Allogeneic chondrogenic-induced mesenchymal stem cells for the treatment of tarsometatarsal lameness in horses

OBJECTIVE

To assess the efficacy of commercial intra-articular blood-derived allogeneic-induced mesenchymal stem cells (CIMSCs) to treat tarsometatarsal lameness in horses.

STUDY DESIGN

This was a retrospective cohort study.

ANIMALS

Records from 167 adult light breed horses with bilateral tarsometatarsal lameness.

METHODS

Horses with tarsometatarsal lameness were retrospectively selected from medical records. Diagnosis followed subjective graded lameness assessment before and after intra-articular analgesia, with graded radiographic tarsal examination. Horses were excluded if they were diagnosed or treated for any other concurrent lameness conditions during the study. Time to last follow-up and time of recurrence of lameness was recorded at veterinary re-assessment.

RESULTS

A total of 67 horses were recruited to the CIMSC-treated group and 100 to the corticosteroid (CS)-treated group. Median age was 9 years, with no difference in signalment, use or radiographic grade between groups. First re-examination was 38 days (95% CI: 38-49), with no difference between groups, CIMSC 42 (35-45), control 34 (25-42). Median follow-up was 438 days for CIMSC, 546 for controls. Symptoms of lameness recurred in 86/100 controls compared to 17/67 (25%) CIMSC. Median time to lameness recurring in CIMSC was 336 days (95% CI: 239-400), control 90 days (95% CI: 80-108), p < .0001. Cox proportional hazard ratio for treatment was 8.35, 95% CI: 4.67 to 14.92, p < .0001.

CONCLUSIONS

Lameness was abolished in all treated horses. It recurred significantly less often, and later, in CIMSC-treated horses.

CLINICAL SIGNIFICANCE

Intra-articular CIMSC treatment results in prolonged soundness in horses with tarsometatarsal lameness.

Red cell haemolysis secondary to intraosseous (IO) blood transfusion in adult patients with major trauma: a systematic review

INTRODUCTION

Intraosseous (IO) administration of medications and blood products is accepted practice in major trauma when intravenous access is not immediately available. However, there is a concern that the high infusion pressures required for IO transfusion may increase the risk of red cell haemolysis and its associated complications. The aim of this systematic review is to synthesise the existing evidence describing the risks of red cell haemolysis in IO blood transfusion.

METHODS

We undertook a systematic search of MEDLINE, CINAHL and EMBASE using the search terms: "intraosseous transfusion" and "haemolysis". Two authors independently screened abstracts, and reviewed full-text articles against the inclusion criteria. Reference lists of included studies were reviewed and a grey literature search undertaken. Studies were assessed for risk of bias. Inclusion criteria were: all human and animal study types that reported novel data on IO-associated red cell haemolysis. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses guideline was used.

RESULTS

Twenty-three abstracts were identified; n=9 full papers met the inclusion criteria. No further studies were identified from reference lists or grey literature. These papers included: seven large animal translational studies, a prospective and a retrospective human study. The overall risk of bias was high. One animal study with good translatability to adult patients with trauma demonstrated haemolysis. Other animal studies had methodological constraints that limit their human applicability. No haemolysis was observed in low-density flat bones (sternum), whereas haemolysis was reported in long bones (humerus, tibia). IO infusion using a three-way tap was associated with haemolysis. Conversely, pressure bag transfusion was not associated with haemolysis, but this method may result in insufficient flow rates for effective resuscitation.

CONCLUSIONS

There is a paucity of high-quality evidence surrounding the risks of red cell haemolysis in IO blood transfusion. However, evidence from one study suggests that the likelihood is increased by use of a three-way tap to administer blood transfusion to young adult male patients with trauma. Further research is needed to address this important clinical question.

PROSPERO REGISTRATION NUMBER

CRD42022318902.

Cable failure tolerant control and planning in a planar reconfigurable cable driven parallel robot

The addition of geometric reconfigurability in a cable driven parallel robot (CDPR) introduces kinematic redundancies which can be exploited for manipulating structural and mechanical properties of the robot through redundancy resolution. In the event of a cable failure, a reconfigurable CDPR (rCDPR) can also realign its geometric arrangement to overcome the effects of cable failure and recover the original expected trajectory and complete the trajectory tracking task. In this paper we discuss a fault tolerant control (FTC) framework that relies on an Interactive Multiple Model (IMM) adaptive estimation filter for simultaneous fault detection and diagnosis (FDD) and task recovery. The redundancy resolution scheme for the kinematically redundant CDPR takes into account singularity avoidance, manipulability and wrench quality maximization during trajectory tracking. We further introduce a trajectory tracking methodology that enables the automatic task recovery algorithm to consistently return to the point of failure. This is particularly useful for applications where the planned trajectory is of greater importance than the goal positions, such as painting, welding or 3D printing applications. The proposed control framework is validated in simulation on a planar rCDPR with elastic cables and parameter uncertainties to introduce modeled and unmodeled dynamics in the system as it tracks a complete trajectory despite the occurrence of multiple cable failures. As cables fail one by one, the robot topology changes from an over-constrained to a fully constrained and then an under-constrained CDPR. The framework is applied with a constant-velocity kinematic feedforward controller which has the advantage of generating steady-state inputs despite dynamic oscillations during cable failures, as well as a Linear Quadratic Regulator (LQR) feedback controller to locally dampen these oscillations.

Active travel to school: a longitudinal millennium cohort study of schooling outcomes

OBJECTIVES

Assess longitudinal associations between active travel during the school commute and later educational outcomes.

SETTING

England, Wales and Northern Ireland.

PARTICIPANTS

6778 children, surveyed at ages 7, 11, 14 and 17.

PRIMARY AND SECONDARY OUTCOMES

School-leaver General Certificate of Secondary Education exam scores summed to provide a single measure of educational success.

RESULTS

Controlling a range of sociodemographic and health variables, using active versus passive travel modes during a child's commute to school during earlier years predicted differences in school-leaver exam performance at age 16. These effects were mediated through changes in self-esteem, emotional difficulties and behavioural difficulties. Examples include: being driven to school at 11 was associated with improved exam performance at 16 mediated through enhanced self-esteem at 14 (ab=0.08, 95% CI=0.01 to 0.20, p=0.05) and cycling at 14 was associated with better exam scores at 16 mediated through reduced emotional difficulty at 16 (ab=0.10, 95% CI=0.01 to 0.30, p=0.05). The relationship between travel mode and exam performance was moderated by household income quintile, most notably with poorer exam performance seen in high-income children who were driven to school. Importantly, although our model predicted 21% of variance in exam performance, removing travel mode barely reduced its ability to predict exam scores (ΔR ²=-0.005, F _20,6469 = 2.50, p<0.001).

CONCLUSION

There are differences in school-leaver exam performance linked to travel mode choices earlier in the school career, but these differences are extremely small. There appears to be no realistic educational disadvantage from any given travel mode, strengthening the case for cleaner, healthier modes to become the default.

COVID-19 vaccination intentions and subsequent uptake: An analysis of the role of marginalisation in society using British longitudinal data

COVID-19 vaccine hesitancy has previously been modelled using data on intentions - expressed prior to vaccine availability. Once vaccines became widely available, it became possible to model hesitancy using actual vaccination uptake data. This paper estimates the determinants of the joint distribution of COVID-19 vaccination intentions (declared before the release of any vaccine) and actual vaccination take-up (when it was widely available across the age distribution). We use high quality longitudinal data (UK Household Longitudinal Study) collected during the pandemic in the UK, merged to a wide variety of individual characteristics collected prior to the COVID-19 pandemic. Our estimation draws on pre-Covid values of variables for a sample that includes 10,073 observations from the September 2021 wave. The contribution of this paper is to model hesitancy and uptake jointly. The work shows that people who might be regarded as marginalised in society (measured, before the pandemic began) are less likely to say that they intend to be vaccinated and they go on to also be more likely to actually remain unvaccinated. It also shows that there is a large positive correlation between the unobservable determinants of intention and of uptake. This high positive correlation has an important implication - that information campaigns can be reasonably well profiled to target specific groups on the basis of intention data alone. We also show that changing one's mind is not correlated with observable data. This is consistent with two explanations. Firstly, the new information available on the arrival of vaccines, that they are safe and effective, may be more optimistic than was originally assumed. Secondly, individuals may have been more pessimistic about the effects associated with infection before vaccines became available.

Cardiovascular events among recipients of hematopoietic stem cell transplantation-A systematic review and meta-analysis

Cardiovascular diseases are an emerging cause of mortality and morbidity in survivors of hematopoietic stem cell transplantation (HSCT); however, the incidence of cardiovascular events (CVEs) in this population is not well described. This systematic review summarizes the evidence on the incidence of CVEs in HSCT recipients. Medline and Embase were searched from inception to December 2020. Inclusion criteria were cohort studies and phase 3 randomized controlled trials that reported CVEs among adults who underwent HSCT for hematological malignancies. After reviewing 8386 citations, 57 studies were included. The incidence of CVEs at 100 days was 0.19 (95% CI: 0.17-0.21) per 100 person-days after autologous HSCT and 0.06 (95% CI: 0.05-0.07) per 100 person-days after allogeneic HSCT. This higher incidence after autologous HSCT was driven by reports of arrhythmia from one population-based study in patients with multiple myeloma. The incidence of long-term CVEs was 3.98 (95% CI; 3.44-4.63) per 1000 person-years in survivors of autologous HSCT and 3.06 (95% CI; 2.69-3.48) per 1000 person-years in survivors of allogeneic HSCT. CVEs remain an important but under-reported cause of morbidity and mortality in recipients of HSCT. Future studies are required to better understand the incidence and risk factors for CVEs in HSCT recipients.

Cannabinoid hyperemesis syndrome in North America: evaluation of health burden and treatment prevalence

BACKGROUND

Cannabinoid hyperemesis syndrome (CHS) is a poorly understood vomiting disorder associated with chronic cannabis use.

AIMS

To characterise patients experiencing CHS in North America and to obtain a population-based estimate of CHS treatment prevalence in Canada before and during the Covid-19 pandemic METHODS: Internet survey of 157 CHS sufferers in Canada and the United States. Administrative health databases for the province of Alberta (population 5 million) were accessed to measure emergency department (ED) visits for vomiting, with a concurrent diagnostic code for cannabis use. Three time periods of 1 year were assessed: prior to recreational cannabis legalisation (2017-2018), after recreational legalisation (2018-2019) and during the first year of the Covid-19 pandemic (2020-2021).

RESULTS

Problematic cannabis use (defined as a CUDIT-R score ≥8) was universal among the survey cohort, and 59% and 68% screening for moderate or worse anxiety or depression, respectively. The overall treatment prevalence of CHS across all ages increased from 15 ED visits per 100,000 population (95% CI, 14-17) prior to legalisation, to 21 (95% CI, 20-23) after legalisation, to 32 (95% CI, 31-35) during the beginning of the Covid-19 pandemic (p < 0.001). Treatment prevalence among chronic cannabis users was as high as 6 per 1000 in the 16-24 age group.

CONCLUSION

Survey data suggest patients with CHS almost universally suffer from a cannabis use disorder, which has significant treatment implications. Treatment prevalence in the ED has increased substantially over a very short time period, with the highest rates seen during the Covid-19 pandemic.

A perspective on plant robotics: from bioinspiration to hybrid systems

As miscellaneous as the Plant Kingdom is, correspondingly diverse are the opportunities for taking inspiration from plants for innovations in science and engineering. Especially in robotics, properties like growth, adaptation to environments, ingenious materials, sustainability, and energy-effectiveness of plants provide an extremely rich source of inspiration to develop new technologies-and many of them are still in the beginning of being discovered. In the last decade, researchers have begun to reproduce complex plant functions leading to functionality that goes far beyond conventional robotics and this includes sustainability, resource saving, and eco-friendliness. This perspective drawn by specialists in different related disciplines provides a snapshot from the last decade of research in the field and draws conclusions on the current challenges, unanswered questions on plant functions, plant-inspired robots, bioinspired materials, and plant-hybrid systems looking ahead to the future of these research fields.

Integrating mental health into emergency preparedness and response: lessons learned from Covid-19

Introduction

The COVID-19 crisis has disrupted health systems all over the world. In a survey by the WHO, 93% of the countries reported disruption in their mental health services. This research assessed the extent to which mental health was included in the national response to the COVID-19 pandemic in African countries. It also explored barriers and enablers to mental health integration into the COVID-19 response. Lessons learned from COVID-19 can help improve the response to future public health emergencies.

Methods

A web-based survey was sent to mental health focal points in 55 African countries. The survey assessed the perceived degree of implementation of the Inter-Agency Standing Committee (IASC) “14 Globally Recommended Activities” for mental health response to COVID-19. This was followed by in-depth interviews to explore barriers and enablers to mental health integration into the COVID-19 response.

Results

Responses were received from 28 countries. Lack of political will, poor funding, limited human resources, and weak pre-existing mental health systems were the key challenges in addressing mental health needs during COVID-19. Participants highlighted the need to capitalize on the increased attention to mental health during COVID-19 to support its integration into the emergency preparedness and response plans and strengthen health systems in the longer term. They have also stressed the importance of sustaining and strengthening the new partnerships and service delivery models that emerged during the COVID-19 pandemic.

Conclusions

The number of recommended mental health activities implemented during the COVID-19 pandemic varied considerably across African countries. Several factors limit mental health integration into emergency response. However, there are signs of optimism, as mental health gained some attention during COVID-19, which can be built on to integrate mental health into emergency response and strengthen health systems in the long term.

Key messages

• Capitalize on the increased attention to mental health during COVID-19 to support its integration into the emergency preparedness and response plans and strengthen health systems in the long term.

• Sustain and strengthen the new partnerships and service delivery models that emerged during the COVID-19 pandemic.

Evaluation of prognostic risk models for postoperative pulmonary complications in adult patients undergoing major abdominal surgery: a systematic review and international external validation cohort study

BACKGROUND

Stratifying risk of postoperative pulmonary complications after major abdominal surgery allows clinicians to modify risk through targeted interventions and enhanced monitoring. In this study, we aimed to identify and validate prognostic models against a new consensus definition of postoperative pulmonary complications.

METHODS

We did a systematic review and international external validation cohort study. The systematic review was done in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. We searched MEDLINE and Embase on March 1, 2020, for articles published in English that reported on risk prediction models for postoperative pulmonary complications following abdominal surgery. External validation of existing models was done within a prospective international cohort study of adult patients (≥18 years) undergoing major abdominal surgery. Data were collected between Jan 1, 2019, and April 30, 2019, in the UK, Ireland, and Australia. Discriminative ability and prognostic accuracy summary statistics were compared between models for the 30-day postoperative pulmonary complication rate as defined by the Standardised Endpoints in Perioperative Medicine Core Outcome Measures in Perioperative and Anaesthetic Care (StEP-COMPAC). Model performance was compared using the area under the receiver operating characteristic curve (AUROCC).

FINDINGS

In total, we identified 2903 records from our literature search; of which, 2514 (86·6%) unique records were screened, 121 (4·8%) of 2514 full texts were assessed for eligibility, and 29 unique prognostic models were identified. Nine (31·0%) of 29 models had score development reported only, 19 (65·5%) had undergone internal validation, and only four (13·8%) had been externally validated. Data to validate six eligible models were collected in the international external validation cohort study. Data from 11 591 patients were available, with an overall postoperative pulmonary complication rate of 7·8% (n=903). None of the six models showed good discrimination (defined as AUROCC ≥0·70) for identifying postoperative pulmonary complications, with the Assess Respiratory Risk in Surgical Patients in Catalonia score showing the best discrimination (AUROCC 0·700 [95% CI 0·683-0·717]).

INTERPRETATION

In the pre-COVID-19 pandemic data, variability in the risk of pulmonary complications (StEP-COMPAC definition) following major abdominal surgery was poorly described by existing prognostication tools. To improve surgical safety during the COVID-19 pandemic recovery and beyond, novel risk stratification tools are required.

FUNDING

British Journal of Surgery Society.

Hemostats in Spine Surgery: Literature Review and Expert Panel Recommendations

Bleeding in spine surgery is a common occurrence but when bleeding is uncontrolled the consequences can be severe due to the potential for spinal cord compression and damage to the central nervous system. There are many factors that influence bleeding during spine surgery including patient factors and those related to the type of surgery and the surgical approach to bleeding. There are a range of methods that can be employed to both reduce the risk of bleeding and achieve hemostasis, one of which is the adjunct use of hemostatic agents. Hemostatic agents are available in a variety of forms and materials and with considerable variation in cost, but specific evidence to support their use in spine surgery is sparse. A literature review was conducted to identify the pre-, peri-, and postsurgical considerations around bleeding in spine surgery. The review generated a set of recommendations that were discussed and ratified by a wider expert group of spine surgeons. The results are intended to provide a practical guide to the selection of hemostats for specific bleeding situations that may be encountered in spine surgery.

Prevention of Periprosthetic Joint Infection in Total Hip and Knee Replacement: One European Consensus

Periprosthetic joint infection (PJI) is a devastating complication in total hip and knee replacement. Its prevention is key to decrease the incidence and avoid some consequences that seriously impact patients and health systems. In view of the variety of recommendations and guidelines, we decided to conduct an expert, peer-reviewed European consensus analysis about the pre-, intra-, and postoperative prevention of PJI. A multinational group of practicing orthopedic experts developed a series of 47 consensus statements in 6 main groups of intervention, and a 2-stage Delphi approach was launched with a threshold for agreement at 75% and for very high agreement at more than 90%. A total of 306 orthopedic surgeon responses were gathered from 9 countries. Consensus was reached for 42/47 statements, 31/47 of which achieved a very high consensus. Many preoperative actions gathered strong consensus, although areas like the use of alcoholic chlorhexidine or the timing of hair removal did not attain strong consensus, despite available evidence. Intra- and postoperative actions showed more variability regarding incise drapes, skin suturing techniques, and wound follow-up. This study confirms an important consensus among orthopedic surgeons across Europe in many areas well known to contribute to the prevention of PJI; however, there are still grounds for improvement.

Examining the effectiveness of Gateway-an out-of-court community-based intervention to reduce recidivism and improve the health and well-being of young adults committing low-level offences: study protocol for a randomised controlled trial

BACKGROUND

Young adult offenders represent a third of the UK prison population and are at risk of poor health outcomes including drug and alcohol misuse, self-harm and suicide. Court diversion interventions aim to reduce the negative consequences of formal criminal justice sanctions and focus resources on addressing the root causes of offending. Although diversions are widely used, evidence of their effectiveness has not yet been established. Hampshire Constabulary, working together with local charities, have developed the Gateway programme, an out-of-court intervention aimed at improving the life chances of young adults. Issued as a conditional caution, participants undertake a health and social care needs assessment, attend workshops encouraging analysis of own behaviour and its consequences and agree not to re-offend during the 16-week caution.

METHODS

This is a pragmatic, multi-site, parallel-group, superiority randomised controlled trial with a target sample size of 334. Participants are aged 18-24, reside in Hampshire and Isle of Wight and are being questioned for an eligible low-level offence. Police investigators offer potential participants a chance to receive the Gateway caution, and those interested are also invited to take part in the study. Police officers obtain Stage 1 consent and carry out an eligibility check, after which participants are randomised on a 1:1 basis either to receive Gateway or follow the usual process, such as court appearance or a different conditional caution. Researchers subsequently obtain Stage 2 consent and collect data at weeks 4 and 16, and 1 year post-randomisation. The primary outcome is the Warwick-Edinburgh Mental Well-being Scale (WEMWBS). Secondary outcomes include health status, alcohol and drug use, recidivism and resource use. The primary analysis will compare the WEMWBS score between the two groups at 12 months.

DISCUSSION

This pioneering trial aims to address the evidence gap surrounding diversion in 18-24-year-olds. The findings will inform law enforcement agencies, third sector organisations, policymakers and commissioners, as well as researchers working in related fields and with vulnerable target populations.

TRIAL REGISTRATION

International Standard Randomised Controlled Trial Register ( ISRCTN 11888938 ).

Cardiovascular events among recipients of hematopoietic stem cell transplantation

Background

Allogeneic and autologous hematopoietic stem cell transplantation (HSCT) are potential curative treatments for several hematological malignancies (1). Survival after HSCT has improved over the last decade, but survivors remain at risk for health issues after transplantation. Cardiovascular complications after HSCT are increasingly recognized (2). Cardiovascular diseases may be an important cause of mortality and morbidity in patients after HSCT owing to the toxicities of the cancer therapies; however, the incidence of cardiovascular events (CVEs) in this population has not been completely characterized. The objective of this systematic review is to summarize the evidence on the incidence of CVEs in HSCT recipients.

Methods

Medline and Embase were searched from inception to December 2020 without language restriction. Two authors independently screened the titles and abstracts. Inclusion criteria were: cohort studies and phase 3 randomized controlled trials that reported CVEs (i.e., heart failure, arrythmias, acute coronary syndrome, and stroke) or cardiovascular death among adults who underwent HSCT for a hematological malignancy. All-cause mortality, relapse-related mortality, and non-relapse-related mortality (NRM) were also collected. Studies in which the follow up period was not started immediately after HSCT were excluded due to the risk of immortal bias.

Results

Of 8151 nonduplicate articles, 30 studies including 14019 individuals post autologous HSCT, and 22 studies including 31049 individuals post allogeneic HSCT met the inclusion criteria.

The cumulative incidence of CVEs in the first 100 days post autologous HSCT was 9% and arrhythmia (i.e., atrial fibrillation) was the most common CVE. In recipients of allogeneic HSCT, the 100-day cumulative incidence of CVEs was 3%, and heart failure (HF) was the most common reported CVE. In recipients of autologous and allogeneic HSCT, cardiovascular death was responsible for 43% and 10% of NRM within 100 days, respectively (Table 1).

The incidence of CVEs was 4.96 per 1000-person years (95% CI; 4.21–5.80) in long-term survivors (beyond 100-days) of autologous HSCT, and HF was the most common CVE in this population. In long-term survivors of allogeneic HSCT, the incidence of CVEs was 1.90 per 1000-person years (95% CI: 1.59–2.24). Cardiovascular death was the most frequently reported CVE in long-term survivors of allogeneic HSCT (Table 2).

Conclusion

CVEs remain a major cause of non relapse morbidity and mortality in recipients of HSCT, especially recipients of autologous HSCT within the first 100 days. Future studies are needed to identify the risk factors for CVEs that are specific to HSCT recipients.

Funding Acknowledgement

Type of funding sources: None.

Exploring consensus for the optimal sealant use to prevent air leak following lung surgery: a modified Delphi survey from The European Society of Thoracic Surgeons

OBJECTIVES

The use of sealants is one of the methods available to reduce the occurrence of intraoperative air leaks. The objective of this modified Delphi survey among ESTS members is to understand the attitudes of clinicians to the optimal use of sealants in air leak management.

METHODS

To understand the attitudes of a wider sample of clinicians, a questionnaire was developed highlighting key issues through 37 statements. Respondents were invited to score their level of agreement with each. A modified Delphi methodology was used to review responses with a threshold of agreement for consensus of 75%.

RESULTS

A total of 258 responses were received (response rate 17%). Respondents agreed that prolonged air leaks are a common complication in thoracic surgery presenting a burden to the patient and increasing the costs of care. There is clear support for the use of sealants to reduce costs and improve the efficiency of healthcare provision and duration of chest tube use in selected high-risk patients with intraoperative air leak at the end of the lung surgery. Respondents also agreed that, due to often complex nature of thoracic surgery, sealants should be developed specifically for this application.

CONCLUSION

There is a clear role for sealants in the management of air leaks and certain surgical procedures demand their use (i.e. lung volume reduction surgery, decortication). This opinion-based consensus review helps to raise the debate about the burden of air leaks in thoracic surgery in order that this issue is recognized in practice and informs the optimal use of sealants in lung surgery.

An equity-oriented admissions model for Indigenous student recruitment in an undergraduate medical education program

BACKGROUND

With the 2015 publication of the Truth and Reconciliation Commission of Canada's calls to action, health professional schools are left grappling with how to increase the recruitment and success of Indigenous learners. Efforts to diversify trainee pools have long looked to quota-based approaches to recruit students from underserved communities, though such approaches pose dilemmas around meaningfully dismantling structural barriers to health professional education. Lessons shared here from developing one multi-layered admissions strategy highlight the importance of equity-rather than equality-in any recruitment for learners from medically underserved communities.

SUMMARY

The promotion of fairness in the recruitment of future practitioners is not just a question of equalizing access to, in this case, medical school; it involves recognizing the wider social and structural mechanisms that enable privileged access to the medical profession by members of dominant society. This recognition compels a shift in focus beyond merely giving the disadvantaged increased access to an unfair system, towards building tools to address deeper questions about what is meant by the kind of excellence expected of applicants, how it is to be measured, and to what extent these recruits may contribute to improved care for the communities from which they come.

CONCLUSION

Equity-based approaches to student recruitment move health professional schools beyond the dilemma of recruiting students from marginalized backgrounds who happen to be most similar to the dominant student population. Achieving this requires a complex view of the target population, recognizing that disadvantage is experienced in many diverse ways, that barriers are encountered along a spectrum of access, and that equity may only emerge when a critically, socially conscious approach is embedded throughout institutional practices.

Guideline on the peri-operative management of patients with sickle cell disease: Guideline from the Association of Anaesthetists

Sickle cell disease is a multisystem disease characterised by chronic haemolytic anaemia, painful vaso-occlusive crises and acute and chronic end-organ damage. It is one of the most common serious inherited single gene conditions worldwide and has a major impact on the health of affected individuals. Peri-operative complications are higher in patients with sickle cell disease compared with the general population and may be sickle or non-sickle-related. Complications may be reduced by meticulous peri-operative care and transfusion, but unnecessary transfusion should be avoided, particularly to reduce the risk of allo-immunisation. Planned surgery and anaesthesia for patients with sickle cell disease should ideally be undertaken in centres with experience in caring for these patients. In an emergency, advice should be sought from specialists with experience in sickle cell disease through the haemoglobinopathy network arrangements. Emerging data suggest that patients with sickle cell disease are at increased risk of COVID-19 infection but may have a relatively mild clinical course. Outcomes are determined by pre-existing comorbidities, as for the general population.

Causality matters in medical imaging

Causal reasoning can shed new light on the major challenges in machine learning for medical imaging: scarcity of high-quality annotated data and mismatch between the development dataset and the target environment. A causal perspective on these issues allows decisions about data collection, annotation, preprocessing, and learning strategies to be made and scrutinized more transparently, while providing a detailed categorisation of potential biases and mitigation techniques. Along with worked clinical examples, we highlight the importance of establishing the causal relationship between images and their annotations, and offer step-by-step recommendations for future studies.

Judgments of a Product's Quality and Perceptions of User Experience Can Be Mediated by Brief Messaging That Matches the Person's Pre-existing Attitudes

The mediation of an attitude to a product following a brief message is investigated. Statements indicating whether a computer was running on energy from renewable or more conventional sources were presented and users' experiences were measured. Participants' pre-existing environmental concern and the satisfaction they expressed with the computers were related, but only when the "renewable energy" message was presented. We conclude that enduring attitudes to environmental concern and situation-specific knowledge can interact in evaluations of a situation - a finding with implications for behavior-change strategies. Theoretically, results are discussed in terms of "spillover" from one behavior to another, the Halo Effect and self-activation, where those with a self-identity of being environmentally conscious have this identity activated by messaging congruent with their self-identity, resulting in an influence of their opinion of a product. Conversely, those with an anti-environmental worldview might rate products more negatively when the product's environmental credentials are mentioned, presumably because these credentials are not congruent with self-identity.

"Death is a better option than being treated like this": a prevalence survey and qualitative study of depression among multi-drug resistant tuberculosis in-patients

Background

Understanding of the relationship between multi-drug resistant tuberculosis and mental health is limited. With growing prevalence of multi-drug resistant tuberculosis, addressing mental ill-health has potential to improve treatment outcomes and well-being. In several low and middle-income contexts hospitalisation during treatment is common. Understanding of the impact on mental ill-health are required to inform interventions for patients with multi-drug resistant tuberculosis.

Our aim was to identify the prevalence of comorbid depression among in-patients being treated for multi-drug resistant tuberculosis and to explore their experiences of comorbid disease and the care they received in a large specialist chest hospital in Dhaka, Bangladesh.

Methods

We conducted a quantitative cross-sectional survey among 150 multi-drug resistant tuberculosis in-patients (new cases = 34%, previously treated = 66%) in 2018. A psychiatrist assessed depression was assessed with the Structured Clinical Interview for Depression (SCID DSM-IV). We used multi-level modelling to identify associations with depression. Experience Bangladeshi researchers conducted qualitative interviews with 8 patients, 4 carers, 4 health professionals and reflective notes recorded. Qualitative data was analysed thematically.

Results

We found 33.8% (95% CI 26.7%; 41.7%) of patients were depressed. While more women were depressed 39.3% (95% CI 27.6%; 52.4%) than men 30.4% (95% CI 22%; 40.5%) this was not significant. After controlling for key variables only having one or more co-morbidity (adjusted odds ratio [AOR] = 2.88 [95% CI 1.13; 7.33]) and being a new rather than previously treated case (AOR = 2.33 [95% CI 1.06; 5.14]) were associated (positively) with depression. Qualitative data highlighted the isolation and despair felt by patients who described a service predominantly focused on providing medicines. Individual, familial, societal and health-care factors influenced resilience, nuanced by gender, socio-economic status and home location.

Conclusions

Patients with multi-drug resistant tuberculosis are at high risk of depression, particularly those with co- and multi-morbidities. Screening for depression and psycho-social support should be integrated within routine TB services and provided throughout treatment.

A global database of Holocene paleotemperature records

A comprehensive database of paleoclimate records is needed to place recent warming into the longer-term context of natural climate variability. We present a global compilation of quality-controlled, published, temperature-sensitive proxy records extending back 12,000 years through the Holocene. Data were compiled from 679 sites where time series cover at least 4000 years, are resolved at sub-millennial scale (median spacing of 400 years or finer) and have at least one age control point every 3000 years, with cut-off values slackened in data-sparse regions. The data derive from lake sediment (51%), marine sediment (31%), peat (11%), glacier ice (3%), and other natural archives. The database contains 1319 records, including 157 from the Southern Hemisphere. The multi-proxy database comprises paleotemperature time series based on ecological assemblages, as well as biophysical and geochemical indicators that reflect mean annual or seasonal temperatures, as encoded in the database. This database can be used to reconstruct the spatiotemporal evolution of Holocene temperature at global to regional scales, and is publicly available in Linked Paleo Data (LiPD) format.

Geometric constraint-based modeling and analysis of a novel continuum robot with Shape Memory Alloy initiated variable stiffness

Continuum robots exhibit promising adaptability and dexterity for soft manipulation due to their intrinsic compliance. However, this compliance may lead to challenges in modeling as well as positioning and loading. In this paper, a virtual work-based static model is established to describe the deformation and mechanics of continuum robots with a generic rod-driven structure, taking the geometric constraint of the drive rods into account. Following this, this paper presents a novel variable stiffness mechanism powered by a set of embedded Shape Memory Alloy (SMA) springs, which can make the drive rods become ‘locked’ on the body structure with different configurations. The resulting effects of variable stiffness are then presented in the static model by introducing tensions of the SMA and friction on the rods. Compared with conventional models, there is no need to predefine the actuation forces of the drive rods; instead, actuation displacements are used in this new mechanism system with stiffness being regulated. As a result, the phenomenon that the continuum robot can exhibit an S-shaped curve when subject to single-directional forces is observed and analyzed. Simulations and experiments demonstrated that the presented mechanism has stiffness variation of over 287% and further demonstrated that the mechanism and its model are achievable with good accuracy, such that the ratio of positioning error is less than 2.23% at the robot end-effector to the robot length.

A systematic review and meta-analysis of the prevalence of common mental disorders in people with non-communicable diseases in Bangladesh, India, and Pakistan

Background

The prevalence of mental and physical comorbidities is unknown in South Asia, as estimates of mental ill health in patients with non-communicable diseases (NCDs) have predominantly come from studies based in the United States, Europe and Australasia. This systematic review and meta-analysis summarises evidence and provides pooled estimates of the prevalence of common mental disorders in adults with non-communicable diseases in South Asia.

Methods

We included prevalence studies of depression and anxiety in adults with diabetes, cancer, cardiovascular disease, and chronic respiratory conditions in Bangladesh, India, and Pakistan, published from 1990 onwards in international and country-specific databases.

Results

Out of 96 included studies, 83 provided data for random effects meta-analyses. The pooled prevalence of depression was 44% (95% confidence interval (CI) = 26 to 62) for patients with COPD, 40% (95% CI = 34 to 45) for diabetes, 39% (95% CI = 23 to 56) for stroke, 38% (95% CI = 32 to 45) for hypertension, and 37% (95% CI = 30 to 45) for cancer. The pooled prevalence of anxiety based on 28 studies was 29% (95% CI = 22 to 36). Many quality issues were identified in a critical appraisal of included studies, mostly relating to the sampling frame and selection process, the description of the methods and basic data, and the description of non-responders.

Conclusions

Depression and anxiety are prevalent and underdiagnosed in people with physical comorbidities in Bangladesh, India, and Pakistan.

Empty mast cell syndrome: fallacy or fact?

Post-anaphylaxis mast cell anergy (PAMA), commonly referred to as 'empty mast cell (MC) syndrome', is a state of temporary loss of cutaneous MC reactivity in the immediate aftermath of anaphylaxis. Data relating to this condition are sparse and the incidence rate is currently unknown. PAMA has been described only in a few published case reports in the context of hymenoptera venom allergy and perioperative anaphylaxis. Best practice guidelines regarding optimal timing for performing skin tests postanaphylaxis are largely based on expert opinion, and allergy work-up has been recommended after 4-6 weeks postanaphylaxis to avoid false-negative results.This article provides a review of clinical literature surrounding PAMA, critically evaluates intracellular events in MCs from in vitro data and hypothesises regarding plausible immune mechanisms. There are no published data to directly explain molecular mechanisms underlying this phenomenon. Although not evidence based, PAMA has been attributed to depletion of MC granules following anaphylaxis. It is also plausible that exposure to high allergen concentrations in anaphylaxis can induce a temporary shift in MCs towards dominance of inhibitory signalling pathways, thus contributing to a state of transient hyporesponsiveness observed in some patients. Other potential contributory factors for reduced MC reactivity include downregulation of FcεRI expression, cross-linking of FcεRI to the inhibitory, low-affinity IgG receptors and administration of pharmacotherapeutic agents for anaphylaxis treatment. It is likely that this interesting phenomenon can be explained by a combination of these proposed mechanisms in addition to other genetic/host factors that have not yet been identified.

Defective tubulin detyrosination causes structural brain abnormalities with cognitive deficiency in humans and mice

Reversible detyrosination of tubulin, the building block of microtubules, is crucial for neuronal physiology. Enzymes responsible for detyrosination were recently identified as complexes of vasohibins (VASHs) one or two with small VASH-binding protein (SVBP). Here we report three consanguineous families, each containing multiple individuals with biallelic inactivation of SVBP caused by truncating variants (p.Q28* and p.K13Nfs*18). Affected individuals show brain abnormalities with microcephaly, intellectual disability and delayed gross motor and speech development. Immunoblot testing in cells with pathogenic SVBP variants demonstrated that the encoded proteins were unstable and non-functional, resulting in a complete loss of VASH detyrosination activity. Svbp knockout mice exhibit drastic accumulation of tyrosinated tubulin and a reduction of detyrosinated tubulin in brain tissue. Similar alterations in tubulin tyrosination levels were observed in cultured neurons and associated with defects in axonal differentiation and architecture. Morphological analysis of the Svbp knockout mouse brains by anatomical magnetic resonance imaging showed a broad impact of SVBP loss, with a 7% brain volume decrease, numerous structural defects and a 30% reduction of some white matter tracts. Svbp knockout mice display behavioural defects, including mild hyperactivity, lower anxiety and impaired social behaviour. They do not, however, show prominent memory defects. Thus, SVBP-deficient mice recapitulate several features observed in human patients. Altogether, our data demonstrate that deleterious variants in SVBP cause this neurodevelopmental pathology, by leading to a major change in brain tubulin tyrosination and alteration of microtubule dynamics and neuron physiology.

Executive Function: Cognition and Behaviour in Adults with Autism Spectrum Disorders (ASD)

Studies of executive function (EF) in autism spectrum disorder (ASD) have reported mixed findings. Possible confounds include EF domain assessed and co-occurring neurodevelopmental diagnoses. EF task performance across multiple domains and everyday function of autistic adults (n = 110) was significantly different to age- and IQ-matched controls (n = 31). Although significantly more likely to fall into the clinically impaired range, 35.8% of the ASD group showed no impairment on EF measures. Factor analysis revealed a single unifying EF construct rather than a selective pattern of impairment. Dysexecutive behaviours were frequently reported in the ASD group, unrelated to Autism symptoms, EF task performance or co-occurring conditions. This study suggests autistic adults can experience clinically significant executive function difficulties and co-occuring dysexecutive behaviours that are disabling in everyday life.

Enzymatic quantification of total serum bile acids as a monitoring strategy for women with intrahepatic cholestasis of pregnancy receiving ursodeoxycholic acid treatment: a cohort study

OBJECTIVE

To evaluate enzymatic total serum bile acid quantification as a monitoring strategy for women with intrahepatic cholestasis of pregnancy (ICP) treated with ursodeoxycholic acid (UDCA).

DESIGN

Cohort.

SETTING

One UK university hospital.

POPULATION

29 ICP cases treated with UDCA.

METHODS

Serial samples were collected prospectively throughout gestation. Total serum bile acids were measured enzymatically and individual bile acids by high-performance liquid chromatography-tandem mass spectrometry. Data were log-transformed and analysed with random effects generalised least square regression.

MAIN OUTCOME MEASURES

The relationship between enzymatic total bile acid measurements and individual bile acid concentrations after UDCA treatment.

RESULTS

In untreated women, cholic acid was the principal bile acid (51%) and UDCA concentrations were <0.5%, whereas UDCA constituted 60% (IQR 43-69) of serum bile acids following treatment and cholic acid fell to <20%. Changes in the total bile acid measurement reflected similar alterations in the concentrations of the pathologically elevated bile acids, e.g. a two-fold increase in enzymatic total bile acids is accompanied by approximately a two-fold increase in cholic acid and chenodeoxycholic acid at most UDCA doses (P < 0.001). Most of the effects of UDCA on cholic acid occur in the first week of treatment (60% relative reduction, P = 0.025, 95% CI 0.2-0.9, from 10 micromol/l (4.7-17.6) to 3.5 micromol/l (1.4-7.5).

CONCLUSION

Ursodeoxycholic acid becomes the main component of the bile acid measurement after treatment. Enzymatic total bile acid assays are good predictors of both cholic acid and chenodeoxycholic acid, the primary bile acids that are raised prior to treatment.

TWEETABLE ABSTRACT

Ursodeoxycholic acid constitutes approximately 60% of the bile acid measurement and reduces pathological cholic acid in treated women.

Correction to: The macro-economic determinants of health and health inequalities-umbrella review protocol

Following publication of the original article [1], the authors opted to correct the following reference on page 3.

The Safer Anaesthesia from Education (SAFE)® paediatric anaesthesia course: educational impact in five countries in East and Central Africa

There is an urgent need to improve access to safe surgical and anaesthetic care for children living in many low- and middle-income countries. Providing quality training for healthcare workers is a key component of achieving this. The 3-day Safer Anaesthesia from Education (SAFE)^® paediatric anaesthesia course was developed to address the specific skills and knowledge required in this field. We undertook a project to expand this course across five East and Central African countries (Ethiopia, Kenya, Malawi, Uganda and Zambia) and train local faculty. This study reports the outcomes from course evaluation data, exploring the impact on knowledge, skills and behaviour change in participants. Eleven courses were conducted in a 15-month period, with 381 participants attending. Fifty-nine new faculty members were trained. Knowledge scores (0-50 scale) increased significantly from mean (SD) 37.5 (4.7) pre-course to 43.2 (3.5) post-course (p < 0.0001). Skills scores (0-10 scale) increased significantly from 5.7 (2.0) pre-course to 8.0 (1.5) post-course (p < 0.0001). One hundred and twenty-six participants in Malawi, Uganda and Zambia were visited in their workplace 3-6 months later. Knowledge and skills were maintained at follow-up, with scores of 41.5 (5.0) and 8.3 (1.4), respectively (p < 0.0001 compared with pre-course scores). Content analysis from interviews with these participants highlighted positive behaviour changes in the areas of preparation, peri-operative care, resuscitation, management of the sick child, communication and teaching. This study indicates that the SAFE paediatric anaesthesia course is an effective way to deliver training, and could be used to help strengthen emergency and essential surgical care for children as a component of universal health coverage.

Alcohol quantity and quality price elasticities: quantile regression estimates

Many people drink more than the recommended level of alcohol, with some drinking substantially more. There is evidence that suggests that this leads to large health and social costs, and price is often proposed as a tool for reducing consumption. This paper uses quantile regression methods to estimate the differential price (and income) elasticities across the drinking distribution. This is also done for on-premise (pubs, bars and clubs) and off-premise (supermarkets and shops) alcohol separately. In addition, we examine the extent to which drinkers respond to price changes by varying the 'quality' of the alcohol that they consume. We find that heavy drinkers are much less responsive to price in terms of quantity, but that they are more likely to substitute with cheaper products when the price of alcohol increases. The implication is that price-based policies may have little effect in reducing consumption amongst the heaviest drinkers, provided they can switch to lower quality alternatives.

Does the Medical College Admission Test (MCAT) predict licensing examination performance in the Canadian context?

BACKGROUND

Research on the predictive validity of the Medical College Admissions Test (MCAT) on licensing examination performance is varied in its conclusions, with only a few studies examining this relationship in a Canadian context. We assessed the predictive validity of the MCAT on successful performance on the Medical Council of Canada Qualifying Examination (MCCQE) Part 1 by students attending the Cumming School of Medicine.

METHODS

Prospective data were collected on MCAT score and sub-section scores, MCCQE decision, multiple mini interview (MMI) performance, gender, and age. The cohort was divided into a derivation cohort (2013 and 2014) and validation cohort (2015 and 2016). Students were dichotomized into pass or fail on MCCQE. Multiple logistic regression in which our dependent variable was MCCQE Part I examination success at the first attempt was used, and potential explanatory variables were age, gender, MCAT total score, and sub-scores for the biological sciences (MCAT-BS), physical sciences, and verbal reasoning, GPA, and MMI ratings.

RESULTS

For the derivation cohort MCAT-BS was associated with success on the MCCQE Part I. The odds ratio for this association of 1.37 (95% confidence interval [1.01, 1.85], p = 0.04). When we applied the MCAT-BS to our validation cohort the odds ratio of MCCQE Part I examination success was 1.42 [1.10, 1.83], p = 0.007) and the area under the ROC curve was 0.66 [0.54, 0.79]).

CONCLUSION

The MCAT-BS predicted successful performance on the MCCQE Part 1 Examination in the Canadian setting.

Bicycle helmet wearing is associated with closer overtaking by drivers: A response to Olivier and Walter, 2013

There is a body of research on how driver behaviour might change in response to bicyclists' appearance. In 2007, Walker published a study suggesting motorists drove closer on average when passing a bicyclist if the rider wore a helmet, potentially increasing the risk of a collision. Olivier and Walter re-analysed the same data in 2013 and claimed helmet wearing was not associated with close vehicle passing. Here we show how Olivier and Walter's analysis addressed a subtly, but importantly, different question than Walker's. Their conclusion was based on omitting information about variability in driver behaviour and instead dividing overtakes into two binary categories of 'close' and 'not close'; we demonstrate that they did not justify or address the implications of this choice, did not have sufficient statistical power for their approach, and moreover show that slightly adjusting their definition of 'close' would reverse their conclusions. We then present a new analysis of the original dataset, measuring directly the extent to which drivers changed their behaviour in response to helmet wearing. This analysis confirms that drivers did, overall, get closer when the rider wore a helmet. The distribution of overtaking events shifted just over one-fifth of a standard deviation closer to the rider - a potentially important behaviour if, as theoretical frameworks suggest, near-misses and collisions lie on a continuum. The paper ends by considering wider issues surrounding this topic and suggests public health research might be best served by shifting focus to risk elimination rather than harm mitigation.

The effect of the Winter Fuel Payment on household temperature and health: a regression discontinuity design study

Background

The Winter Fuel Payment (WFP) is a non-NHS population-level policy intervention that aims to reduce cold exposure and enhance the health and well-being of older adults. Labelling this cash transfer as ‘winter fuel’ has been shown to lead to increased household energy expenditure, but it is not known if this expenditure produces warmer homes or health benefits.

Objectives

First, the association between indoor temperature and health was established to identify the outcome measures most likely to be affected by the WFP. Then, whether or not receiving the WFP is associated with raised household temperature levels and/or improved health was assessed.

Design

Random and fixed effects regression models were used to estimate the link between ambient indoor temperature and health. A regression discontinuity (RD) design analysis exploiting the sharp eligibility criteria for the WFP was employed to estimate the potential impact of the payment.

Setting

The sample was drawn from the English Longitudinal Study of Ageing (ELSA), an observational study of community-dwelling individuals aged ≥ 50 years in England.

Participants

Analyses examining the association between household temperature and health had a maximum sample of 12,210 adults aged 50–90 years. The RD analyses drew on a maximum of 5902 observations.

Intervention

The WFP provides households with a member who is aged > 60 years (up to 2010, from which point the minimum age increased) in the qualifying week with a lump sum annual payment, typically in November or December.

Main outcome measures

Differences in indoor temperature were examined, and, following an extensive literature review of relevant participant-reported health indicators and objectively recorded biomarkers likely to be affected by indoor temperature, a series of key measures were selected: blood pressure, inflammation, lung function, the presence of chest infections, subjective health and depressive symptom ratings.

Data sources

The first six waves of the ELSA were drawn from, accessible through the UK Data Service (SN:5050 English Longitudinal Study of Ageing: Waves 0–7, 1998–2015).

Results

Results from both random and fixed-effects multilevel regression models showed that low levels of indoor temperature were associated with raised systolic and diastolic blood pressure levels and raised fibrinogen levels. However, across the RD models, no evidence was found that the WFP was consistently associated with differences in either household temperature or the health of qualifying (vs. non-qualifying) households.

Limitations

The presence of small effects cannot be ruled out, not detectable because of the sample size in the current study.

Conclusions

This study capitalised on the sharp assignment rules regarding WFP eligibility to estimate the potential effect of the WFP on household temperature and health in a national sample of English adults. The RD design employed did not identify evidence linking the WFP to warmer homes or potential health and well-being effects.

Future work

Further research should utilise larger samples of participants close to the WFP eligibility cut-off point examined during particularly cold weather in order to identify whether or not the WFP is linked to health benefits not detected in the current study, which may have implications for population health and the evaluation of the effectiveness of the WFP.

Funding

The National Institute for Health Research Public Health Research programme.

Somatic cancer genetics in the UK: real-world data from phase I of the Cancer Research UK Stratified Medicine Programme

INTRODUCTION

Phase I of the Cancer Research UK Stratified Medicine Programme (SMP1) was designed to roll out molecular pathology testing nationwide at the point of cancer diagnosis, as well as facilitate an infrastructure where surplus cancer tissue could be used for research. It offered a non-trial setting to examine common UK cancer genetics in a real-world context.

METHODS

A total of 26 sites in England, Wales and Scotland, recruited samples from 7814 patients for genetic examination between 2011 and 2013. Tumour types involved were breast, colorectal, lung, prostate, ovarian cancer and malignant melanoma. Centralised molecular testing of surplus material from resections or biopsies of primary/metastatic tissue was performed, with samples examined for 3-5 genetic alterations deemed to be of key interest in site-specific cancers by the National Cancer Research Institute Clinical Study groups.

RESULTS

10 754 patients (98% of those approached) consented to participate, from which 7814 tumour samples were genetically analysed. In total, 53% had at least one genetic aberration detected. From 1885 patients with lung cancer, KRAS mutation was noted to be highly prevalent in adenocarcinoma (37%). In breast cancer (1873 patients), there was a striking contrast in TP53 mutation incidence between patients with ductal cancer (27.3%) and lobular cancer (3.4%). Vast inter-tumour heterogeneity of colorectal cancer (1550 patients) was observed, including myriad double and triple combinations of genetic aberrations. Significant losses of important clinical information included smoking status in lung cancer and loss of distinction between low-grade and high-grade serous ovarian cancers.

CONCLUSION

Nationwide molecular pathology testing in a non-trial setting is feasible. The experience with SMP1 has been used to inform ongoing CRUK flagship programmes such as the CRUK National Lung MATRIX trial and TRACERx.

Using affective judgement to increase physical activity in British adults

Mobile phone apps have been shown to increase physical activity (PA), but existing apps fail to target the emotional aspects of PA, which influence whether individuals are active. We developed an app that encourages individuals to focus on the emotional aspects of PA. We aimed to assess the acceptability of this app, and conduct a preliminary evaluation of efficacy. The app was developed in collaboration with users through focus groups. Seven users tested the app over 4 months and provided feedback on acceptability, aesthetics and functionality in a follow-up focus group. Results were summarized descriptively. Before testing the app, participants completed a questionnaire assessing their current PA and psychological antecedents of PA. A second questionnaire was completed at the follow-up focus group. Change scores are reported for each participant and overall.The social and reminder aspects facilitated motivation to be active and many found it easy to integrate into their lives. Most suggested modifications. Small improvements in number of minutes spent walking per week were observed (overall mean change +25 min) and some psychological antecedents of PA (overall mean change for social support for PA +0.14, self-efficacy for PA +0.17, outcome expectations about PA +0.20; all five-point scales), but reductions were seen in other domains. The app was acceptable to users, although developments are required. Testing with a small number of individuals, offering preliminary evidence of efficacy of this app, provides justification for further evaluation on a larger scale.

Goal setting dynamics that facilitate or impede a client-centered approach

BACKGROUND

Client-centred goal setting is central to the process of enabling occupation. Yet, there are multiple barriers to incorporating client-centred goal setting in practice. We sought to determine what might facilitate or impede the formation of client-centred goals in a context highly supportive of client-centred goal setting Methods: We used conversational analysis to examine goal-setting conversations that took place during a pilot trial of Occupational Performance Coaching for stroke survivors. Twelve goal-setting sessions were purposively selected, transcribed, and analyzed according to conventions for conversation analysis.

RESULTS

Two main types of interactions were observed: introductory actions and goal selection actions. Introductory actions set the context for goal setting and involved sharing information and seeking clarification related to goal requirements and clients' occupational performance competencies. Goal selection actions were a series of interactions whereby the goals were explored, endorsed or dropped.

CONCLUSION

Client-centred occupational performance goals may be facilitated through placing goal-setting in the context of life changes and lifelong development of goals, and through listening to clients' stories. Therapists may improve consistency in adoption of client-suggested goals through clarifying meaning attached to goals and being attuned to power dynamics and underlying values and beliefs around risk and goal attainability.

A critical scoping review of the connections between social mission and medical school admissions: BEME Guide No. 47

BACKGROUND

Despite a growing focus on the social accountability of medical schools, there has been no substantive review of admissions related to the social mission of medical schools. This paper reports on a critical scoping review of the connections between social mission and medical school admissions.

METHODS

Searches of seven bibliographic databases identified 1258 unique articles. After filtering for relevance, 71 articles were considered for final review. The results of the data extraction were synthesized using a combination of qualitative and quantitative techniques.

RESULTS

Five reviewers conducted 149 data extractions from 71 papers. Social missions tended to focus either on access and equity issues for applicants from underrepresented populations or on the career choices of medical graduates and how they meet particular social needs. The connection between social missions and admissions was often implied but rarely considered or evaluated directly. There was a notable absence of empirical evidence, with calls for reform or program descriptions far outweighing the number of papers based on empirical findings.

CONCLUSIONS

Despite the move to social missions in medical education, there remains little direct connection between missions and admissions and little evidence reflecting the efficacy or impacts of making this connection.

An Evidence-based, Longitudinal Curriculum for Resident Physician Wellness: The 2017 Resident Wellness Consensus Summit

Introduction

Physicians are at much higher risk for burnout, depression, and suicide than their non-medical peers. One of the working groups from the May 2017 Resident Wellness Consensus Summit (RWCS) addressed this issue through the development of a longitudinal residency curriculum to address resident wellness and burnout.

Methods

A 30-person (27 residents, three attending physicians) Wellness Curriculum Development workgroup developed the curriculum in two phases. In the first phase, the workgroup worked asynchronously in the Wellness Think Tank – an online resident community – conducting a literature review to identify 10 core topics. In the second phase, the workgroup expanded to include residents outside the Wellness Think Tank at the live RWCS event to identify gaps in the curriculum. This resulted in an additional seven core topics.

Results

Seventeen foundational topics served as the framework for the longitudinal resident wellness curriculum. The curriculum includes a two-module introduction to wellness; a seven-module “Self-Care Series” focusing on the appropriate structure of wellness activities and everyday necessities that promote physician wellness; a two-module section on physician suicide and self-help; a four-module “Clinical Care Series” focusing on delivering bad news, navigating difficult patient encounters, dealing with difficult consultants and staff members, and debriefing traumatic events in the emergency department; wellness in the workplace; and dealing with medical errors and shame.

Conclusion

The resident wellness curriculum, derived from an evidence-based approach and input of residents from the Wellness Think Tank and the RWCS event, provides a guiding framework for residency programs in emergency medicine and potentially other specialties to improve physician wellness and promote a culture of wellness.

Development of a Case-based Reading Curriculum and Its Effect on Resident Reading

Textbook reading plays a foundational role in a resident's knowledge base. Many residency programs place residents on identical reading schedules, regardless of the clinical work or rotation the resident is doing. We sought to develop a reading curriculum that takes into account the clinical work a resident is doing so their reading curriculum corresponds with their clinical work. Preliminary data suggests an increased amount of resident reading and an increased interest in reading as a result of this change to their reading curriculum.

A computational model for designing energy behaviour change interventions

The conflicting evidence in the literature on energy feedback as a driver for energy behaviour change has lead to the realization that it is a complex problem and that interventions must be proposed and evaluated in the context of a tangled web of individual and societal factors. We put forward an integrated agent-based computational model of energy consumption behaviour change interventions based on personal values and energy literacy, informed by research in persuasive technologies, environmental, educational and cognitive psychology, sociology, and energy education. Our objectives are: (i) to build a framework to accommodate a rich variety of models that might impact consumption decisions, (ii) to use the simulation as a means to evaluate persuasive technologies in-silico prior to deployment. The model novelty lies in its capacity to connect the determinants of energy related behaviour (values, energy literacy and social practices) and several generic design strategies proposed in the area of persuasive technologies within one framework. We validate the framework using survey data and personal value and energy consumption data extracted from a 2-year field study in Exeter, UK. The preliminary evaluation results demonstrate that the model can predict energy saving behaviour much better than a random model and can correctly estimate the effect of persuasive technologies. The model can be embedded into an adaptive decision-making system for energy behaviour change.

Efficacy and Safety of the Factor VIII/von Willebrand Factor Concentrate, Haemate-P/Humate-P: Ristocetin Cofactor Unit Dosing in Patients with von Willebrand Disease

The present study was initiated to evaluate the safety and efficacy of Haemate-P® (Humate-P® in North America) (anti-hemophilic FVIII/VWF complex [human] dried, pasteurized) dosed in ristocetin cofactor units (VWF:RCo) in the treatment of von Willebrand disease (VWD) patients in Canada. This retrospective data collection reviewed the medical records of VWD patients treated under the Canadian Emergency Drug Release Program from November 22, 1991, to April 30, 1996. Data collection was accomplished by on-site retrieval from source data for 97 patients. Dosing was based on the German package insert, which lists only Factor VIII:C (FVIII:C) units, which were converted in the study analysis to VWF:RCo units based on the analysis of the individual manufactured lots of product used in these patients (average ratio of 2.6 IU VWF:RCo per IU FVIII:C). Twenty five different lots of Haemate-P/Humate-P were used to treat 437 different events in the 97 study patients (344 hemorrhagic events, 73 surgical interventions and 20 prophylactic infusion cycles). Overall, the median dose of concentrate per infusion used to treat surgical events was 69.1 IU VWF:RCo/kg (range 11.9-222.8); bleeding events 55.3 IU VWF:RCo/kg (range 17.1-227.5) and prophylaxis 41.6 IU VWF:RCo/kg (range 34.6-81.0). Treatment periods varied, with the majority of events treated for ≤ 10 days (91%). Fifty percent of events that were treated longer than 10 days were given for prophylactic reasons. Efficacy was determined in a standardized manner by the physician, based on dosing in VWF:RCo activity. An overall clinical result of “excellent” or “good” was reported in 97% (424/437) of treatment events. A pediatric sub-population analysis of the patient population reported “excellent/good” efficacy in 100% (17/17) of treatment events in infants, 95% (155/164) in children, and 94% (76/81) in adolescent patients. Related adverse events (AEs) were observed in only 4 (4%) patients and were not deemed to be serious. The findings in this study confirm the safety and efficacy of Haemate-P/Humate-P using VWF:RCo dosing in pediatric and adult patients with various types of VWD.

The macro-economic determinants of health and health inequalities-umbrella review protocol

BACKGROUND

The economic determinants of health have been widely recognised as crucial factors affecting health; however, to date, no comprehensive review has been undertaken to summarise these factors and the ways in which they can influence health. We conceptualise the economy as a complex system made up of underlying approaches, regulation from institutions, markets, finance, labour, the public-private balance as well as production and distributional effects, which collectively impact on health through the effect of moderators. This protocol details the methods for an umbrella review to explore the macro-economic factors, strategies, policies and interventions that affect health outcomes and health inequalities.

METHODS

We will identify relevant systematic reviews using search terms derived from the Journal of Economic Literature classification. Reviews will be included if they meet the Database of Abstracts and Reviews of Effects criteria for systematic reviews. Reviews of studies with and without controls will be included; both association and intervention studies will be included. Primary outcomes will include but are not limited to morbidity, mortality, prevalence and incidence of conditions and life expectancy. Secondary outcomes will include health inequalities by gender, ethnicity or socio-economic status. Six databases will be searched using tailored versions of our piloted search strategy to locate relevant reviews. Data will be extracted using a standardized pro forma, and the findings will be synthesized into a conceptual framework to address our review aim.

DISCUSSION

Our umbrella review protocol provides a robust method to systematically appraise the evidence in this field, using new conceptual models derived specifically to address the study question. This will yield important information for policymakers, practitioners and researchers at the local, national and international level. It will also help set the future research agenda in this field and guide the development of interventions.

SYSTEMATIC REVIEW REGISTRATION

This umbrella review protocol has been registered with PROSPERO CRD42017068357 .