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Clinical trials frequently include multiple end points that mature at different times. The initial report, typically based on the primary end point, may be published when key planned coprimary or secondary analyses are not yet available. Clinical trial updates provide an opportunity to disseminate additional results from studies, published in JCO or elsewhere, for which the primary end point has already been reported.PALOMA-2 demonstrated statistically and clinically significant improvement in progression-free survival with palbociclib plus letrozole versus placebo plus letrozole in estrogen receptor-positive/human epidermal growth factor receptor 2-negative (ER+/HER2-) advanced breast cancer (ABC). Here, we report results for the secondary end point overall survival (OS). Postmenopausal women (N = 666) with ER+/HER2- ABC without previous systemic therapy for ABC were randomly assigned 2:1 to palbociclib plus letrozole or placebo plus letrozole. After a median follow-up of 90.1 months, 405 deaths were observed and 155 patients were known to be alive. The median OS was 53.9 months (95% CI, 49.8 to 60.8) with palbociclib plus letrozole versus 51.2 months (95% CI, 43.7 to 58.9) with placebo plus letrozole (hazard ratio [HR], 0.96 [95% CI, 0.78 to 1.18]; stratified one-sided P = .34). An imbalance in the number of patients with unknown survival outcome between the treatment arms (13.3% v 21.2%, respectively) limited interpretation of OS results. With recovered survival data, the median OS was 53.8 (95% CI, 49.8 to 59.2) versus 49.8 months (95% CI, 42.3 to 56.4), respectively (HR, 0.92 [95% CI, 0.76 to 1.12]; one-sided P = .21). OS was not significantly improved with palbociclib plus letrozole compared with placebo plus letrozole.

Abstract Background Namaste Care is an intervention designed to improve the quality of life for people with advanced dementia by providing individualised stimulation and personalised activities in a group setting. Current evidence indicates there may be benefits from this intervention, but there is a need to explore the practical realities of its implementation, including potential barriers, enablers, and how it is delivered within the context of nursing care homes. Objective To systematically assess the factors involved in implementing Namaste Care for people with advanced dementia in nursing care homes. To provide pragmatic suggestions on how Namaste Care can be delivered in the context of nursing care homes. Design Systematically constructed review using framework synthesis. Data sources Comprehensive searches were conducted in Medline, CINAHL, and PsycINFO databases for studies published between 2018 and 2024. Search concepts included “Namaste Care,” “advanced dementia,” and related terms. Review methods Studies were included if they focused on the use of Namaste Care for people with advanced dementia in nursing care homes. Data extraction and quality assessment were performed by two independent researchers using standardised forms and critical appraisal tools. A framework synthesis of the results was conducted, which involves systematically combining qualitative and quantitative data within a structured analytical framework to identify overarching themes and insights. Findings Twenty-five studies met the inclusion criteria. Key themes identified were: (1) Frequency and duration of Namaste sessions. (2) Namaste Care environment and personalisation of care. (3) Staff engagement and training needs. (4) Involvement of family members and volunteers. Conclusions Implementing Namaste Care in nursing care homes presents various challenges but also significant opportunities for enhancing the quality of life for residents with advanced dementia. Addressing key themes such as the frequency and duration of sessions, the environment and personalisation of care, staff engagement and training needs, and the involvement of family members and volunteers is crucial. Specifically, providing tailored training programmes for staff, creating dedicated Namaste Care spaces, and encouraging active family and volunteer participation can facilitate effective integration. By incorporating these pragmatic recommendations, Namaste Care can be sustainably integrated into daily care routines, leading to improved resident well-being, reduced behavioural symptoms, and enhanced caregiver-resident interactions.

Recent decades have seen an exponential rise in the application of machine learning in geoscience. However, fundamental differences distinguish geoscience data from most other data types. Geoscience datasets are typically multi-dimensional, and contain 1D (drill holes), 2D (maps or cross-sections), and 3D volumetric and point data (models/voxels). Geoscience data quality is a product of the data's resolution and the precision of the methods used to acquire them. The dimensionality, resolution, and precision of each layer within a geoscience dataset translate into limitations to the spatiality, scale, and uncertainty of resulting interpretations. Historically, geoscience datasets were overlaid cartographically to incorporate subjective, experience-driven knowledge and variances in scale and resolution. These nuances and limitations that underpin the reliability of automated interpretation are well understood by geoscientists but are rarely appropriately transferred to data science. For true integration of geoscience data, such issues cannot be overlooked without consequence. To apply data analytics to complex geoscience data (e.g. hydrothermal mineral systems) effectively, methodologies that characterise the system quantitatively at a common scale, using collocated analyses, should be sought. This paper provides research and exploration insights from an innovative district-wide, scale-integrated geoscience data project, which analysed 1590 samples from 23 mineral deposits and prospects across the Cloncurry district, Queensland, Australia. Nine different analytical techniques were used, including density, magnetic susceptibility, remanent magnetisation, anisotropy of magnetic susceptibility, radiometrics, conductivity, automated mineralogy based on scanning electron microscopy (SEM), geochemistry, and short-wave infrared (SWIR) hyperspectral data with 561 columns of scale-integrated data (+2151 columns of SWIR data). All data were collected on 2.2 cm × 2.5 cm sample cylinders, a scale at which the confidence in the coupling of data from techniques can be high. These data are integrated by design to eliminate the need to downscale coarser measurements via assumptions, inferences, inversions, and interpolations. This scale-consistent approach is critical to the quantitative characterisation of mineral systems and has numerous applications in mineral exploration, such as linking alteration paragenesis with structural controls and petrophysical zonation. The Cloncurry METAL dataset is made freely available via the AuScope Data Repository: https://doi.org/10.60623/82trleue (Austin et al., 2024).

To address the issue of gender disparity in participation in the physics state matriculation exam, a novel school visit program was designed. The program was facilitated by undergraduate university students of physics and related courses who visited schools providing lower secondary education and delivered a single-session workshop including hands-on demonstrations of physics principles, presentations about famous female scientists, information on physics-related careers, and the importance of adopting a growth mindset. In this paper, we present a detailed description of the principles underlying the workshop's design and its final outline. Participants' responses to a pre-post questionnaire are analyzed to assess the immediate effects of the workshop, particularly as regards changes in their opinions about physics and students' intention to study it for their state matriculation exam. Female and male responses are analyzed separately to establish differences in the intervention's effect between the two genders. Results show an increase among female students with positive perceptions of their physics knowledge and familiarity with physics role models. Our attempt to boost confidence, enjoyment, and perceptions of the relevance of physics proved challenging but yielded some positive results. Strikingly, girls reported positive change in their ability to imagine themselves as physicists and their intention to study physics for their matriculation exam. The intervention was more successful among younger girls. Results obtained from boys were positive but to a lesser extent. The study demonstrates an encouraging and strong positive impact of a uniquely designed, single-session intervention, especially on adolescent girls, and contributes to research on the effectiveness of gender equality-oriented science outreach interventions.

School gardens must overcome a range of challenges to be successful but are often lauded for fostering hands-on education and real-world learning. This thematic literature review synthesises 22 journal articles and two book chapters, extending on previous reviews by amassing their themes into one singular reference point for scholars, while simultaneously exploring ways to overcome the challenges associated with school gardens. Findings highlight that academic enhancement, environmental connection, and enhanced wellbeing (both physical and emotional) are the main benefits of school gardens, while the main barriers are time, funding, maintenance, and curriculum integration. Strategies for overcoming the challenges of garden spaces in educational contexts are identified which will be valuable to scholars and others seeking to establish and maintain gardens in schools.

This study aimed to identify operating conditions and governance mechanisms that would help to facilitate trust in, and willingness to donate to, a hypothetical Australian national genomic repository for health research where commercial use of data is permitted. Semi-structured telephone interviews with members of the Australian public (N = 39) clarified perceived risks and preferred repository conditions. These insights were subsequently tested experimentally in a national sample (N = 1,117). Contrary to what was expected based on the interviews, when certain baseline operating conditions were included (e.g., public management, data access committee to ensure data is restricted to human health research), none of the additional tested governance mechanisms (e.g., financial penalties for misuse) increased trust or donation willingness. Thus, providing suitable baseline conditions are in place, a feasible Australian genomic repository may not require external oversight or new legislation to optimize recruitment, even if commercial users are anticipated.

AbstractArts-in-nature practice has been shown to have positive impacts on children’s mental health and wellbeing; however, introducing new innovations in schools can be challenging and requires involvement of staff in the process. The ‘Branching Out’ project explored how arts-in-nature practice can be scaled up to achieve greater reach in primary schools by mobilising community volunteers. We implemented an exploratory, multi-level mixed methods approach, including a modified e-Delphi study which was used to achieve consensus around a new delivery model of arts-in-nature practice in primary schools. Whilst a pilot study tested the implementation of the proposed model in one region, the e-Delphi study explored how the proposed Branching Out model, including the use of volunteers and various options for delivery, would be perceived more widely by primary school staff across different contexts. The survey incorporated implementation measures designed to determine the acceptability, appropriateness, and feasibility of the proposed model. Completion of two rounds of the e-Delphi study captured the views of 42 primary school staff members in total. The findings confirmed the acceptability of the arts-in-nature practice and the use of volunteers, suggested appropriate staff champions and groups of children who would benefit, and determined the preferred options for delivery in terms of feasibility. Overall, consensus was reached regarding the proposed model of arts-in-nature practice in primary schools with high levels of agreement regarding its acceptability, appropriateness, and feasibility. The e-Delphi study provided valuable perspectives of primary school staff that led to the refinement of the Branching Out model for mobilising volunteers to deliver arts-in-nature practice to promote children’s mental health. Delphi studies have the potential to enable expert input into policy and practice and provide an opportunity for teachers to have a voice in the delivery and development of school-based interventions.

Background Nutritional intake and sleep, play an important role for recovery and performance in elite sport but little work has been undertaken in archery. The present study aimed to assess energy intake (EI), hydration status, and sleep parameters in world-class male archers over the course of a four-day competition.Methods Results, Conclusions Six male, elite-standard archers participated in the study and measurements of hydration status, EI, competition load, and sleep were recorded throughout each day of competition.Results Daily energy, carbohydrate, and protein intake ranged between 2,563 and 3,986 kcal, 4 and 7.1 g/kg BM, 2.2 and 3.6 g/kg BM per day, respectively. Thus, archers practiced elements of periodized nutrition such that energy and carbohydrate intake was greater on the high-volume competition days (i.e. days 1 and 3; more numbers of arrows, longer duration, and walking distance) in comparison to low-volume days (days 2 and 4) over the tournament (all p > 0.01). Additionally, urine specific gravity was higher after waking, compared to pre- and post-competition, and before bed (all p

Background: People with intellectual disabilities are more likely to experience sleep problems, which can affect quality of life, physical health, mental health and well-being. Methods: An integrative literature review was conducted to investigate what is known about behavioural sleep disturbances in people with an intellectual disability. The search used the following databases: Scopus, PsycInfo and Cinahl, to find papers published since 2015. Results: Within intellectual disability research, sleep appears as a common issue due to its high prevalence, negative relationships with an individual's physical and mental health, their quality of life, and impact of sleep problems on family or carers. The growing evidence base appears to support the use of behavioural, lifestyle and pharmacological interventions to improve sleep in people with an intellectual disability. Conclusion: A wide array of literature provides evidence that people with intellectual disabilities are affected by and need support with their sleep.

Given the importance of their roles in society, the education of professionals is a central concern for providers and recipients of public services. In this article we consider the contribution of research on professional learning to current debate on the form and content of professional education. This mapping review asked, 'What does the research literature tell us about the characteristics of research into professional learning across professions?' We identified and synthesised primary research involving post-qualification professionals' professional learning. We searched seven databases using terms such as 'professional learning', 'professional development' and 'continuing education' from 2000 to date. We carefully screened articles against agreed criteria, extracted data and mapped the findings. After removing duplicates, 20,616 records remained. After full text screening, 356 articles were included: 266 from teaching (75%), 77 from healthcare (22%) and 13 from another profession or cross-professional (4%). Three included papers that spanned professions. Only 6% of articles studied the institution as the unit of analysis (rather than the individual). Around half of the included papers (49%) included an intervention. Most teaching interventions were proximal to the workplace whereas most healthcare/other studies were distal to the workplace, perhaps reflecting stage of development of the research field. Our study synthesised a heterogeneous literature to indicate the types or research that are needed to progress the debate. The clear differences in 'style' between professions suggested that collaboration could provide mutual benefit. Future research requires studies that report research in ways that lend themselves to evidence synthesis or replication.

Abstract Background Ethnic differences influence end-of-life health behaviours and use of palliative care services. Use of formal Advance care planning is not common in minority ethnic heritage communities. Older adults expect and trust their children to be their decision makers at the end of life. The study aim was to construct a theory of the dynamics that underpin end-of-life conversations within families of African and Caribbean heritage. This is a voice not well represented in the current debate on improving end-of-life outcomes. Methods Using Charmaz’s constructivist grounded theory approach, a purposive sample of elders, adult-children, and grandchildren of African and Caribbean Heritage were recruited. In-person and online focus groups were conducted and analysed using an inductive, reflexive comparative analysis process. Initial and axial coding facilitated the creation of categories, these categories were abstracted to constructs and used in theory construction. Results Elders (n = 4), adult-children (n = 14), and adult grandchildren (n = 3) took part in 5 focus groups. A grounded theory of living and dying between cultural traditions in African and Caribbean heritage families was created. The constructs are (a) Preparing for death but not for dying (b) Complexity in traditions crosses oceans (c) Living and dying between cultures and traditions (d) There is culture, gender and there is personality (e) Watching the death of another prompts conversations. (f) An experience of Hysteresis. Discussion African and Caribbean cultures celebrate preparation for after-death processes resulting in early exposure to and opportunities for discussion of these processes. Migration results in reforming of people’s habitus/ world views shaped by a mixing of cultures. Being in different geographical places impacts generational learning-by-watching of the dying process and related decision making. Conclusions Recognising the impact of migration on the roles of different family members and the exposure of those family members to previous dying experiences is important. This can provide a more empathetic and insightful approach to partnership working between health care professionals and patients and families of minority ethic heritage facing serious illness. A public health approach focusing on enabling adult-children to have better end of life conversations with their parents can inform the development of culturally competent palliative care.

Safer Community provides a centralised reporting service for La Trobe University students and staff to report “concerning, threatening, inappropriate or uncomfortable behaviour” they may have witnessed or experienced at the university. Safer Community utilises a systems-based approach to explore all areas of an individual’s university experience to mitigate risk, increase psychological and physical safety, and decrease unwelcome behaviour on campus. Whilst navigating Victorian state statutes and governing legislation, Safer Community applies risk management and de-escalation strategies to promote the safety of all on campus. This includes targeted education and resources directed to high-risk cohorts, such as students living in on-campus accommodation and international students. It also involves supporting staff to manage problematic behaviours, both online and in the classroom, and empowering them to understand, recognise, and respond to distressing behaviours. When reporting to Safer Community, individuals share their experiences in a trauma-informed and confidential environment where the team collaboratively mitigates risk, conducts safety planning, and empowers students to participate in the response. Respondents to the concerns are offered natural justice and encouraged to engage with the investigative process. Individuals with complex psychosocial needs are offered a multidisciplinary approach, with referrals made within the Health, Wellbeing and Inclusion division or to external stakeholders such as the police. This proactive approach to early prevention is informed by data collected by Safer Community to allow for a university-wide response. This paper describes the significance of adopting a circular, holistic, multi-divisional, collaborative approach aimed at fostering the wellbeing of the university community, encompassing both physical and psychological safety. This paper also explores effective strategies to achieve this through the presentation of a case example and service model. --- A multi-divisional collaborative approach to student safety and behavioural management: Safer community by Talia Vescio, Courtney Walshe, Aleece Brady, & Rachel Blance-Palmer is licensed under CC BY 4.0

Background The use of locum doctors in the National Health Service is widely believed to have increased, and there have been widespread and sustained concerns among policy-makers, healthcare providers, professional associations and professional regulators about the quality/safety, cost and effective use of locum doctors. Objectives To provide evidence on the extent, quality and safety of medical locum practice and the implications of medical locum working for health service organisation and delivery in primary and secondary care in the English National Health Service, to support policy and practice. Design Four interlinked work packages involving surveys of National Health Service trusts and of general practices in England; semistructured interviews and focus groups across 11 healthcare organisations in England; analysis of existing routine data sets on the medical workforce in primary care and in National Health Service trusts in England from National Health Service Digital and National Health Service Improvement; and analysis of data from the Clinical Practice Research Datalink in primary care and of electronic patient record data from two National Health Service hospitals in secondary care. Results In primary care, about 6% of general practice medical consultations were undertaken by locums in 2010 and this had risen slightly to about 7.1% in 2021. In National Health Service trusts (mostly secondary care and mental health), about 4.4% of medical staff full-time equivalent was provided by locum doctors. But those overall national rates of locum use hide a great deal of variation. In primary care, we found the National Health Service Digital workforce returns showed the rate of locum use by Clinical Commissioning Group varied from 1% to almost 31%. Among National Health Service trusts, the reported rate of locum use varied from < 1% to almost 16%. We found that there was poor awareness of and adherence to national guidance on locum working arrangements produced by National Health Service England. Our research showed that locum working can have adverse consequences for the quality and safety of care, but that such consequences were probably more likely to result from the organisational setting and the working arrangements than they were from the locum doctors themselves and their competence, clinical practice or behaviours. Limitations Our research was hampered in some respects by the COVID pandemic which both resulted in some delays and other challenges. Our efforts to use electronic patient record data in secondary care to explore locum doctor working were stymied by the problems of data access and quality. Conclusions Locum doctors are a key component of the medical workforce in the National Health Service, and provide necessary flexibility and additional capacity for healthcare organisations and services. We found that the extent of reliance on locum doctors varied considerably, but that an over-reliance on locums for service provision was undesirable. Some differences in practice and performance between locum and permanent doctors were found, but these seemed often to arise from organisational characteristics. We found that patients were more concerned with the clinical expertise and skills of the doctor they saw than whether they were a locum or not. Organisational arrangements for locum working could be improved in many respects. Funding This award was funded by the National Institute for Health and Care Research (NIHR) Health and Social Care Delivery Research programme (NIHR award ref: NIHR128349) and is published in full in Health and Social Care Delivery Research; Vol. 12, No. 37. See the NIHR Funding and Awards website for further award information. Plain language summary Doctors who work in the National Health Service in temporary positions are generally known as ‘locum doctors’. They may be working for a hospital or a general practice just for a single shift or a few days, or may work there for several weeks or even months. Often, locum doctors are used to cover staff sickness or absence, or to provide for longer-term cover for staff vacancies. While some doctors just work as locums, others will have a permanent job but do some extra shifts as a locum as well. The number of doctors working as locums and the costs of this to the National Health Service have caused some concerns nationally. It has also been suggested that locum doctors may not provide as good a quality of care as permanent doctors. So we set out to find out more, through two large surveys of National Health Service trusts and general practices in England; interviews and focus group discussions across 11 National Health Service organisations; and by analysing data that had already been collected about the National Health Service workforce and about clinical care. We found that about 6% of medical care in general practices is provided by locum doctors, and about 4.4% of the medical workforce in National Health Service trusts are locums, but this varies a great deal and can be much higher in some organisations. The high and continuing use of locums in some services or areas should be a cause for concern. We found locum working could cause problems with the quality and safety of care, but that this was often because of the way organisations used locums without sufficient support. When concerns about the practice of a locum doctor arose, they were often not dealt with properly. We found that patients were generally more interested in being able to see a good doctor promptly than with whether or not they were a locum. This research has important implications for how the National Health Service uses locum doctors in future, and our recommendations are designed to help the National Health Service use locums safely and appropriately. Scientific summary Background The numbers of doctors working as locums in the NHS in England are thought to have grown substantially over the last decade, although there have been surprisingly little empirical data published on the NHS medical workforce to substantiate this trend. There have been concerns about the costs of locum working, and about the quality and safety of locum doctors’ practice. Our earlier qualitative research on the experiences of and attitudes towards locum doctors, involving interviews with locum doctors, locum agency staff and representatives of healthcare organisations who use locums, showed that locums were often perceived to be inferior to permanently employed doctors in terms of quality, competency and safety. Our findings suggested that the treatment and use of locums could have important potential negative implications for team functioning and patient safety. Objectives The overall aim of our research was to provide evidence on the extent, quality and safety of medical locum practice and the implications of medical locum working for health service organisation and delivery in primary and secondary care in the English NHS. Our three main research questions were: What is the nature, scale and scope of locum doctor working in the NHS in England? Why are locum doctors needed, what kinds of work do they undertake and how is locum working organised? How may locum doctor working arrangements affect patient safety and the quality of care? What are the mechanisms or factors which may lead to variations in safety/quality between locum and permanent doctors? What strategies or systems do organisations use to assure and improve safety and quality in locum practice? How do locum doctors themselves seek to assure and improve the quality and safety of their practice? How do the clinical practice and performance of locum and permanent doctors compare? What differences in practice and performance exist and what consequences may they have for patient safety and quality of care? Methods This was a mixed-methods study, consisting of four main work packages: Work package 1 (addressing research questions 1 and 2) involved a survey of medical directors/medical staffing leads in NHS trusts in England and a survey of general practices in England. The two surveys examined the nature, scale and scope of locum doctor working, why locums were needed, what work they undertook and how their work was organised, and sought views on the performance of locum doctors and a range of issues concerning governance and oversight of practice. Work package 2 (addressing research questions 1, 2 and 3) involved a combination of semistructured interviews and focus groups conducted across 11 healthcare organisations in both primary and secondary care in the NHS in England. We developed and used three interview schedules (for interviews with locum doctors; people who worked with locums in healthcare organisations; and patients and members of the public). Work package 3 (addressing research question 1) involved the collection and analysis of existing routine quantitative data sets on locum doctors working in the NHS in England. We used quarterly workforce returns from all general practices in England to NHS Digital to examine locum working in primary care. We used weekly locum usage returns from all NHS trusts in England to NHS Improvement to examine locum working in secondary and community services. Work package 4 (addressing research question 3) involved the collection and analysis of existing, routine quantitative data sets on doctors’ practice/performance which identify whether doctors are locum or permanent staff and so allow us to compare the practice/performance of locums and permanent doctors. We used the Clinical Practice Research Datalink (CPRD) linked to Hospital Episode Statistics to examine these issues in primary care. We sought to undertake a similar analysis in secondary care, using electronic patient record (EPR) data from two NHS hospitals: Salford Royal Hospital and the Bradford Royal Infirmary. However, we encountered a number of problems both in securing data extraction from the two hospitals' EPR systems and in identifying locum and permanent staff activity in the data sets, which severely limited our ability to examine these issues in secondary care. Results We report our results from the four work packages grouped around our three main research questions. The nature, scale and scope of locum doctor working in the NHS in England In primary care, we found from our analysis of NHS Digital workforce returns that just over 3% of medical staffing was provided by locums and that it had not changed much over the time period 2017–20. However, our analysis of CPRD data for the longer time period of 2010–21 suggested that about 6% of general practice medical consultations were undertaken by locums in 2010 and that this had risen slightly to about 7.1% in 2021. We think there are two main explanations for this discrepancy. First, locums generally only undertake consultations while permanent general practitioners do a lot of other non-consultation clinical and administrative tasks – the NHS Digital workforce returns measure staff numbers in full-time equivalent (FTE), while the CPRD data measure numbers of consultations. Second, the NHS Digital workforce returns from general practices may under-report the numbers of locum doctors, and there have been concerns about the quality and completeness of the data. But both data sources suggest a relatively low – and stable – rate of locum use in primary care. In NHS trusts (mostly secondary care and mental health), our analysis of NHS Improvement returns from NHS trusts indicated that about 4.4% of medical staff FTE was provided by locum doctors. With a much shorter time series from 2019 to 2021, it is rather more difficult to draw any conclusions about the secular trend, although in that time period the rate of locum use was fairly stable – dropping as expected in the first phase of the COVID pandemic in early to mid-2020, and then recovering. We found NHS trusts making more use of bank (rather than agency) locums over the time period, and some an increase in the reported numbers of unfilled shifts which would indicate increasing unmet need. However, those overall national rates of locum use hide a great deal of variation between organisations which it is important to consider. In primary care, we found the NHS Digital workforce returns showed the rate of locum use by Clinical Commissioning Group (CCG) varied from 1% to almost 31%. Among NHS trusts, the reported rate of locum use varied from < 1% to almost 16%. Our qualitative work suggested that there were some particularly problematic specialties in which workforce shortages were acute, such as psychiatry. Our multivariate quantitative analyses suggested that there was some variation by region/geography which might reflect workforce capacity or shortage in some parts of England. But they also showed that both smaller general practices and smaller NHS trusts made more use of locums, which might plausibly suggest that larger organisations are more able to cope with workforce gaps without having to resort to locums. In both primary care and NHS trusts, there was an association between Care Quality Commission (CQC) ratings and locum use, with organisations with lower CQC ratings making more use of locums. Our surveys of general practices and of NHS trusts showed both some similarities in their reasons for needing locums and ways of using them, as well as some notable differences. Both gave as common reasons for using locums the need to cover either planned or unplanned absences or gaps in staffing – mainly leave and sickness absence – and both reported using them to provide additional workforce capacity when it was needed. But NHS trusts were much more likely to report needing locums because of difficulties recruiting doctors. We also found some interesting differences in where general practices and NHS trusts sourced locum doctors from. Practices said they made much less use of locum agencies and tended to use trusted locums who were familiar to the practice, while NHS trusts made much more use of locum agencies and staff banks, and within that there was a lot of variation in that some NHS trusts made much more use of locum agencies rather than staff banks. Overall, NHS trusts sourced about a third of their locums from staff banks according to our analysis of NHS Improvement returns. Our qualitative research found that respondents thought an over-reliance on locums (however that might be defined) could be a ‘red flag’. Respondents suggested that the consistent use of high levels of locums was both a concern in itself, because of the implications for quality and safety (which we turn to later in this discussion) and a potential indicator of wider organisational problems in the general practice or NHS trust. How locum doctor working arrangements affect patient safety and the quality of care Our surveys of NHS trusts and general practices suggested that awareness of the national NHS England guidance on locum working was very mixed – and particularly poor among respondents from general practice. Those who were aware of it in NHS trusts generally viewed it quite favourably, but some commented that it set out an ideal model which was hard to follow in practice. Among general practices, it was often seen as less relevant to their needs and to the setting of an individual general practice. Self-reported compliance with the guidance was generally high in areas like pre-employment checks and induction, but much less good in areas like end-of-placement reporting and supporting the locum with appraisal and revalidation. Our qualitative research confirmed and extended the survey findings. For example, we found that giving locums a proper induction was viewed by locums as really important to their subsequent ability to perform in their role, and that issues not covered properly in their induction hampered them and could add to the workload of other members of the clinical team. But in our qualitative interviews with respondents who work with locums, we often found an unrealistic expectation that locums should come into the organisation and be able to start work immediately – to ‘hit the ground running’ – and that they should devote all their time to clinical work as that was what they were being paid – and paid well – to do. Locums themselves reported taking steps – like working in fewer organisations and avoiding some organisations, working at a lower level/grade and limiting their scope of practice – to deal with the problems of being inadequately inducted and supported. This was part of a wider negative and stigmatising narrative which often cast locums as less professional, less committed, less competent, less reliable and more financially motivated than permanent medical staff. By ‘othering’ locum doctors in this way, it was easier both to justify treating them differently (and less well) than other staff and to explain problems or difficulties with quality and safety as being attributable to locums and locum working. In short, it was easy to blame locums when things went wrong, and they were often either not there to defend themselves or not able to do so. The position of locum doctors was, by definition, precarious – they could be removed or have a placement ended easily. We would contrast this with the attitudes of patients to locum doctors, which were generally more accepting of locum working, and which valued access to seeing a doctor in a timely fashion over whether the doctor was a locum or not. Patients thought that traditional notions of relational continuity were not consistent with their own experiences of care, and some valued the fresh perspectives on their condition which came from seeing a different doctor. It is clear from our research that locum working can have adverse consequences for the quality and safety of care, but that such consequences were probably more likely to result from the organisational setting and the working arrangements than they were from the locum doctors themselves and their competence, clinical practice or behaviours. It is also clear that there is great variation in the characteristics both of organisations which use locums and of locums themselves. One of the concerning findings from our research was that when problems related to locum doctors’ practice arose, they were not dealt with well. How the clinical practice and performance of locum and permanent doctors compare From our surveys of NHS trusts and general practices, respondents generally reported that on a range of areas of clinical practice, they thought locum doctors performed about the same as or worse than permanent doctors. It is notable that the areas where they tended to think locums performed worse were things like continuity of care, and adherence to guidelines and protocols, which are, as we have already discussed, more influenced by the organisational setting and arrangements like induction than by the locum doctor’s own clinical expertise and fitness to practice. We were able to explore differences in practice in primary care directly through our quantitative analysis of the CPRD data set, and this provided some very interesting but quite mixed findings which should be interpreted with great caution. For example, our multivariate analysis found that patients who saw a locum doctor were less likely to make a return visit to the general practice within 7 days than those who had seen a permanent doctor. We found that locum doctors and permanent doctors had some differences in prescribing behaviour, but they were mixed (locums prescribed antibiotics and opioids more frequently but hypnotics less frequently than permanent doctors). Locum doctors were less likely to make referrals and to order tests. In terms of hospital events following a consultation with a locum, patients were more likely to visit accident and emergency within 7 days but there was no difference for hospital admission. Conclusions Locum doctors are a key component of the medical workforce in the NHS and provide necessary flexibility and additional capacity for healthcare organisations and services. We found that the extent of reliance on locum doctors varied considerably, but that an over-reliance on locums for service provision was undesirable. Some differences in practice and performance between locum and permanent doctors were found, but these seemed often to arise from organisational characteristics. We found patients were more concerned with the clinical expertise and skills of the doctor they saw than whether they were a locum or not. Organisational arrangements for locum working could be improved in many respects, and there were particular problems with the way any concerns about locum doctors were managed. Funding This award was funded by the National Institute for Health and Care Research (NIHR) Health and Social Care Delivery Research programme (NIHR award ref: NIHR128349) and is published in full in Health and Social Care Delivery Research; Vol. 12, No. 37. See the NIHR Funding and Awards website for further award information.

Introduction: Invasive lobular carcinoma (ILC) accounts for 5–15% of invasive breast cancers. Typical ILC is oestrogen receptor (ER) positive and human epidermal growth factor receptor 2 (HER2) negative. Atypical biomarker profiles (ER- and HER2+, ER+ and HER2+ or triple negative) appear to differ from typical ILCs. This study compared subtypes of ILC in terms of clinical and pathological parameters, and response to neoadjuvant chemotherapy (NACT) according to biomarker profile. Methods: All patients with ILC treated in a single centre from January 2005 to December 2020 were identified from a prospectively maintained database. Clinicopathologic and outcome data was collected and analysed according to tumour biomarker profile. Results: A total of 582 patients with ILC were treated. Typical ILC was observed in 89.2% (n = 519) and atypical in 10.8% (n = 63). Atypical ILCs were of a higher grade (35% grade 3 vs 9.6% grade 3, p

ABSTRACT Introduction There have been some concerns about the impact of temporary doctors, otherwise known as locums, on patient safety and the quality of care. Despite these concerns, research has paid little attention to the implications of locum working on patient experience. Methods A qualitative semi‐structured interview study was conducted with 130 participants including locums, people working with locums and patients with experience of being seen or treated by locums. Analysis was conducted using a reflexive thematic approach and abductive analysis to position themes against wider knowledge. Results Three main themes were constructed through analysis: (1) Awareness and disclosure; patients were not always aware if their doctor was a locum, and there was some debate about whether patients had a right to know, particularly if locum working presented quality and safety risks. (2) Continuity and accessibility of care; access was regarded as priority for acute conditions, but for long‐term or serious conditions, patients preferred to see a permanent doctor who knew their history, although it was acknowledged that locums could provide fresh perspectives. (3) Communication and practice; locums and patients described how consultations were approached differently when doctors worked as locums. Patients evaluated their interactions based on how safe they felt with practitioners. Conclusion Patients reported that they were unlikely to have continuity of care with any doctors delivering care, regardless of their contractual status. Locums sometimes provided new perspectives on care which could be beneficial for patient outcomes, but for patients with long‐term, complex or serious conditions continuity of care was important, and these patients may avoid or delay seeking care when locums are the only available option. Patient or Public Contribution Patients and carers were involved in our study from inception to dissemination. Our Patient and Public Involvement (PPI) forum was involved throughout project design and planning and gave us feedback and guidance on research materials and outputs (e.g., study protocol, participant information sheets, survey tools, interview schedules, emerging findings). Our PPI forum co‐produced our patient interview schedule, two members of our PPI forum led the patient focus groups and all were involved in analysis of patient interviews. Our PPI Chair was involved in the preparation of this manuscript.

BackgroundPrevious analyses from the PALOMA-2 and PALOMA-3 studies showed that palbociclib (PAL) plus endocrine therapy (ET) prolongs time to first subsequent chemotherapy (TTC) versus placebo (PBO) plus ET in the overall population of patients with hormone receptor‒positive/human epidermal growth factor receptor 2‒negative (HR+/HER2-) advanced breast cancer (ABC). Here, we evaluated TTC in relevant patient subgroups.MethodsThese post hoc analyses evaluated TTC by subgroup using data from 2 randomized, phase 3 studies of women with HR+/HER2- ABC. In PALOMA-2, postmenopausal patients previously untreated for ABC were randomized 2:1 to receive PAL (125 mg/day, 3/1-week schedule) plus letrozole (LET; 2.5 mg/day; n = 444) or PBO plus LET (n = 222). In PALOMA-3, premenopausal or postmenopausal patients whose disease had progressed after prior ET were randomized 2:1 to receive PAL (125 mg/day, 3/1-week schedule) plus fulvestrant (FUL; 500 mg; n = 347) or PBO plus FUL (n = 174).ResultsFirst subsequent chemotherapy was received by 35.5% and 56.2% in PALOMA-2 and PALOMA-3 after progression on palbociclib plus ET or placebo plus ET. Across all subgroups analyzed, the median progression-free survival (PFS) was longer in the PAL plus ET arm than the PBO plus ET arm. TTC was longer with PAL plus ET versus PBO plus ET across the same patient subgroups in both studies.ConclusionsAcross all subgroups, PAL plus ET versus PBO plus ET had longer median PFS and resulted in prolonged TTC in both the PALOMA-2 and PALOMA-3 studies. Pfizer Inc (NCT01740427, NCT01942135).

Background: This study, using real-world data, assesses the impact of RS testing on treatment pathways and the associated economic consequences of such testing. This paper pertains to lobular breast cancer. Methods: A retrospective, observational study was undertaken between 2011 and 2019 on a cross-section of hormone receptor-positive (HR+), HER2-negative, lymph node-negative, early-stage breast cancer patients. All patients had ILC and had RS testing in Ireland. The patient population is representative of the national population. Patients were classified as low (RS ≤ 25) or high (RS > 25) risk. Patients aged ≤50 were stratified as low (RS 0–15), intermediate (RS 16–25), or high risk (RS > 25). Results: A total of 168 patients were included, most of whom had grade 2 (G2) tumors (n = 154, 92%). Overall, 155 patients (92.3%) had low RS (≤25), 12 (7.1%) had high RS (>25), and 1 (0.6%) had unknown RS status. In 29 (17.5%) patients aged ≤50 at diagnosis, RS was ≤15 in 16 (55%), 16–20 in 6 (21%), 21–25 in 5 (17%), >25 in 1 (3.5%), and unknown in 1 (3.5%). Post RS testing, 126 patients (78%) had a change in chemotherapy recommendation; all to hormone therapy. In total, only 35 patients (22%) received chemotherapy. RS testing achieved a 75% reduction in chemotherapy use, resulting in savings of €921,543.84 in treatment costs, and net savings of €387,283.84. Conclusions: The use of this test resulted in a 75% reduction in chemotherapy and a significant cost savings in our publicly funded health system.

This article provides findings from a small-scale project undertaken to understand the student experience of the lesbian, gay, bisexual, transgender, and queer plus (LGBTQ+) student community in a large post-92 university in England. Focus groups were conducted with students that explored areas of student life, including support, the campus environment, and belonging. A social constructivist theoretical perspective underpins the article. Students develop common knowledge via social processes that are powerfully influenced by cultural factors that are constantly in a state of flux. The article also rejects essentialist delineations of LGBTQ+ gender and sexuality and subscribes instead to a Butlerian framework of identity where behaviours associated with gender and sexuality are instruments of regulatory regimes. Even within a university culture that is inclusive and welcoming, opportunities were not always provided for LGBTQ+ students to speak about their personal lives and identities authentically, and university classrooms did not always feel like safe places for students. Whilst staff were generally helpful and supportive to their LGBTQ+ students, many lacked the knowledge and skills to confidently meet the needs of these students, particularly those identifying as trans and non-binary. The recommendations include calls for universities to commit to high-quality mandatory training for staff so that trans and non-binary students in particular are supported by staff appropriately equipped to support their needs.

Standardisation has become imperative to retaining order and development in modern society. The simplest actions, such as train timings and the width of the railroad, would be very difficult to achieve without Standardisation. Standardisation also solves problems, such as the use of mobile devices, which requires travel abroad when out of range. We perform a large-scale quantitative analysis for papers dealing with (1) standards and (2) Information and communications technology (ICT) data in three important databases, namely Web of Science, IEEE Explore, and ACM digital library, in this paper. These three databases presented 216 articles that were divided into five categories: standard-related review and survey studies, information management across hardware and software standards, energy management standards, machine learning model classification performance, privacy-aware software system standards, and health information and communications technology standards. This paper discusses how Standardisation facilitates the planning of the entire research and innovation process by encouraging discussions regarding the specific outputs the research aims to achieve. The paper further illustrates that references related to standardisation within the call topics act as a crucial motivating factor in the decision to adopt standardisation. In conclusion, our contribution provides a better understanding of standards in peer-reviewed publications and an essential foundation for future research. In addition, we demonstrate that standards play an important role in innovation.

IntroductionCoaches, practitioners, and leadership in amateur female sport must navigate many obstacles in the pursuit of athlete availability and optimal performance. The present study aims to evaluate opportunities and challenges to both injury prevention and management in amateur female sport, as experienced by mixed-gender coaches, allied healthcare professionals, and general practitioners.MethodsSemi-structured virtual interviews of coaches, allied healthcare professionals, and general practitioners (N = 25), recruited via convenience snowball sample. Data transcribed verbatim with reflexive thematic analysis through a critical realism framework.ResultsFemale-specific issues, education, and resource capital were challenges to the implementation of injury prevention and management in amateur female sport, thus negatively impacting on performance, prevention, and rehabilitation. Opportunities for improved care for female athletes were developing communication and relationships, outsourcing responsibility, and providing greater education, in response to desires for such, and lastly exposure to elite sport and national governing bodies’ protocols.DiscussionIn amateur female sport, developing communication pathways and relationships, along with upskilling coaches, can help better support female athletes, coaches, and healthcare professionals. Leaders and stakeholders must advocate for and support greater education, resourcing, and an understanding of female-specific issues in amateur female sport. It is intended that these findings will provide evidence and opportunities for discourse between stakeholders in amateur female sport to improve standard of supports for female athletes, coaches, and healthcare professionals. These findings may also help practitioners better exploit opportunities and circumvent challenges to improve the welfare and performance of amateur female athletes.

Social isolation causes profound changes in social behaviour in a variety of species. However, the genetic and molecular mechanisms modulating behavioural responses to social isolation and social recovery remain to be elucidated. Here, we quantified the behavioural response of vinegar flies to social isolation using two distinct protocols (social space preference and sociability, the spontaneous tendencies to form groups). We found that social isolation increased social space and reduced sociability. These effects of social isolation were reversible and could be reduced after 3 days of group housing. Flies with a loss of function of neuroligin3 (orthologue of autism-related neuroligin genes) with known increased social space in a socially enriched environment were still able to recover from social isolation. We also show that dopamine (DA) is needed for a response to social isolation and recovery in males but not in females. Furthermore, only in males, DA levels are reduced after isolation and are not recovered after group housing. Finally, in socially enriched flies mutant for neuroligin3, DA levels are reduced in males, but not in females. We propose a model to explain how DA and neuroligin3 are involved in the behavioural response to social isolation and its recovery in a dynamic and sex-specific manner.