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Devolution and decentralisation policies involving health and other government sectors have been promoted with a view to improve efficiency and equity in local service provision. Evaluations of these reforms have focused on specific health or care measures, but little is known about their full impact on local health systems. We evaluated the impact of devolution in Greater Manchester (England) on multiple outcomes using a whole system approach. We estimated the impact of devolution until February 2020 on 98 measures of health system performance, using the generalised synthetic control method and adjusting for multiple hypothesis testing. We selected measures from existing monitoring frameworks to populate the WHO Health System Performance Assessment framework. The included measures captured information on health system functions, intermediatory objectives, final goals, and social determinants of health. We identified which indicators were targeted in response to devolution from an analysis of 170 health policy intervention documents. Life expectancy (0.233 years, S.E. 0.012) and healthy life expectancy (0.603 years, S.E. 0.391) increased more in GM than in the estimated synthetic control group following devolution. These increases were driven by improvements in public health, primary care, hospital, and adult social care services as well as factors associated with social determinants of health, including a reduction in alcohol-related admissions (-110.1 admission per 100,000, S.E. 9.07). In contrast, the impact on outpatient, mental health, maternity, and dental services was mixed. Devolution was associated with improved population health, driven by improvements in health services and wider social determinants of health. These changes occurred despite limited devolved powers over health service resources suggesting that other mechanisms played an important role, including the allocation of sustainability and transformation funding and the alignment of decision-makin

Solar-induced chlorophyll fluorescence (SIF) has previously been shown to strongly correlate with gross primary productivity (GPP); however this relationship has not yet been quantified for the recently launched TROPOspheric Monitoring Instrument (TROPOMI). Here we use a Gaussian mixture model to develop a parsimonious relationship between SIF from TROPOMI and GPP from flux towers across the conterminous United States (CONUS). The mixture model indicates the SIF-GPP relationship can be characterized by a linear model with two terms. We then estimate GPP across CONUS at 500ĝ€¯m spatial resolution over a 16ĝ€¯d moving window. We observe four extreme precipitation events that induce regional GPP anomalies: drought in western Texas, flooding in the midwestern US, drought in South Dakota, and drought in California. Taken together, these events account for 28ĝ€¯% of the year-to-year GPP differences across CONUS. Despite these large regional anomalies, we find that CONUS GPP varies by less than 4ĝ€¯% between 2018 and 2019.

BACKGROUND: The population of older adults (ie, those aged ≥55 years) in England is becoming increasingly ethnically diverse. Previous reports indicate that ethnic inequalities in health exist among older adults, but information is limited by the paucity of data from small minority ethnic groups. This study aimed to analyse inequalities in health-related quality of life (HRQoL) and five determinants of health in older adults across all ethnic groups in England. METHODS: In this cross-sectional study, we analysed data from five waves (July 1, 2014, to April 7, 2017) of the nationally representative English General Practice Patient Survey (GPPS). Study participants were adults aged 55 years or older who were registered with general practices in England. We used regression models (age-adjusted and stratified by gender) to estimate the association between ethnicity and HRQoL, measured by use of the EQ-5D-5L index and its domains (mobility, self-care, usual activities, pain or discomfort, and anxiety or depression). We also estimated associations between ethnicity and five determinants of health (presence of long-term conditions or multimorbidity, experience of primary care, degree of support from local services, patient self-confidence in managing own health, and degree of area-level social deprivation). We examined robustness to differential handling of missing data, alternative EQ-5D-5L value sets, and differences in area-level social deprivation. FINDINGS: There were 1 416 793 GPPS respondents aged 55 years and older. 1 394 361 (98·4%) respondents had complete data on ethnicity and gender and were included in our analysis. Of these, 152 710 (11·0%) self-identified as belonging to minority ethnic groups. HRQoL was worse for men or women, or both, in 15 (88·2%) of 17 minority ethnic groups than the White British ethnic group. In both men and women, inequalities were widest for Gypsy or Irish Traveller (linear regression coefficient -0·192 [95% CI -0·318 to -0·066] in m

BACKGROUND: School-based social and emotional learning interventions can improve wellbeing and educational attainment in childhood. However, there is no evidence on their effects on health-related quality of life (HRQoL) or on their cost effectiveness. OBJECTIVE: Our objective was to evaluate the cost effectiveness of the Promoting Alternative Thinking Strategies (PATHS) curriculum. METHODS: A prospective economic evaluation was conducted alongside a cluster-randomised controlled trial of the PATHS curriculum implemented in the Greater Manchester area of England. In total, 23 schools (n = 2676 children) were randomised to receive PATHS, and 22 schools (n = 2542 children) were randomised to continue with usual practice. A UK health service perspective and a 2-year time horizon were used. HRQoL data were collected prospectively from all children in the trial via the Child Health Utility Nine-Dimension questionnaire. Micro-costing was undertaken to estimate the intervention costs. Missing data were imputed using multiple imputation. RESULTS: The mean incremental cost of the PATHS curriculum compared with usual practice was £32.01 per child, and mean incremental quality-adjusted life-years (QALYs) were positive (0.0019; 95% confidence interval [CI] 0.0009-0.0029). Assuming a willingness-to-pay threshold of £20,000 per QALY, the expected incremental net benefit of introducing the PATHS curriculum was £5.56 per child (95% CI - 14.68 to 25.81), and the probability of cost effectiveness was 84%. However, this probability fell to 0% when intervention costs included teacher's salary costs. CONCLUSION: The PATHS curriculum has the potential to be cost effective at standard UK willingness-to-pay thresholds. However, the sensitivity of the cost-effectiveness estimates to key assumptions means decision makers should seek further information before allocating scarce public resources. TRIAL REGISTRATION NUMBER: ISRCTN85087674.

At the 2017 joint meeting of the International Society for Neurochemistry (ISN) and the European Society for Neurochemistry, 150 years of neurochemistry - the 50th anniversary of ISN, 40 years of European Society for Neurochemistry, and 60 years of the Journal of Neurochemistry (JNC) - was celebrated with a historical symposium that explored the foundations of neurochemical societies, key international figures in the discipline of neurochemistry, and the pre-eminent role of the JNC. The foundations of neurochemistry were laid in Europe, notably France and Germany, in the late 18th and early 19th centuries. Neurochemists in the United Kingdom made globally relevant contributions before and after the Second World War, and Swedish contributions were especially prominent in the 1950s and 1960s. As neurochemistry is a truly international branch of neuroscience, the important contributions of neurochemists in the Americas and the Asia-Pacific were also recognized, as were the seminal roles of the American, Asia-Pacific, and Japanese Societies of Neurochemistry. Although ISN was only formed in 1967, earlier international meetings in Europe and the Americas reflected the growing recognition of the importance of chemistry and biochemistry for understanding and responding to the pathophysiology of clinical conditions and diseases of the central and peripheral nervous systems. JNC was first published in 1956, but the ISN only assumed complete ownership of the journal under tempestuous circumstances in 1970. The ISN-JNC interface and the sterling work of the JNC Editors has meant that the income generated by the journal has allowed the ISN Council to implement diverse programs for supporting neurochemistry internationally, including sustaining regional neurochemical societies, and supporting neurochemists in the developing world and schools of neurochemistry.

Crowding in emergency departments (EDs) is increasing in many health systems. Previous studies of the relationship between crowding and care quality are limited by the use of data from single hospitals, a focus on particular patient groups, a focus on a narrow set of quality measures, and use of crowding measures which induce bias from unobserved hospital and patient characteristics. Using data from 139 hospitals covering all major EDss in England, we measure crowding using quasi-exogenous variation in the volume of EDs attendances and examine its impacts on indicators of performance across the entire EDs care pathway. We exploit variations from expected volume estimated using high-dimensional fixed effects capturing hospital-specific variation in attendances by combinations of month and hour-of-the-week. Unexpected increases in attendance volume result in substantially longer waiting times, lower quantity and complexity of care, more patients choosing to leave without treatment, changes in referral and discharge decisions, but only small increases in reattendances and no increase in mortality. Causal bounds under potential omitted variable bias are narrow and exclude zero for the majority of outcomes. Results suggest that physician and patient responses may largely mitigate the impacts of demand increases on patient outcomes in the short-run.

End-of-life (EOL) care has become an integral part of intensive care medicine and includes the exploration of possibilities for deceased organ and tissue donation. Donation physicians are specialist doctors with expertise in EOL processes encompassing organ and tissue donation, who contribute significantly to improvements in organ and tissue donation services in many countries around the world. Donation physicians are usually also intensive care physicians, and thus they may be faced with the dual obligation of caring for dying patients and their families in the intensive care unit (ICU), whilst at the same time ensuring organ and tissue donation is considered according to best practice. This dual obligation poses specific ethical challenges that need to be carefully understood by clinicians, institutions and health care networks. These obligations are complementary and provide a unique skillset to care for dying patients and their families in the ICU. In this paper we review current controversies around EOL care in the ICU, including the use of palliative analgesia and sedation specifically with regards to withdrawal of cardiorespiratory support, the usefulness of the so-called doctrine of double effect to guide ethical decision-making, and the management of potential or perceived conflicts of interest in the context of dual professional roles.

One of the most intriguing features of the brain is its ability to be malleable, allowing it to adapt continually to changes in the environment. Specific neuronal activity patterns drive long-lasting increases or decreases in the strength of synaptic connections, referred to as long-term potentiation and long-term depression, respectively. Such phenomena have been described in a variety of model organisms, which are used to study molecular, structural, and functional aspects of synaptic plasticity. This review originated from the first International Society for Neurochemistry (ISN) and Journal of Neurochemistry (JNC) Flagship School held in Alpbach, Austria (Sep 2016), and will use its curriculum and discussions as a framework to review some of the current knowledge in the field of synaptic plasticity. First, we describe the role of plasticity during development and the persistent changes of neural circuitry occurring when sensory input is altered during critical developmental stages. We then outline the signaling cascades resulting in the synthesis of new plasticity-related proteins, which ultimately enable sustained changes in synaptic strength. Going beyond the traditional understanding of synaptic plasticity conceptualized by long-term potentiation and long-term depression, we discuss system-wide modifications and recently unveiled homeostatic mechanisms, such as synaptic scaling. Finally, we describe the neural circuits and synaptic plasticity mechanisms driving associative memory and motor learning. Evidence summarized in this review provides a current view of synaptic plasticity in its various forms, offers new insights into the underlying mechanisms and behavioral relevance, and provides directions for future research in the field of synaptic plasticity. Read the Editorial Highlight for this article on page 788. Cover Image for this issue: doi: 10.1111/jnc.13815.

Genetic tools that permit functional or connectomic analysis of neuronal circuits are rapidly transforming neuroscience. The key to deployment of such tools is selective transfection of target neurons, but to date this has largely been achieved using transgenic animals or viral vectors that transduce subpopulations of cells chosen according to anatomical rather than functional criteria. Here, we combine single-cell transfection with conventional electrophysiological recording techniques, resulting in three novel protocols that can be used for reliable delivery of conventional dyes or genetic material in vitro and in vivo. We report that techniques based on single cell electroporation yield reproducible transfection in vitro, and offer a simple, rapid and reliable alternative to established dye-labeling techniques in vivo, but are incompatible with targeted transfection in deep brain structures. In contrast, we show that intracellular electrophoresis of plasmid DNA transfects brainstem neurons recorded up to 9 mm deep in the anesthetized rat. The protocols presented here require minimal, if any, modification to recording hardware, take seconds to deploy, and yield high recovery rates in vitro (dye labeling: 89%, plasmid transfection: 49%) and in vivo (dye labeling: 66%, plasmid transfection: 27%). They offer improved simplicity compared to the juxtacellular labeling technique and for the first time offer genetic manipulation of functionally characterized neurons in previously inaccessible brain regions.

There can be little doubt that the two short historical tracts of Sallust (C. Sallustius Crispus), Bellum Catilinae (BC) and Bellum Iugurthinum (BJ), quickly attained their prominent place in the Roman educational curriculum because of admiration for language—most notably Sallust’s construction and placement of speeches, his use of rhetorical figures to highlight antitheses or urgency of action, his concision, and his striking use of archaic forms. Aulus Gellius in his Noctes Atticae defends ‘the elegance of Sallust’s speeches and his eagerness to invent or revive words’ (‘elegantia orationis Sallustii uerborumque fingendi et nouandi studium’ [IV.15.1]) against the attacks of some anonymous critics; in the Controversiae of the Elder Seneca we read that (for otherwise busy readers) ‘the speeches of Sallust are read as a sign of respect to his Histories’ (‘orationes Sallustii in honorem historiarum leguntur’ [exc. 3. pr. 8]); while Quintilian himself refers in the Institutio oratoriato...

Recycled water has increasingly been considered as a means to deal with water supply-demand imbalances, treated wastewater disposal and stormwater management. It contributes to the sustainability of urban water systems and the regeneration of the urban landscape. However, recycled water schemes are not mainstream, and are often confronted with numerous challenges. By considering the contextual and project related risks associated with a diverse selection of recycling projects in Australia, a range of business related risks have become apparent. There is now evidence that shifts in both the contextual landscape and the objectives of the various players involved can occur over the life of a project, resulting in risk and uncertainty often not foreseen. Many guidelines on recycling have been produced which focus mainly on technical risk. Drawing on the experiences of a diverse selection of case studies in Australia, this paper contemplates the additional risks and uncertainties, often not initially considered at the inception of a recycling scheme. This paper presents an overview and discussion of six key issues to consider when planning a recycling scheme.