Mortality associated with alternative policy options for primary care and the Mais Médicos (More Doctors) Program in Brazil: forecasting future scenarios

Objective.

To forecast the impact of alternative scenarios of coverage changes in Brazil’s Family Health Strategy (Estratégia Saúde da Família) (ESF)—due to fiscal austerity measures and to the end of the Mais Médicos (More Doctors) Program (PMM)—on overall under-5 mortality rates (U5MRs) and under-70 mortality rates (U70MRs) from ambulatory care sensitive conditions (ACSCs) up through 2030.

Methods.

A synthetic cohort of 5 507 Brazilian municipalities was created for the period 2017-2030. A municipal-level microsimulation model was developed and validated using longitudinal data. Reductions in ESF coverage, and its effects on U5MRs and U70MRs from ACSCs, were forecast based on two probable austerity scenarios, as compared to the maintenance of current ESF coverage. Fixed effects longitudinal regression models were employed to account for secular trends, demographic and socioeconomic changes, variables related to health care, and program duration effects.

Results.

In comparison to maintaining stable ESF coverage, with the decrease in ESF coverage due to austerity measures and PMM termination, the mean U5MR and U70MR would be 13.2% and 8.6% higher, respectively, in 2030. The end of PMM would be responsible for a mean U5MR from ACSCs that is 4.3% higher and a U70MR from ACSCs that is 2.8% higher in 2030. The reduction of PMM coverage due only to the withdrawal of Cuban doctors who have been working in PMM would alone be responsible for a U5MR that is 3.2% higher, and a U70MR that is 2.0% higher in 2030.

Conclusions.

Reductions in primary health care coverage due to austerity measures and the end of the PMM could be responsible for many avoidable adult and child deaths in coming years in Brazil.

Utilization and Cost of an Employer-Sponsored Comprehensive Primary Care Delivery Model

IMPORTANCE

Primary care is increasingly delivered at or near workplaces, yet utilization and cost of employer-sponsored primary care services remain unknown.

OBJECTIVE

To compare the health care utilization and cost of an employer-sponsored on-site, near-site, and virtual comprehensive primary care service delivery model with those of traditional community-based primary care.

DESIGN, SETTING, AND PARTICIPANTS

This population-based cohort study of 23 518 commercially insured employees and dependents of an engineering and manufacturing firm headquartered in southern California was performed from January 1, 2016, to July 1, 2019. A subset of the population with most (≥50%) primary care visits through employer-sponsored on-site, near-site, or virtual care clinics was matched to a subset not having most such visits through the employer-sponsored clinics using propensity score matching (n = 1983 each). In sensitivity analyses, employees were matched to dependents at neighboring firms that lacked access to the employer-sponsored primary care delivery model (additional n = 1680).

EXPOSURES

Integrated primary care, mental health, and physical therapy delivered through on-site, near-site, and virtual clinics.

MAIN OUTCOMES AND MEASURES

Utilization (inpatient, outpatient, emergency department, pharmaceutical, radiology, and laboratory visits per 1000 member-months) and spending (2019 costs per member per month in US dollars) by service type.

RESULTS

A total of 23 518 individuals (mean [SD] age, 27 [15] years; 14 604 [62.1%] male) were included in the full population sample and had been enrolled in the employer-sponsored health plan for a mean of 29 months (interquartile range, 14-48 months). Of eligible members, 5292 (22.5%) used the employer-sponsored services, with 2305 (9.8%) using them for most of their primary care. The mean (SD) cost of employer-sponsored service delivery was $87 ($32) per member month. Among the matched populations (mean [SD] age, 31 [11] years; 3349 [84.5%] male) of primary users vs control individuals, total spending was 45% lower per member per month (95% CI, 35%-55%; cost difference, -$167 per member per month; 95% CI, -$204 to -$130; P < .001) among users after adjustment. The lower spending was associated with lower spending on non-primary care services, such as emergency department (-33%; 95% CI, -44% to -22%) and hospital visits (-16%; 95% CI, -22% to -10%), despite higher spending on primary care (109%; 95% CI, 102%-116%) and mental health (20%; 95% CI, 13%-27%).

CONCLUSIONS AND RELEVANCE

The findings suggest that individuals who used the models' services for most of their primary care had lower total spending despite higher primary care spending, which may be associated with self-selection of lower-risk persons to the employer-sponsored services and/or with the use of comprehensive primary care.

Dental Practice Integration into Primary Care: A Microsimulation of Financial Implications for Practices

Given the widespread lack of access to dental care for many vulnerable Americans, there is a growing realization that integrating dental and primary care may provide comprehensive care. We sought to model the financial impact of integrating dental care provision into a primary care practice. A microsimulation model was used to estimate changes in net revenue per practice by simulating patient visits to a primary dental practice within primary care practices, utilizing national survey and un-identified claims data from a nationwide health insurance plan. The impact of potential changes in utilization rates and payer distributions and hiring additional staff was also evaluated. When dental care services were provided in the primary care setting, annual net revenue changes per practice were −$92,053 (95% CI: −93,054, −91,052) in the first year and $104,626 (95% CI: 103,315, 105,316) in subsequent years. Net revenue per annum after the first year of integration remained positive as long as the overall utilization rates decreased by less than 25%. In settings with a high proportion of publicly insured patients, the net revenue change decreased but was still positive. Integrating primary dental and primary care providers would be financially viable, but this viability depends on demands of dental utilization and payer distributions.

Scattering Studies with Low-Energy Kaon-Proton Femtoscopy in Proton-Proton Collisions at the LHC

The study of the strength and behavior of the antikaon-nucleon (K[over ¯]N) interaction constitutes one of the key focuses of the strangeness sector in low-energy quantum chromodynamics (QCD). In this Letter a unique high-precision measurement of the strong interaction between kaons and protons, close and above the kinematic threshold, is presented. The femtoscopic measurements of the correlation function at low pair-frame relative momentum of (K^{+}p⊕K^{-}p[over ¯]) and (K^{-}p⊕K^{+}p[over ¯]) pairs measured in pp collisions at sqrt[s]=5, 7, and 13 TeV are reported. A structure observed around a relative momentum of 58  MeV/c in the measured correlation function of (K^{-}p⊕K^{+}p[over ¯]) with a significance of 4.4σ constitutes the first experimental evidence for the opening of the (K[over ¯]^{0}n⊕K^{0}n[over ¯]) isospin breaking channel due to the mass difference between charged and neutral kaons. The measured correlation functions have been compared to Jülich and Kyoto models in addition to the Coulomb potential. The high-precision data at low relative momenta presented in this work prove femtoscopy to be a powerful complementary tool to scattering experiments and provide new constraints above the K[over ¯]N threshold for low-energy QCD chiral models.

Global, regional, and national burden of chronic kidney disease, 1990-2017: a systematic analysis for the Global Burden of Disease Study 2017

BACKGROUND

Health system planning requires careful assessment of chronic kidney disease (CKD) epidemiology, but data for morbidity and mortality of this disease are scarce or non-existent in many countries. We estimated the global, regional, and national burden of CKD, as well as the burden of cardiovascular disease and gout attributable to impaired kidney function, for the Global Burden of Diseases, Injuries, and Risk Factors Study 2017. We use the term CKD to refer to the morbidity and mortality that can be directly attributed to all stages of CKD, and we use the term impaired kidney function to refer to the additional risk of CKD from cardiovascular disease and gout.

METHODS

The main data sources we used were published literature, vital registration systems, end-stage kidney disease registries, and household surveys. Estimates of CKD burden were produced using a Cause of Death Ensemble model and a Bayesian meta-regression analytical tool, and included incidence, prevalence, years lived with disability, mortality, years of life lost, and disability-adjusted life-years (DALYs). A comparative risk assessment approach was used to estimate the proportion of cardiovascular diseases and gout burden attributable to impaired kidney function.

FINDINGS

Globally, in 2017, 1·2 million (95% uncertainty interval [UI] 1·2 to 1·3) people died from CKD. The global all-age mortality rate from CKD increased 41·5% (95% UI 35·2 to 46·5) between 1990 and 2017, although there was no significant change in the age-standardised mortality rate (2·8%, -1·5 to 6·3). In 2017, 697·5 million (95% UI 649·2 to 752·0) cases of all-stage CKD were recorded, for a global prevalence of 9·1% (8·5 to 9·8). The global all-age prevalence of CKD increased 29·3% (95% UI 26·4 to 32·6) since 1990, whereas the age-standardised prevalence remained stable (1·2%, -1·1 to 3·5). CKD resulted in 35·8 million (95% UI 33·7 to 38·0) DALYs in 2017, with diabetic nephropathy accounting for almost a third of DALYs. Most of the burden of CKD was concentrated in the three lowest quintiles of Socio-demographic Index (SDI). In several regions, particularly Oceania, sub-Saharan Africa, and Latin America, the burden of CKD was much higher than expected for the level of development, whereas the disease burden in western, eastern, and central sub-Saharan Africa, east Asia, south Asia, central and eastern Europe, Australasia, and western Europe was lower than expected. 1·4 million (95% UI 1·2 to 1·6) cardiovascular disease-related deaths and 25·3 million (22·2 to 28·9) cardiovascular disease DALYs were attributable to impaired kidney function.

INTERPRETATION

Kidney disease has a major effect on global health, both as a direct cause of global morbidity and mortality and as an important risk factor for cardiovascular disease. CKD is largely preventable and treatable and deserves greater attention in global health policy decision making, particularly in locations with low and middle SDI.

FUNDING

Bill & Melinda Gates Foundation.

In cellulo crystallization of Trypanosoma brucei IMP dehydrogenase enables the identification of genuine co-factors

Sleeping sickness is a fatal disease caused by the protozoan parasite Trypanosoma brucei (Tb). Inosine-5’-monophosphate dehydrogenase (IMPDH) has been proposed as a potential drug target, since it maintains the balance between guanylate deoxynucleotide and ribonucleotide levels that is pivotal for the parasite. Here we report the structure of TbIMPDH at room temperature utilizing free-electron laser radiation on crystals grown in living insect cells. The 2.80 Å resolution structure reveals the presence of ATP and GMP at the canonical sites of the Bateman domains, the latter in a so far unknown coordination mode. Consistent with previously reported IMPDH complexes harboring guanosine nucleotides at the second canonical site, TbIMPDH forms a compact oligomer structure, supporting a nucleotide-controlled conformational switch that allosterically modulates the catalytic activity. The oligomeric TbIMPDH structure we present here reveals the potential of in cellulo crystallization to identify genuine allosteric co-factors from a natural reservoir of specific compounds.

Trypanosoma brucei inosine-5′-monophosphate dehydrogenase (IMPDH) is an enzyme in the guanine nucleotide biosynthesis pathway and of interest as a drug target. Here the authors present the 2.8 Å room temperature structure of TbIMPDH determined by utilizing X-ray free-electron laser radiation and crystals that were grown in insect cells and find that ATP and GMP are bound at the canonical sites of the Bateman domains.

Opioid prescribing patterns among medical providers in the United States, 2003-17: retrospective, observational study

OBJECTIVE

To examine the distribution and patterns of opioid prescribing in the United States.

DESIGN

Retrospective, observational study.

SETTING

National private insurer covering all 50 US states and Washington DC.

PARTICIPANTS

An annual average of 669 495 providers prescribing 8.9 million opioid prescriptions to 3.9 million patients from 2003 through 2017.

MAIN OUTCOME MEASURES

Standardized doses of opioids in morphine milligram equivalents (MMEs) and number of opioid prescriptions.

RESULTS

In 2017, the top 1% of providers accounted for 49% of all opioid doses and 27% of all opioid prescriptions. In absolute terms, the top 1% of providers prescribed an average of 748 000 MMEs-nearly 1000 times more than the middle 1%. At least half of all providers in the top 1% in one year were also in the top 1% in adjacent years. More than two fifths of all prescriptions written by the top 1% of providers were for more than 50 MMEs a day and over four fifths were for longer than seven days. In contrast, prescriptions written by the bottom 99% of providers were below these thresholds, with 86% of prescriptions for less than 50 MMEs a day and 71% for fewer than seven days. Providers prescribing high amounts of opioids and patients receiving high amounts of opioids persisted over time, with over half of both appearing in adjacent years.

CONCLUSIONS

Most prescriptions written by the majority of providers are under the recommended thresholds, suggesting that most US providers are careful in their prescribing. Interventions focusing on this group of providers are unlikely to effect beneficial change and could induce unnecessary burden. A large proportion of providers have established relationships with their patients over multiple years. Interventions to reduce inappropriate opioid prescribing should be focused on improving patient care, management of patients with complex pain, and reducing comorbidities rather than seeking to enforce a threshold for prescribing.

Global, regional, and national incidence, prevalence, and mortality of HIV, 1980-2017, and forecasts to 2030, for 195 countries and territories: a systematic analysis for the Global Burden of Diseases, Injuries, and Risk Factors Study 2017

BACKGROUND

Understanding the patterns of HIV/AIDS epidemics is crucial to tracking and monitoring the progress of prevention and control efforts in countries. We provide a comprehensive assessment of the levels and trends of HIV/AIDS incidence, prevalence, mortality, and coverage of antiretroviral therapy (ART) for 1980-2017 and forecast these estimates to 2030 for 195 countries and territories.

METHODS

We determined a modelling strategy for each country on the basis of the availability and quality of data. For countries and territories with data from population-based seroprevalence surveys or antenatal care clinics, we estimated prevalence and incidence using an open-source version of the Estimation and Projection Package-a natural history model originally developed by the UNAIDS Reference Group on Estimates, Modelling, and Projections. For countries with cause-specific vital registration data, we corrected data for garbage coding (ie, deaths coded to an intermediate, immediate, or poorly defined cause) and HIV misclassification. We developed a process of cohort incidence bias adjustment to use information on survival and deaths recorded in vital registration to back-calculate HIV incidence. For countries without any representative data on HIV, we produced incidence estimates by pulling information from observed bias in the geographical region. We used a re-coded version of the Spectrum model (a cohort component model that uses rates of disease progression and HIV mortality on and off ART) to produce age-sex-specific incidence, prevalence, and mortality, and treatment coverage results for all countries, and forecast these measures to 2030 using Spectrum with inputs that were extended on the basis of past trends in treatment scale-up and new infections.

FINDINGS

Global HIV mortality peaked in 2006 with 1·95 million deaths (95% uncertainty interval 1·87-2·04) and has since decreased to 0·95 million deaths (0·91-1·01) in 2017. New cases of HIV globally peaked in 1999 (3·16 million, 2·79-3·67) and since then have gradually decreased to 1·94 million (1·63-2·29) in 2017. These trends, along with ART scale-up, have globally resulted in increased prevalence, with 36·8 million (34·8-39·2) people living with HIV in 2017. Prevalence of HIV was highest in southern sub-Saharan Africa in 2017, and countries in the region had ART coverage ranging from 65·7% in Lesotho to 85·7% in eSwatini. Our forecasts showed that 54 countries will meet the UNAIDS target of 81% ART coverage by 2020 and 12 countries are on track to meet 90% ART coverage by 2030. Forecasted results estimate that few countries will meet the UNAIDS 2020 and 2030 mortality and incidence targets.

INTERPRETATION

Despite progress in reducing HIV-related mortality over the past decade, slow decreases in incidence, combined with the current context of stagnated funding for related interventions, mean that many countries are not on track to reach the 2020 and 2030 global targets for reduction in incidence and mortality. With a growing population of people living with HIV, it will continue to be a major threat to public health for years to come. The pace of progress needs to be hastened by continuing to expand access to ART and increasing investments in proven HIV prevention initiatives that can be scaled up to have population-level impact.

FUNDING

Bill & Melinda Gates Foundation, National Institute of Mental Health of the US National Institutes of Health (NIH), and the National Institute on Aging of the NIH.

Machine learning with sparse nutrition data to improve cardiovascular mortality risk prediction in the USA using nationally randomly sampled data

OBJECTIVES

We aimed to test whether or not adding (1) nutrition predictor variables and/or (2) using machine learning models improves cardiovascular death prediction versus standard Cox models without nutrition predictor variables.

DESIGN

Retrospective study.

SETTING

Six waves of Survey (NHANES) data collected from 1999 to 2011 linked to the National Death Index (NDI).

PARTICIPANTS

29 390 participants were included in the training set for model derivation and 12 600 were included in the test set for model evaluation. Our study sample was approximately 20% black race and 25% Hispanic ethnicity.

PRIMARY AND SECONDARY OUTCOME MEASURES

Time from NHANES interview until the minimum of time of cardiovascular death or censoring.

RESULTS

A standard risk model excluding nutrition data overestimated risk nearly two-fold (calibration slope of predicted vs true risk: 0.53 (95% CI: 0.50 to 0.55)) with moderate discrimination (C-statistic: 0.87 (0.86 to 0.89)). Nutrition data alone failed to improve performance while machine learning alone improved calibration to 1.18 (0.92 to 1.44) and discrimination to 0.91 (0.90 to 0.92). Both together substantially improved calibration (slope: 1.01 (0.76 to 1.27)) and discrimination (C-statistic: 0.93 (0.92 to 0.94)).

CONCLUSION

Our results indicate that the inclusion of nutrition data with available machine learning algorithms can substantially improve cardiovascular risk prediction.

Implementation of duty of candour within neurosurgery: a national survey and framework for improved application in clinical practice

INTRODUCTION

Statutory duty of candour was introduced in November 2014 for NHS bodies in England. Contained within the regulation were definitions regarding the threshold for what constitutes a notifiable patient safety incident. However, it can be difficult to determine when the process should be implemented. The aim of this survey was to evaluate the interpretation of these definitions by British neurosurgeons.

MATERIALS AND METHODS

All full (consultant) members of the Society of British Neurological Surgeons were electronically invited to participate in an online survey. Surgeons were presented with 15 cases and asked to decide in the case of each one whether they would trigger the process of duty of candour. Cases were stratified according to their likelihood and severity.

RESULTS

In all, 106/357 (29.7%) members participated in the survey. Responses varied widely, with almost no members triggering the process of duty of candour in cases where adverse events were common (greater than 10% likelihood) and required only outpatient follow-up (7/106; 6.6%), and almost all members doing so in cases where adverse events were rare (less than 0.1% likelihood) and resulted in death (102/106; 96.2%). However, there was clear equipoise in triggering the process of duty of candour in cases where adverse events were uncommon (0.1-10% likelihood) and resulted in moderate harm (38/106; 35.8%), severe harm (57/106; 53.8%) or death (49/106; 46.2%).

CONCLUSION

There is considerable nationwide variation in the interpretation of definitions regarding the threshold for duty of candour. To this end, we propose a framework for the improved application of duty of candour in clinical practice.

Population Health Impact and Cost-Effectiveness of Community-Supported Agriculture Among Low-Income US Adults: A Microsimulation Analysis

Objectives. To estimate the population-level effectiveness and cost-effectiveness of a subsidized community-supported agriculture (CSA) intervention in the United States.Methods. In 2019, we developed a microsimulation model from nationally representative demographic, biomedical, and dietary data (National Health and Nutrition Examination Survey, 2013-2016) and a community-based randomized trial (conducted in Massachusetts from 2017 to 2018). We modeled 2 interventions: unconditional cash transfer ($300/year) and subsidized CSA ($300/year subsidy).Results. The total discounted disability-adjusted life years (DALYs) accumulated over the life course to cardiovascular disease and diabetes complications would be reduced from 24 797 per 10 000 people (95% confidence interval [CI] = 24 584, 25 001) at baseline to 23 463 per 10 000 (95% CI = 23 241, 23 666) under the cash intervention and 22 304 per 10 000 (95% CI = 22 084, 22 510) under the CSA intervention. From a societal perspective and over a life-course time horizon, the interventions had negative incremental cost-effectiveness ratios, implying cost savings to society of -$191 100 per DALY averted (95% CI = -$191 767, -$188 919) for the cash intervention and -$93 182 per DALY averted (95% CI = -$93 707, -$92 503) for the CSA intervention.Conclusions. Both the cash transfer and subsidized CSA may be important public health interventions for low-income persons in the United States.

CRISPR/Cas9 gene editing in the West Nile Virus vector, Culex quinquefasciatus Say

Culex quinquefasciatus Say is an opportunistic blood feeder with a wide geographic distribution which is also a major vector for a range of diseases of both animals and humans. CRISPR/Cas technologies have been applied to a wide variety of organisms for both applied and basic research purposes. CRISPR/Cas methods open new possibilities for genetic research in non-model organisms of public health importance. In this work we have adapted microinjection techniques commonly used in other mosquito species to Culex quinquefasciatus, and have shown these to be effective at generating homozygous knock-out mutations of a target gene in one generation. This is the first description of the kmo gene and mutant phenotype in this species.

Personalizing Medical Treatment Decisions: Integrating Meta-analytic Treatment Comparisons with Patient-Specific Risks and Preferences

Background. Network meta-analyses (NMAs) that compare treatments for a given condition allow physicians to identify which treatments have higher or lower probabilities of reducing the risks of disease complications or increasing the risks of treatment side effects. Translating these data into personalized treatment plans requires integration of NMA data with patient-specific pretreatment risk estimates and preferences regarding treatment objectives and acceptable risks. Methods. We introduce a modeling framework to integrate data probabilistically from NMAs with data on individualized patient risk estimates for disease outcomes, treatment preferences (such as willingness to incur greater side effects for increased life expectancy), and risk preferences. We illustrate the modeling framework by creating personalized plans for antipsychotic drug treatment and evaluating their effectiveness and cost-effectiveness. Results. Compared with treating all patients with the drug that yields the greatest quality-adjusted life-years (QALYs) on average (amisulpride), personalizing the selection of antipsychotic drugs for schizophrenia patients over the next 5 years would be expected to yield 0.33 QALYs (95% credible interval [crI]: 0.30-0.37) per patient at an incremental cost of $4849/QALY gained (95% crI: dominant-$12,357), versus 0.29 and 0.04 QALYs per patient when accounting for only risks or preferences, respectively, but not both. Limitations. The analysis uses a linear, additive utility function to reflect patient treatment preferences and does not consider potential variations in patient time discounting. Conclusions. Our modeling framework rigorously computes what physicians normally have to do mentally. By integrating 3 key components of personalized medicine-evidence on efficacy, patient risks, and patient preferences-the modeling framework can provide personalized treatment decisions to improve patient health outcomes.

Measurement of ϒ(1S) Elliptic Flow at Forward Rapidity in Pb-Pb Collisions at sqrt[s_{NN}]=5.02 TeV

The first measurement of the ϒ(1S) elliptic flow coefficient (v_{2}) is performed at forward rapidity (2.5<y<4) in Pb-Pb collisions at sqrt[s_{NN}]=5.02  TeV with the ALICE detector at the LHC. The results are obtained with the scalar product method and are reported as a function of transverse momentum (p_{T}) up to 15  GeV/c in the 5%-60% centrality interval. The measured ϒ(1S)v_{2} is consistent with 0 and with the small positive values predicted by transport models within uncertainties. The v_{2} coefficient in 2<p_{T}<15  GeV/c is lower than that of inclusive J/ψ mesons in the same p_{T} interval by 2.6 standard deviations. These results, combined with earlier suppression measurements, are in agreement with a scenario in which the ϒ(1S) production in Pb-Pb collisions at LHC energies is dominated by dissociation limited to the early stage of the collision, whereas in the J/ψ case there is substantial experimental evidence of an additional regeneration component.

Investigations of Anisotropic Flow Using Multiparticle Azimuthal Correlations in pp, p-Pb, Xe-Xe, and Pb-Pb Collisions at the LHC

Measurements of anisotropic flow coefficients (v_{n}) and their cross-correlations using two- and multiparticle cumulant methods are reported in collisions of pp at sqrt[s]=13  TeV, p-Pb at a center-of-mass energy per nucleon pair sqrt[s_{NN}]=5.02  TeV, Xe-Xe at sqrt[s_{NN}]=5.44  TeV, and Pb-Pb at sqrt[s_{NN}]=5.02  TeV recorded with the ALICE detector. The multiplicity dependence of v_{n} is studied in a very wide range from 20 to 3000 particles produced in the midrapidity region |η|<0.8 for the transverse momentum range 0.2<p_{T}<3.0  GeV/c. An ordering of the coefficients v_{2}>v_{3}>v_{4} is found in pp and p-Pb collisions, similar to that seen in large collision systems, while a weak v_{2} multiplicity dependence is observed relative to nucleus-nucleus collisions in the same multiplicity range. Using a novel subevent method, v_{2} measured with four-particle cumulants is found to be compatible with that from six-particle cumulants in pp and p-Pb collisions. The magnitude of the correlation between v_{n}^{2} and v_{m}^{2}, evaluated with the symmetric cumulants SC(m,n) is observed to be positive at all multiplicities for v_{2} and v_{4}, while for v_{2} and v_{3} it is negative and changes sign for multiplicities below 100, which may indicate a different v_{n} fluctuation pattern in this multiplicity range. The observed long-range multiparticle azimuthal correlations in high multiplicity pp and p-Pb collisions can neither be described by pythia 8 nor by impact-parameter-Glasma, music, and ultrarelativistic quantum molecular dynamics model calculations, and hence, provide new insights into the understanding of collective effects in small collision systems.

Developing a questionnaire to assess the health effects of bioaerosols

Background

Bioaerosol exposure occurs in several industries including green waste recycling, poultry farming, grain, animal feed and cotton production. Whilst several studies have investigated exposure and health effects in compost workers, the best questions to ask about health are uncertain.

Aims

This study aimed to develop a questionnaire to assess health symptoms in compost workers.

Methods

A 46-item questionnaire to ascertain possible symptoms of occupational illness related to bioaerosol exposure in a cohort of UK industrial compost workers and delivery in an interviewer-led format. The reliability of the questionnaire was assessed using Cronbach's α. A principal component analysis (PCA) was conducted to condense the questionnaire for practical purposes.

Results

One hundred and eleven (89%) workers completed the questionnaire. All items showed very good reliability (Cronbach's α = 0.83). After removing perfectly correlated questions from the data set, the PCA was conducted on a reduced data set of 28 items to explore underlying themes. Nine components were identified that explained 77% of the total variation. Nine of the questions removed prior to PCA due to perfect correlation were reintroduced because they added clinical value. The final questionnaire therefore consisted of 37 items and retained very adequate reliability (Cronbach's α = 0.76).

Conclusions

Our health questionnaire has demonstrated adequate reliability when used within this industrial composting workforce. Further applications may include health surveillance, investigating outbreaks of occupational disease or research. Future work should examine the predictive validity of the questionnaire in these settings.

First Observation of an Attractive Interaction between a Proton and a Cascade Baryon

This Letter presents the first experimental observation of the attractive strong interaction between a proton and a multistrange baryon (hyperon) Ξ^{-}. The result is extracted from two-particle correlations of combined p-Ξ^{-}⊕p[over ¯]-Ξ[over ¯]^{+} pairs measured in p-Pb collisions at sqrt[s_{NN}]=5.02  TeV at the LHC with ALICE. The measured correlation function is compared with the prediction obtained assuming only an attractive Coulomb interaction and a standard deviation in the range [3.6, 5.3] is found. Since the measured p-Ξ^{-}⊕p[over ¯]-Ξ[over ¯]^{+} correlation is significantly enhanced with respect to the Coulomb prediction, the presence of an additional, strong, attractive interaction is evident. The data are compatible with recent lattice calculations by the HAL-QCD Collaboration, with a standard deviation in the range [1.8, 3.7]. The lattice potential predicts a shallow repulsive Ξ^{-} interaction within pure neutron matter and this implies stiffer equations of state for neutron-rich matter including hyperons. Implications of the strong interaction for the modeling of neutron stars are discussed.