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The Cassini Titan Radar Mapper obtained Synthetic Aperture Radar images of Titan's surface during four fly-bys during the mission's first year. These images show that Titan's surface is very complex geologically, showing evidence of major planetary geologic processes, including cryovolcanism. This paper discusses the variety of cryovolcanic features identified from SAR images, their possible origin, and their geologic context. The features which we identify as cryovolcanic in origin include a large (180 km diameter) volcanic construct (dome or shield), several extensive flows, and three calderas which appear to be the source of flows. The composition of the cryomagma on Titan is still unknown, but constraints on rheological properties can be estimated using flow thickness. Rheological properties of one flow were estimated and appear inconsistent with ammonia-water slurries, and possibly more consistent with ammonia-water-methanol slurries. The extent of cryovolcanism on Titan is still not known, as only a small fraction of the surface has been imaged at sufficient resolution. Energetic considerations suggest that cryovolcanism may have been a dominant process in the resurfacing of Titan. Keywords: Titan; Volcanism; Satellites of Saturn

Author(s): E. R. Stofan (corresponding author) [1, 2]; C. Elachi [3]; J. I. Lunine [4]; R. D. Lorenz [5]; B. Stiles [3]; K. L. Mitchell [3]; S. Ostro [3]; L. [...]

The first two swaths collected by Cassini's Titan Radar Mapper were obtained in October of 2004 (Ta) and February of 2005 (T3). The Ta swath provides evidence for cryovolcanic processes, the possible occurrence of fluvial channels and lakes, and some tectonic activity. The T3 swath has extensive areas of dunes and two large impact craters. We interpret the brightness variations in much of the swaths to result from roughness variations caused by fracturing and erosion of Titan's icy surface, with additional contributions from a combination of volume scattering and compositional variations. Despite the small amount of Titan mapped to date, the significant differences between the terrains of the two swaths suggest that Titan is geologically complex. The overall scarcity of impact craters provides evidence that the surface imaged to date is relatively young, with resurfacing by cryovolcanism, fluvial erosion, aeolian erosion, and likely atmospheric deposition of materials. Future radar swaths will help to further define the nature of and extent to which internal and external processes have shaped Titan's surface. Keywords: Titan; Geological processes; Saturn, satellites; Satellites, surfaces

Author(s): C. Elachi [1]; S. Wall (corresponding author) [1]; M. Janssen [1]; E. Stofan [2]; R. Lopes [1]; R. Kirk [3]; R. Lorenz [4]; J. Lunine [4, 5]; F. Paganelli [...]

The Cassini Titan Radar Mapper imaged about 1% of Titan's surface at a resolution of ~0.5 kilometer, and larger areas of the globe in lower resolution modes. The images reveal a complex surface, with areas of low relief and a variety of geologic features suggestive of dome-like volcanic constructs, flows, and sinuous channels. The surface appears to be young, with few impact craters. Scattering and dielectric properties are consistent with porous ice or organics. Dark patches in the radar images show high brightness temperatures and high emissivity and are consistent with frozen hydrocarbons., Saturn's largest satellite, Titan, is the only moon and one of only four solid bodies in the solar system to host a thick atmosphere, uniquely distinguished by nitrogen and methane [...]

Author(s): C. Elachi; S. Wall; M. Janssen; E. Stofan; R. Lopes; R. Kirk; R. Lorenz; J. Lunine; F. Paganelli; L. Soderblom; C. Wood; L. Wye; H. Zebker; Y. Anderson; S. [...]

Cassini's Titan Radar Mapper imaged the surface of Saturn's moon Titan on its February 2005 fly-by (denoted T3), collecting high-resolution synthetic-aperture radar and larger-scale radiometry and scatterometry data. These data provide the first definitive identification of impact craters on the surface of Titan, networks of fluvial channels and surficial dark streaks that may be longitudinal dunes. Here we describe this great diversity of landforms. We conclude that much of the surface thus far imaged by radar of the haze-shrouded Titan is very young, with persistent geologic activity. [ABSTRACT FROM AUTHOR]

BACKGROUND: Any intervention to reduce the inappropriate use of antibiotics for infections in children has the potential to reduce the selective pressure on antimicrobial resistance and minimise the medicalisation of self-limiting illness. Little is known about whether homeopathic products might be used by some families as an alternative to antibiotics or the characteristics of such families. We used the Avon Longitudinal Study of Parents and Children (ALSPAC) observational dataset to explore the hypothesis that the use of homeopathic products is associated with reduced antibiotic use in pre-school children and to identify characteristics of the families of pre-school children given homeopathic products. METHODS: Questionnaires data were completed by the parents of 9723 children while aged between 3-4.5 years in Bristol UK. Univariable and multivariable analyses were used to explore the relationships between antibiotic and homeopathic product use. RESULTS: Six percent of children had received one or more homeopathic products and 62% one or more antibiotics between the ages of 3 and 4.5 years. After adjustment for factors associated with antibiotic use, there was no association between homeopathic product and antibiotic use (adjusted OR = 1.02, 95% CI 0.84, 1.24). Factors independently associated with child homeopathic product use were: higher maternal education, maternal use of homeopathic products, maternal lack of confidence in doctors, mothers reporting that they were less likely to see doctor when the child was ill, children being given vitamins, watching less television and suffering from wheeze and food allergies. CONCLUSION: In this observational study, the use of homeopathic products was not associated with decreased antibiotic consumption, suggesting the use of homeopathic product complements rather than competes with the use of antibiotics in pre-school children. The characteristics of mothers giving homeopathic products to their children are similar to those associated with adult self-administration. [ABSTRACT FROM AUTHOR]

Background: Healthcare policy-makers are expected to develop 'evidence-based' policies. Yet, studies have consistently shown that, like clinical practitioners, they need to combine many varied kinds of evidence and information derived from divergent sources. Working in the complex environment of healthcare decision-making, they have to rely on forms of (practical, contextual) knowledge quite different from that produced by researchers. It is therefore important to understand how and why they transform research-based evidence into the knowledge they ultimately use., Methods: We purposively selected four healthcare-commissioning organisations working with external agencies that provided research-based evidence to assist with commissioning; we interviewed a total of 52 people involved in that work. This entailed 92 interviews in total, each lasting 20-60 minutes, including 47 with policy-making commissioners, 36 with staff of external agencies, and 9 with freelance specialists, lay representatives and local-authority professionals. We observed 25 meetings (14 within the commissioning organisations) and reviewed relevant documents. We analysed the data thematically using a constant comparison method with a coding framework and developed structured summaries consisting of 20-50 pages for each case-study site. We iteratively discussed and refined emerging findings, including cross-case analyses, in regular research team meetings with facilitated analysis. Further details of the study and other results have been described elsewhere., Results: The commissioners' role was to assess the available care provision options, develop justifiable arguments for the preferred alternatives, and navigate them through a tortuous decision-making system with often-conflicting internal and external opinion. In a multi-transactional environment characterised by interactive, pressurised, under-determined decisions, this required repeated, contested sensemaking through negotiation of many sources of evidence. Commissioners therefore had to subject research-based knowledge to multiple 'knowledge behaviours'/manipulations as they repeatedly re-interpreted and recrafted the available evidence while carrying out their many roles. Two key 'incorporative processes' underpinned these activities, namely contextualisation of evidence and engagement of stakeholders. We describe five Active Channels of Knowledge Transformation - Interpersonal Relationships, People Placement, Product Deployment, Copy, Adapt and Paste, and Governance and Procedure - that provided the organisational spaces and the mechanisms for commissioners to constantly reshape research-based knowledge while incorporating it into the eventual policies that configured local health services., Conclusions: Our new insights into the ways in which policy-makers and practitioners inevitably transform research-based knowledge, rather than simply translate it, could foster more realistic and productive expectations for the conduct and evaluation of research-informed healthcare provision.

Objectives: To establish how quality indicators used in English community nursing are selected and applied, and their perceived usefulness to service users, commissioners and service providers., Methods: A qualitative multi-site case study was conducted with five commissioning organizations and their service providers. Participants included commissioners, provider organization managers, nurses and service users., Results: Indicator selection and application often entail complex processes influenced by wider health system and cross-organizational factors. All participants felt that current indicators, while useful for accountability and management purposes, fail to reflect the true quality of community nursing care and may sometimes indirectly compromise care., Conclusions: Valuable resources may be better used for comprehensive system redesign, to ensure that patient, carer and nurse priorities are given equivalence with those of other stakeholders.

Objectives: During a cluster randomised trial, (the 3D study) of an intervention enacting recommended care for people with multimorbidity, including continuity of care and comprehensive biennial reviews, we examined implementation fidelity to interpret the trial outcome and inform future implementation decisions., Design: Mixed-methods process evaluation using cross-trial data and a sample of practices, clinicians, administrators and patients. Interviews, focus groups and review observations were analysed thematically and integrated with quantitative data about implementation. Analysis was blind to trial outcomes and examined context, intervention adoption, reach and maintenance, and delivery of reviews to patients., Setting: Thirty-three UK general practices in three areas., Participants: The trial included 1546 people with multimorbidity. 11 general practitioners, 14 nurses, 7 administrators and 38 patients from 9 of 16 intervention practices were sampled for an interview., Results: Staff loss, practice size and different administrative strategies influenced implementation fidelity. Practices with whole administrative team involvement and good alignment between the intervention and usual care generally implemented better. Fewer reviews than intended were delivered (49% of patients receiving both intended reviews, 30% partially reviewed). In completed reviews >90% of intended components were delivered, but review observations and interviews with patients and clinicians found variation in style of component delivery, from 'tick-box' to patient-centred approaches. Implementation barriers included inadequate skills training to implement patient-centred care planning, but patients reported increased patient-centredness due to comprehensive reviews, extra time and being asked about their health concerns., Conclusions: Implementation failure contributed to lack of impact of the 3D intervention on the trial primary outcome (quality of life), but so did intervention failure since modifiable elements of intervention design were partially responsible. When a decisive distinction between implementation failure and intervention failure cannot be made, identifying potentially modifiable reasons for suboptimal implementation is important to enhance potential for impact and effectiveness of a redesigned intervention., Trial Registration Number: ISRCTN06180958., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2019. Re-use permitted under CC BY. Published by BMJ.)

Background: Identification of patients at the end-of-life is the first step in care planning and many general practices have Palliative Care Registers. There is evidence that these largely comprise patients with cancer diagnoses, but little is known about the identification process., Objective: To explore the barriers that hinder GPs from identifying and registering patients on Palliative Care Registers., Methods: An exploratory qualitative approach was undertaken using semi-structured interviews with GPs in South West England. GPs were asked about their experiences of identifying, registering and discussing end-of-life care with patients. Interviews were audio recorded, transcribed and analysed thematically., Results: Most practices had a Palliative Care Register, which were mainly composed of patients with cancer. They reported identifying non-malignant patients at the end-of-life as challenging and were reluctant to include frail or elderly patients due to resource implications. GPs described rarely using prognostication tools to identify patients and conveyed that poor communication between secondary and primary care made prognostication difficult. GPs also detailed challenges around talking to patients about end-of-life care., Conclusions: Palliative Care Registers are widely used by GPs for patients with malignant diagnoses, but seldom for other patients. The findings from our study suggest that this arises because GPs find prognosticating for patients with non-malignant disease more challenging. GPs would value better communication from secondary care, tools for prognostication and training in speaking with patients at the end-of-life enabling them to better identify non-malignant patients at the end-of-life., (© The Author(s) 2019. Published by Oxford University Press. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

The concept of knowledge co-production is used in health services research to describe partnerships (which can involve researchers, practitioners, managers, commissioners or service users) with the purpose of creating, sharing and negotiating different knowledge types used to make improvements in health services. Several knowledge co-production models have been proposed to date, some involving intermediary roles. This paper explores one such model, researchers-in-residence (also known as 'embedded researchers').In this model, researchers work inside healthcare organisations, operating as staff members while also maintaining an affiliation with academic institutions. As part of the local team, researchers negotiate the meaning and use of research-based knowledge to co-produce knowledge, which is sensitive to the local context. Even though this model is spreading and appears to have potential for using co-produced knowledge to make changes in practice, a number of challenges with its use are emerging. These include challenges experienced by the researchers in embedding themselves within the practice environment, preserving a clear focus within their host organisations and maintaining academic professional identity.In this paper, we provide an exploration of these challenges by examining three independent case studies implemented in the UK, each of which attempted to co-produce relevant research projects to improve the quality of care. We explore how these played out in practice and the strategies used by the researchers-in-residence to address them. In describing and analysing these strategies, we hope that participatory approaches to knowledge co-production can be used more effectively in the future., Competing Interests: Competing interests: CV-P worked as an embedded researcher in the UCLH ERT. NJF oversaw the work of the UCLH ERT. MM supervises and mentors a team of researchers-in-residence and lectures on the model nationally and internationally. HC was an embedded researcher at BCCG. HB works as an embedded researcher at BCCG. MU started a modellers-in-residence programme at Great Ormond Street Hospital, contributed to the work of the UCLH ERT and currently works as a researcher-in-residence at Care City London. LE and LW have no competing interests. NP has collaborated with an embedded research team., (© Article author(s) (or their employer(s) unless otherwise stated in the text of the article) 2019. All rights reserved. No commercial use is permitted unless otherwise expressly granted.)

The potential use, influence and impact of health research is seldom fully realised. This stubborn problem has caused burgeoning global interest in research aiming to address the implementation 'gap' and factors inhibiting the uptake of scientific evidence. Scholars and practitioners have questioned the nature of evidence used and required for healthcare, highlighting the complex ways in which knowledge is formed, shared and modified in practice and policy. This has led to rapid expansion, expertise and innovation in the field of knowledge mobilisation and funding for experimentation into the effectiveness of different knowledge mobilisation models. One approach gaining prominence involves stakeholders (e.g. researchers, practitioners, service users, policy-makers, managers and carers) in the co-production, and application, of knowledge for practice, policy and research (frequently termed integrated knowledge translation in Canada). Its popularity stems largely from its potential to address dilemmas inherent in the implementation of knowledge generated using more reductionist methods. However, despite increasing recognition, demands for co-produced research to illustrate its worth are becoming pressing while the means to do so remain challenging. This is due not only to the diversity of approaches to co-production and their application, but also to the ways through which different stakeholders conceptualise, measure, reward and use research. While research co-production can lead to demonstrable benefits such as policy or practice change, it may also have more diffuse and subtle impact on relationships, knowledge sharing, and in engendering culture shifts and research capacity-building. These relatively intangible outcomes are harder to measure and require new emphases and tools. This opinion paper uses six Canadian and United Kingdom case studies to explore the principles and practice of co-production and illustrate how it can influence interactions between research, policy and practice, and benefit diverse stakeholders. In doing so, we identify a continuum of co-production processes. We propose and illustrate the use of a new 'social model of impact' and framework to capture multi-layered and potentially transformative impacts of co-produced research. We make recommendations for future directions in research co-production and impact measurement.

Background: Computer templates for review of single long-term conditions are commonly used to record care processes, but they may inhibit communication and prevent patients from discussing their wider concerns., Aim: To evaluate the effect on patient-centredness of a novel computer template used in multimorbidity reviews., Design and Setting: A qualitative process evaluation of a randomised controlled trial in 33 GP practices in England and Scotland examining the implementation of a patient-centred complex intervention intended to improve management of multimorbidity. A purpose-designed computer template combining long-term condition reviews was used to support the patient-centred intervention., Method: Twenty-eight reviews using the intervention computer template and nine usual-care reviews were observed and recorded. Sixteen patient interviews, four patient focus groups, and 23 clinician interviews were also conducted in eight of the 12 intervention practices. Transcripts were thematically analysed based on predefined core components of patient-centredness and template use., Results: Disrupted communication was more evident in intervention reviews because the template was unfamiliar, but the first template question about patients' important health issues successfully elicited wide-ranging health concerns. Patients welcomed the more holistic, comprehensive reviews, and some unmet healthcare needs were identified. Most clinicians valued identifying patients' agendas, but some felt it diverted attention from care of long-term conditions. Goal-setting was GP-led rather than collaborative., Conclusion: Including patient-centred questions in long-term condition review templates appears to improve patients' perceptions about the patient-centredness of reviews, despite template demands on a clinician's attention. Adding an initial question in standardised reviews about the patient's main concerns should be considered., (© British Journal of General Practice 2018.)

Increasing attention has focused on the role of joint commissioning in health and social care policy and practice in England. This paper provides an empirical examination of the three discourses of joint commissioning developed from an interpretative analysis of documents by Dickinson et al. (2013; BMC Health Services Research, 13) and applied to data from our study exploring the role of knowledge in commissioning in England. Based on interviews with 92 participants undertaken between 2011 and 2013, our analysis confirms that the three discourses of prevention or empowerment or efficiency are used by professionals from across health and social care organisations to frame their experiences of joint commissioning. However, contrary to Dickinson et al., we also demonstrate that commissioners and other stakeholders combine and trade off these different discourses in unexpected ways. Moreover, at sites where the service user experience was central to the commissioning process (joint commissioning as empowerment), a greater sense of agreement about commissioning decisions appeared to have been established even when the other discourses were also in play., (© 2017 John Wiley & Sons Ltd.)

Background: In examining an initiative to develop and implement new cancer diagnostic pathways in two English localities, this paper evaluates 'what works' and examines the role of researchers in facilitating knowledge translation amongst teams of local clinicians and policy-makers., Methods: Using realist evaluation with a mixed methods case study approach, we conducted documentary analysis of meeting minutes and pathway iterations to map pathway development. We interviewed 14 participants to identify the contexts, mechanisms and outcomes (CMOs) that led to successful pathway development and implementation. Interviews were analysed thematically and four CMO configurations were developed., Results: One site produced three fully implemented pathways, while the other produced two that were partly implemented. In explaining the differences, we found that a respected, independent, well-connected leader modelling partnership working and who facilitates a local, stable group that agree about the legitimacy of the data and project (context) can empower local teams to become sufficiently autonomous (mechanism) to develop and implement research-based pathways (outcome). Although both teams designed relevant, research-based cancer pathways, in the site where the pathways were successfully implemented the research team merely assisted, while, in the other, the research team drove the initiative., Conclusion: Based on our study findings, local stakeholders can apply local and research knowledge to develop and implement research-based pathways. However, success will depend on how academics empower local teams to create autonomy. Crucially, after re-packaging and translating research for local circumstances, identifying fertile environments with the right elements for implementation and developing collaborative relationships with local leaders, academics must step back.

Background: The UK National Health Service Emergency Departments (ED) have recently faced increasing attendance rates. This study investigated associations of general practice and practice population characteristics with emergency care service attendance rates., Methods: A longitudinal design with practice-level measures of access and continuity of care, patient population demographics and use of emergency care for the financial years 2009/10 to 2012/13. The main outcome measures were self-referred discharged ED attendance rate, and combined self-referred discharged ED, self-referred Walk-in Centre (WiC) and self-referred Minor Injuries Unit (MIU) attendance rate per 1000 patients. Multilevel models estimated adjusted regression coefficients for relationships between patients' emergency attendance rates and patients' reported satisfaction with opening hours and waiting time at the practice, proportion of patients having a preferred GP, and use of WiC and MIU, both between practices, and within practices over time., Results: Practice characteristics associated with higher ED attendance rates included lower percentage of patients satisfied with waiting time (0.22 per 1% decrease, 95%CI 0.02 to 0.43) and lower percentage having a preferred GP (0.12 per 1% decrease, 95%CI 0.02 to 0.21). Population influences on higher attendance included more elderly, more female and more unemployed patients, and lower male life-expectancy and urban conurbation location. Net reductions in ED attendance were only seen for practices whose WiC or MIU attendance was high, above the 60th centile for MIU and above the 75th centile for WiC. Combined emergency care attendance fell over time if more patients within a practice were satisfied with opening hours (-0.26 per 1% increase, 95%CI -0.45 to -0.08)., Conclusion: Practices with more patients satisfied with waiting time, having a preferred GP, and using MIU and WIC services, had lower ED attendance. Increases over time in attendance at MIUs, and patient satisfaction with opening hours was associated with reductions in service use.

Objectives: To describe how processes of primary care access influence decisions to seek help at the emergency department (ED)., Design: Ethnographic case study combining non-participant observation, informal and formal interviewing., Setting: Six general practitioner (GP) practices located in three commissioning organisations in England., Participants and Methods: Reception areas at each practice were observed over the course of a working week (73 hours in total). Practice documents were collected and clinical and non-clinical staff were interviewed (n=19). Patients with recent ED use, or a carer if aged 16 and under, were interviewed (n=29)., Results: Past experience of accessing GP care recursively informed patient decisions about where to seek urgent care, and difficulties with access were implicit in patient accounts of ED use. GP practices had complicated, changeable systems for appointments. This made navigating appointment booking difficult for patients and reception staff, and engendered a mistrust of the system. Increasingly, the telephone was the instrument of demand management, but there were unintended consequences for access. Some patient groups, such as those with English as an additional language, were particularly disadvantaged, and the varying patient and staff semantic of words like 'urgent' and 'emergency' was exacerbated during telephone interactions. Poor integration between in-hours and out-of-hours care and patient perceptions of the quality of care accessible at their GP practice also informed ED use., Conclusions: This study provides important insight into the implicit role of primary care access on the use of ED. Discourses around 'inappropriate' patient demand neglect to recognise that decisions about where to seek urgent care are based on experiential knowledge. Simply speeding up access to primary care or increasing its volume is unlikely to alleviate rising ED use. Systems for accessing care need to be transparent, perceptibly fair and appropriate to the needs of diverse patient groups., Competing Interests: Competing interests: None declared., (© Article author(s) (or their employer(s) unless otherwise stated in the text of the article) 2017. All rights reserved. No commercial use is permitted unless otherwise expressly granted.)