontinuity and substantial mass points at lower counts. A Bayesian hurdle quantile regression model for count data with a substantial mass point at zero was proposed by King and Song (2019). It uses quantile regression for modeling the nonzero data and logistic regression for modeling the probability of zeros versus nonzeros. We show that substantial mass points for low citation counts will almost certainly also affect parameter estimation in the quantile regression part of the model, similar to a mass point at zero. We update the King and Song model by shifting the hurdle point past the main mass points. This model delivers more accurate quantile regression for moderately to highly cited articles, especially at quantiles corresponding to values just beyond the mass points, and enables estimates of the extent to which factors influence the chances that an article will be low cited. To illustrate the potential of this method, it is applied to simulated citation counts and data from Scopus.

Abstract Background Contemporary health policy is shifting towards remotely delivered care. A growing need to provide effective and accessible services, with maximal population reach has stimulated demand for flexible and efficient service models. The implementation of evidence-based practice has been slow, leaving many services ill equipped to respond to requests for non-face-to-face delivery. To address this translation gap, and provide empirically derived evidence to support large-scale practice change, our study aimed to explore practitioners’ perspectives of the factors that enhance the delivery of a NICE-recommended psychological intervention, i.e. guided self-help by telephone (GSH-T), in routine care. We used the Theoretical Domains Framework (TDF) to analyse our data, identify essential behaviour change processes and encourage the successful implementation of remote working in clinical practice. Method Thirty-four psychological wellbeing practitioners (PWPs) from the UK NHS Improving Access to Psychological Therapies (IAPT) services were interviewed. Data were first analysed inductively, with codes cross-matched deductively to the TDF. Results Analysis identified barriers to the delivery, engagement and implementation of GSH-T, within eight domains from the TDF: (i) Deficits in practitioner knowledge, (ii) Sub-optimal practitioner telephone skills, (iii) Practitioners’ lack of beliefs in telephone capabilities and self-confidence, (iv) Practitioners’ negative beliefs about consequences, (v) Negative emotions, (vi) Professional role expectations (vii) Negative social influences, and (viii) Challenges in the environmental context and resources. A degree of interdependence was observed between the TDF domains, such that improvements in one domain were often reported to confer secondary advantages in another. Conclusions Multiple TDF domains emerge as relevant to improve delivery of GSH-T; and these domains are theoretically and practically interlinked. A multicomponent approach is recommended to facilitate the shift from in-person to telephone-based service delivery models, and prompt behaviour change at practitioner, patient and service levels. At a minimum, the development of practitioners’ telephone skills, an increase in clients’ awareness of telephone-based treatment, dilution of negative preconceptions about telephone treatment, and robust service level guidance and standards for implementation are required. This is the first study that provides clear direction on how to improve telephone delivery and optimise implementation, aligning with current mental health policy and service improvement.

Abstract The emergence of SARS-CoV-2/Covid-19 affects all of us and is associated with rapid and massive changes in healthcare and societies. As a response, a range of interventions for patients and populations have been implemented in health and preventive settings, or need to be implemented in the short and long term. Implementation science offers a multidisciplinary perspective and systematic approach for the design, evaluation and analysis of programmes and policies to enhance implementation. The emergence of Covid-19 provides an urgent need to develop new perspectives and approaches in implementation science, such as the addition of innovative and rigorous approaches to the collection, use and analysis of ‘real-world’ data. Above all, we hope that implementation scientists will focus on what they can contribute to manage Covid-19 and its consequences for people, healthcare and society.

This is the third in a series of articles reporting on forensic epistemology. Our first two research articles presented scientific results that are based in experimental design; including quantitative and qualitative responses from forensic science practitioners to scenarios and evidence. Based on a synthesis of this research there is evidence of a knowledge gap in formal reasoning for some forensic practitioners, and a limited understanding of case-specific research. Combining these results with a review of the current literature in the field of forensic reasoning, we now offer evidence of teaching and research strategies that can help increase the epistemic status (Confidence in, and justification of knowledge) of forensic science claims. This paper focuses on an integrated narrative review using hermeneutic methods of analysis to identify: (i) the epistemic state of forensic science; (ii) strategies to increase of knowledge; (iii) the need for collaboration between practitioners and academics; and, (iv) areas for future research.

BackgroundUsing traditional simulators (eg, cadavers, animals, or actors) to upskill health workers is becoming less common because of ethical issues, commitment to patient safety, and cost and resource restrictions. Virtual reality (VR) and augmented reality (AR) may help to overcome these barriers. However, their effectiveness is often contested and poorly understood and warrants further investigation. ObjectiveThe aim of this review is to develop, test, and refine an evidence-informed program theory on how, for whom, and to what extent training using AR or VR works for upskilling health care workers and to understand what facilitates or constrains their implementation and maintenance. MethodsWe conducted a realist synthesis using the following 3-step process: theory elicitation, theory testing, and theory refinement. We first searched 7 databases and 11 practitioner journals for literature on AR or VR used to train health care staff. In total, 80 papers were identified, and information regarding context-mechanism-outcome (CMO) was extracted. We conducted a narrative synthesis to form an initial program theory comprising of CMO configurations. To refine and test this theory, we identified empirical studies through a second search of the same databases used in the first search. We used the Mixed Methods Appraisal Tool to assess the quality of the studies and to determine our confidence in each CMO configuration. ResultsOf the 41 CMO configurations identified, we had moderate to high confidence in 9 (22%) based on 46 empirical studies reporting on VR, AR, or mixed simulation training programs. These stated that realistic (high-fidelity) simulations trigger perceptions of realism, easier visualization of patient anatomy, and an interactive experience, which result in increased learner satisfaction and more effective learning. Immersive VR or AR engages learners in deep immersion and improves learning and skill performance. When transferable skills and knowledge are taught using VR or AR, skills are enhanced and practiced in a safe environment, leading to knowledge and skill transfer to clinical practice. Finally, for novices, VR or AR enables repeated practice, resulting in technical proficiency, skill acquisition, and improved performance. The most common barriers to implementation were up-front costs, negative attitudes and experiences (ie, cybersickness), developmental and logistical considerations, and the complexity of creating a curriculum. Facilitating factors included decreasing costs through commercialization, increasing the cost-effectiveness of training, a cultural shift toward acceptance, access to training, and leadership and collaboration. ConclusionsTechnical and nontechnical skills training programs using AR or VR for health care staff may trigger perceptions of realism and deep immersion and enable easier visualization, interactivity, enhanced skills, and repeated practice in a safe environment. This may improve skills and increase learning, knowledge, and learner satisfaction. The future testing of these mechanisms using hypothesis-driven approaches is required. Research is also required to explore implementation considerations.

Abstract Background Type 2 diabetes mellitus is preventable through lifestyle intervention. Diabetes prevention programmes (DPPs) aim to deliver prevention-based behaviour change interventions to reduce incidence. Such programmes vary from usual primary care in terms of where, how, and by whom they are delivered. Implementation is therefore likely to face new commissioning, incentive and delivery challenges. We report on the implementation of a national DPP in NHS England, and identify lessons learned in addressing the implementation challenges. Methods In 2017/18, we conducted 20 semi-structured telephone interviews covering 16 sampled case sites with the designated lead(s) responsible for local implementation of the programme. Interviews explored the process of implementation, including organisation of the programme, expectations and attitudes to the programme, funding, target populations and referral and clinical pathways. We drew on constant comparative methods to analyse the data and generate over-arching themes. We complemented our qualitative data with a survey focused on variation in the financial incentives used across sites to ensure usual primary care services recruited patients to new providers. Results We identified five over-arching areas of learning for implementing this large-scale programme: 1) managing new providers; 2) promoting awareness of services; 3) recruiting patients; 4) incentive payments; and 5) mechanisms for sharing learning. In general, tensions appeared to be caused by a lack of clear roles/responsibilities between hierarchical actors, and lack of communication. Both local sites and the national NHS coordination team gained experience through learning by doing. Initial tensions with roles and expectations have been worked out during implementation. Conclusions Implementing a national disease prevention programme is a major task, and one that will be increasingly faced by health systems globally as they aim to adjust to demand pressures. We provide practical learning opportunities for the wider uptake and sustainability of prevention programmes. Future implementers might wish to define clear responsibilities for each actor prior to implementation, ensure early engagement with new providers, offer mechanisms/forums for sharing learning, generate evidence and provide advice on incentive payments, and prioritise public and professional awareness of the programme.

This article describes the formation of The Tasmanian Historical Dataset a longitudinal data resource spanning the 19th and early 20th century. This resource contains over 1.6 million records drawn from digitised prison and hospital admission registers, military enlistment papers, births, deaths and marriages, census and muster records, arrival and departure lists, bank accounts and property valuations, maps and plans and meteorological observations. As well as providing an account of the many different sources that have been digitised coded and linked as part of this initiative, the article outlines current and past research uses to which this data has been put. Further information on tables and key variables is provided in an appendix.

Introduction Augmented reality (AR) and virtual reality (VR) are increasingly used to upskill health and care providers, including in surgical, nursing and acute care settings. Many studies have used AR/VR to deliver training, providing mixed evidence on their effectiveness and limited evidence regarding contextual factors that influence effectiveness and implementation. This review will develop, test and refine an evidence-informed programme theory on what facilitates or constrains the implementation of AR or VR programmes in health and care settings and understand how, for whom and to what extent they ‘work’.Methods and analysis This realist review adheres to the Realist And Meta-narrative Evidence Syntheses: Evolving Standards (RAMESES) standards and will be conducted in three steps: theory elicitation, theory testing and theory refinement. First, a search will identify practitioner, academic and learning and technology adoption theories from databases (MEDLINE, Scopus, CINAHL, Embase, Education Resources Information Center, PsycINFO and Web of Science), practitioner journals, snowballing and grey literature. Information regarding contexts, mechanisms and outcomes will be extracted. A narrative synthesis will determine overlapping configurations and form an initial theory. Second, the theory will be tested using empirical evidence located from the above databases and identified from the first search. Quality will be assessed using the Mixed Methods Appraisal Tool (MMAT), and relevant information will be extracted into a coding sheet. Third, the extracted information will be compared with the initial programme theory, with differences helping to make refinements. Findings will be presented as a narrative summary, and the MMAT will determine our confidence in each configuration.Ethics and dissemination Ethics approval is not required. This review will develop an evidence-informed programme theory. The results will inform and support AR/VR interventions from clinical educators, healthcare providers and software developers. Upskilling through AR/VR learning interventions may improve quality of care and promote evidence-based practice and continued learning. Findings will be disseminated through conference presentations and peer-reviewed journal articles.

Abstract Population monitoring can take many different forms, and monitoring elusive and endangered species frequently involves a variety of sparse data from different sources. Small populations are often hard to sample precisely and without bias, so when estimates of vital rates like survival or recruitment point to conflicting population trends, it can be hard to determine which is more correct. Furthermore, data can be extremely hard to collect on small populations and it can be helpful to find a way to use all available hard‐won data. To address these issues, we developed an integrated population model (IPM) using all available data to estimate vital rates and abundance for a case study of an endangered woodland caribou (Rangifer tarandus caribou) population. This IPM allowed us to incorporate data from juvenile recruitment surveys, telemetry‐based survival, aerial population counts and mark–resight data, and non‐invasive capture–recapture DNA data to better understand population status and trend. We estimated survival, abundance, and recruitment of four age classes of male and female caribou: young, juveniles, subadults, and adults. The four‐age class structure of the IPM allowed us to estimate recruitment from reproductive‐aged female caribou alone, even though it can be difficult to distinguish age classes—and even sexes—in the field. As part of our IPM, we developed a novel mixture model to break apart data from different age classes when age is unobservable, as it typically is from non‐invasive DNA samples. This helped us decrease bias in juvenile and adult survival estimates from scat data, which was important to our understanding of the population dynamics. Overall, our integrated model provided more precise estimates of population trends than any one method (e.g., telemetry or non‐invasive DNA) alone. This IPM provides a useful, flexible tool for biologists to monitor populations and provides a valuable example of the benefits of integrated population modeling approaches for endangered species management and recovery.

Whilst many numeric methods, such as AIC and deviance, exist for assessing or comparing model fit, diagrammatic methods are few. We present here a diagnostic plot, which we refer to as a `Quantile Band plot', that may be used to visually assess the suitability of a given count data model. In the case of diagnosed model inadequacy, the plot has the unique feature of conveying precise information on the character of the violation, hence pointing the data analyst towards a potentially better model choice.

Wheat farming provides 28.5% of global cereal production. After steady growth in average crop yield from 1950 to 1990, wheat yields have generally stagnated, which prompts the question of whether further improvements are possible. Statistical studies of agronomic parameters such as crop yield have so far exclusively focused on estimating parameters describing the whole of the data, rather than the highest yields specifically. These indicators include the mean or median yield of a crop, or finding the combinations of agronomic traits that are correlated with increasing average yields. In this paper, we take an alternative approach and consider high yields only. We carry out an extreme value analysis of winter wheat yield data collected in England and Wales between 2006 and 2015. This analysis suggests that, under current climate and growing conditions, there is indeed a finite upper bound for winter wheat yield, whose value we estimate to be 17.60 tonnes per hectare. We then refine the analysis for strata defined by either location or level of use of agricultural inputs. We find that there is no statistical evidence for variation of maximal yield depending on location, and neither is there statistical evidence that maximum yield levels are improved by high levels of crop protection and fertilizer use.

Abstract Background Chronic widespread pain (CWP) is a major public health problem. Many people experiencing CWP experience mental health problems such as anxiety or depression. Complete relief of skeletal and body pain symptoms is unlikely but with appropriate treatment the impact upon quality of life, functioning and mental health symptoms can be reduced. Cognitive behavioural therapy (CBT) is widely used for a range of health conditions and can have short and long-term improvements in patients with CWP. This research aimed to explore, from a professional stakeholder perspective, the implementation of a local Pain Platform offering a stepped care approach for interventions including telephone delivered CBT (T-CBT). Methods Fourteen professional stakeholders holding various roles across primary and secondary care services within the Pain Platform took part in semi-structured interviews. Their views and experiences of the implementation of the Pain Platform were explored. Interviews were recorded, transcribed verbatim and analysed according to Normalisation Process Theory (NPT). Results Professional stakeholders were positive about the Pain Platform and its potential to overcome previously identified existing access issues to psychological interventions for CWP patients. It was considered a valuable part of ensuring that patients’ preferences and needs are more readily addressed. In some circumstances, however, introducing psychological interventions to patients was considered challenging and the introduction of new referral processes was raised concerns. To ensure sustainability more work is required to reduce professional isolation and ensure efficient referral procedures between primary and secondary care services are established to reduce concerns over issues related to clinical governance and potential risk to patient. Conclusions The findings provide professional insight into the key challenges of introducing a Pain Platform incorporating psychological support across primary and secondary care services within a local service. These included development of sustainable procedures and closer working relationships. Areas requiring future development are identified.

Abstract Background The Template for Intervention Description and Replication (TIDieR) checklist and guide was developed by an international team of experts to promote full and accurate description of trial interventions. It is now widely used in health research. The aim of this paper is to describe the experience of using TIDieR outside of trials, in a range of applied health research contexts, and make recommendations on its usefulness in such settings. Main body We used the TIDieR template for intervention description in six applied health research projects. The six cases comprise a diverse sample in terms of clinical problems, population, settings, stage of intervention development and whether the intervention was led by researchers or the service deliverers. There was also variation in how the TIDieR description was produced in terms of contributors and time point in the project. Researchers involved in the six cases met in two workshops to identify issues and themes arising from their experience of using TIDieR. We identified four themes which capture the difficulties or complexities of using TIDieR in applied health research: (i) fidelity and adaptation: all aspects of an intervention can change over time; (ii) voice: the importance of clarity on whose voice the TIDieR description represents; (iii) communication beyond the immediate context: the usefulness of TIDieR for wider dissemination and sharing; (iv) the use of TIDieR as a research tool. Conclusion We found TIDieR to be a useful tool for applied research outside the context of clinical trials and we suggest four revisions or additions to the original TIDieR which would enable it to better capture these complexities in applied health research: An additional item, ‘voice’ conveys who was involved in preparing the TIDieR template, such as researchers, service users or service deliverers. An additional item, ‘stage of implementation’ conveys what stage the intervention has reached, using a continuum of implementation research suggested by the World Health Organisation. A new column, ‘modification’ reminds authors to describe modifications to any item in the checklist. An extension of the ‘how well’ item encourages researchers to describe how contextual factors affected intervention delivery.

Background: Flexible, integrated models of service delivery are being developed to meet the changing demands of an ageing population. To underpin the spread of innovative models of care across the NHS, summaries of the current research evidence are needed. This report focuses exclusively on care homes and reviews work in four specific areas, identified as key enablers for the NHS England vanguard programme. Aim: To conduct a rapid synthesis of evidence relating to enhancing health in care homes across four key areas: technology, communication and engagement, workforce and evaluation. Objectives: (1) To map the published literature on the uses, benefits and challenges of technology in care homes; flexible and innovative uses of the nursing and support workforce to benefit resident care; communication and engagement between care homes, communities and health-related organisations; and approaches to the evaluation of new models of care in care homes. (2) To conduct rapid, systematic syntheses of evidence to answer the following questions. Which technologies have a positive impact on resident health and well-being? How should care homes and the NHS communicate to enhance resident, family and staff outcomes and experiences? Which measurement tools have been validated for use in UK care homes? What is the evidence that staffing levels (i.e. ratio of registered nurses and support staff to residents or different levels of support staff) influence resident outcomes? Data sources: Searches of MEDLINE, CINAHL, Science Citation Index, Cochrane Database of Systematic Reviews, DARE (Database of Abstracts of Reviews of Effects) and Index to Theses. Grey literature was sought via Google™ (Mountain View, CA, USA) and websites relevant to each individual search. Design: Mapping review and rapid, systematic evidence syntheses. Setting: Care homes with and without nursing in high-income countries. Review methods: Published literature was mapped to a bespoke framework, and four linked rapid critical reviews of the available evidence were undertaken using systematic methods. Data were not suitable for meta-analysis, and are presented in narrative syntheses. Results: Seven hundred and sixty-one studies were mapped across the four topic areas, and 65 studies were included in systematic rapid reviews. This work identified a paucity of large, high-quality research studies, particularly from the UK. The key findings include the following. (1) Technology: some of the most promising interventions appear to be games that promote physical activity and enhance mental health and well-being. (2) Communication and engagement: structured communication tools have been shown to enhance communication with health services and resident outcomes in US studies. No robust evidence was identified on care home engagement with communities. (3) Evaluation: 6 of the 65 measurement tools identified had been validated for use in UK care homes, two of which provide general assessments of care. The methodological quality of all six tools was assessed as poor. (4) Workforce: joint working within and beyond the care home and initiatives that focus on staff taking on new but specific care tasks appear to be associated with enhanced outcomes. Evidence for staff taking on traditional nursing tasks without qualification is limited, but promising. Limitations: This review was restricted to English-language publications after the year 2000. The rapid methodology has facilitated a broad review in a short time period, but the possibility of omissions and errors cannot be excluded. Conclusions: This review provides limited evidential support for some of the innovations in the NHS vanguard programme, and identifies key issues and gaps for future research and evaluation. Future work: Future work should provide high-quality evidence, in particular experimental studies, economic evaluations and research sensitive to the UK context. Study registration: This study is registered as PROSPERO CRD42016052933, CRD42016052933, CRD42016052937 and CRD42016052938. Funding: The National Institute for Health Research Health Services and Delivery Research programme.

Small and declining populations of large mammals are vulnerable to stochastic events and can be at high risk of extinction. Population viability is also susceptible to the detrimental effects of low genetic diversity and inbreeding. The objective of this study was to do an assessment of three endangered caribou subpopulations using non-invasive genetic sampling to assess demographic population changes by combining capture-recapture modeling, familial pedigree networks, individual fitness and inbreeding coefficients. Three subpopulations of the Central Mountain caribou ecotype (Rangifer tarandus caribou) in Jasper National Park, Canada, were systematically surveyed over a 10-year period and fecal samples collected for DNA analyses. For the Tonquin, population size declined at a rate of 0.86 (95% CI 0.82, 0.91), the number of females decreased from 41 in 2006 to only 14 in 2015. The Brazeau and Maligne subpopulations also declined over the same period, from 22 to 11 individuals (11 and 5 females) in 2006, to 12 and 3 individuals (6 and 1 females) in 2015. The pedigree network confirmed limited interbreeding among subpopulations, varied fitness levels in both males and females, and evidence of inbreeding avoidance among high-fitness individuals. All population parameters pointed to a rapid population decline and low population sizes, putting them at high risk of extinction. The varying reproductive fitness observed amongst males and females was significant and should be considered in future population augmentation or reintroduction efforts. Improved connectivity among and with neighbouring subpopulations should also be considered to sustain or enhance genetic diversity. Keywords: Conservation genetics, Pedigrees, Inbreeding, Non-invasive genetic sampling, Rangifer tarandus, Varied fitness

Evaluation of agricultural intensification requires comprehensive analysis of trends in farm performance across physical and socio-economic aspects, which may diverge across farm types. Typical reporting of economic indicators at sectorial or the "average farm" level does not represent farm diversity and provides limited insight into the sustainability of specific intensification pathways. Using farm business data from a total of 7281 farm survey observations of English and Welsh dairy farms over a 14-year period we calculate a time series of 16 key performance indicators (KPIs) pertinent to farm structure, environmental and socio-economic aspects of sustainability. We then apply principle component analysis and model-based clustering analysis to identify statistically the number of distinct dairy farm typologies for each year of study, and link these clusters through time using multidimensional scaling. Between 2001 and 2014, dairy farms have largely consolidated and specialized into two distinct clusters: more extensive farms relying predominantly on grass, with lower milk yields but higher labour intensity, and more intensive farms producing more milk per cow with more concentrate and more maize, but lower labour intensity. There is some indication that these clusters are converging as the extensive cluster is intensifying slightly faster than the intensive cluster, in terms of milk yield per cow and use of concentrate feed. In 2014, annual milk yields were 6,835 and 7,500 l/cow for extensive and intensive farm types, respectively, whilst annual concentrate feed use was 1.3 and 1.5 tonnes per cow. For several KPIs such as milk yield the mean trend across all farms differed substantially from the extensive and intensive typologies mean. The indicators and analysis methodology developed allows identification of distinct farm types and industry trends using readily available survey data. The identified groups allow the accurate evaluation of the consequences of the reduction in dairy farm numbers and intensification at national and international scales.

A major concern with endangered plants is that they might attract insufficient numbers of pollinators, produce low numbers of seeds, and decline towards extinction. We examined effects of density as it varied within populations on the pollination of Pentachaeta lyonii, an endangered species that requires pollinators for seed set. Generalist bee-flies and bees were abundant pollinators at three sites for two years. Per-capita visitation rates did not decline at sparse points or for plants placed on the order of 10 m away from other flowering individuals. Seed production was not pollinator-limited within patches, but seed set was low beyond 10 m from neighbours. Considering prior findings, factors such as habitat loss, competition with alien plants, and poor establishment of new populations likely contribute to the rarity of P. lyonii more than pollination failure.

Certain floral characteristics are associated with specific pollinators. Hummingbird-pollinated flowers are usually red, lack a landing platform, lack nectar guides, and contain a high amount of dilute sucrose-rich nectar. Here we test hypotheses concerning the reasons for these characters to the extent that they involve hummingbird responses. An array was set up of 16 artificial plants, each with five artificial flowers. (1) Flowers made to differ only in colour elicited a slight preference for red. (2) When colour was associated with nectar offerings, and birds generally learned to visit flowers that provided much more nectar but did not associatively learn differences as little as 2 µL. (3) Birds were offered 8 µL of 12% sucrose versus 2 µL of 48% hexose, and they did not prefer the dilute nectar; they showed no evidence of discerning sucrose from hexose; however, they preferred 48% over 12% sucrose when both were offered in the same quantity. (4) Birds preferred flowers that lacked landing platforms over those with landing platforms. (5) Birds were offered flowers with nectar guides, associated with differing nectar volumes, and they did not associate the higher nectar reward with either flower type. In summary, the feedback from hummingbirds reflects some of the differences between bird- and bee-adapted flowers, but nectar seemed less predictive than expected. Factors other than the behavioural proclivities of hummingbirds, such as adaptation to discourage bees, are discussed as additional causes for the differences between the syndromes. We also discuss significance testing for field experiments involving one unreplicated array. Editors’ comment: The authors and reviewers disagreed about some aspects of the experimental design (e.g. necessity of marking of individual birds) and how the data should be treated (e.g. analysing only first visits versus including all data). On balance the editors decided that publication of this study gives readers the opportunity to make up their own minds about the results as presented.