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BackgroundCold-water immersion (CWI) has gained popularity as a health and wellbeing intervention among the general population.ObjectiveThis systematic review and meta-analysis aimed to evaluate the psychological, cognitive, and physiological effects of CWI in healthy adults.MethodsElectronic databases were searched for randomized trials involving healthy adults aged ≥ 18 years undergoing acute or long-term CWI exposure via cold shower, ice bath, or plunge with water temperature ≤15°C for at least 30 seconds. Outcomes of interest were sleep, stress, fatigue, energy, skin health, immunity, inflammation, mental wellbeing, depression, anxiety, mood, concentration, and alertness or focus. Meta-analyses were conducted using RevMan software (version 5.4), applying random effects models to calculate standardized mean differences (SMD) between pre- and post-CWI exposure outcomes. Risk of bias was assessed using the PEDro scale.ResultsEleven studies were included, comprising 3177 total participants and a mean PEDro score of 6.4 (n = 7 moderate quality, n = 4 high quality). CWI interventions were performed in baths (n = 10) or showers (n = 1) at temperatures ranging from 7°C to 15°C and durations ranging from 30 seconds to 2 hours. The meta-analysis revealed significant increases in inflammation immediately (SMD: 1.03, [95% CI: 0.37, 1.68], p 0.05), 1 hour (SMD: -0.29 [95% CI: -0.66, 0.08], p > 0.05), 24 hours (SMD: -0.06 [95% CI: -0.50, 0.38], p > 0.05), or 48 hours (SMD: 0.09 [95% CI: -0.28, 0.46], p > 0.05) post-exposure. While meta-analysis showed no significant effects on immune function immediately (SMD: -0.16 [95% CI: -0.82, 0.51], p > 0.05) or 1 hour (SMD: -0.18 [95% CI: -1.09, 0.74], p > 0.05) post-CWI, narrative synthesis suggested longer-term benefits, including a 29% reduction in sickness absence among participants who took cold showers. Improvements were also observed in sleep quality and quality of life, but not mood.ConclusionsThis systematic review suggests that CWI delivers time-dependent effects on inflammation, stress, immunity, sleep quality, and quality of life, offering potential practical applications for health practitioners considering CWI for stress management and wellbeing support. However, the current evidence base is constrained by few RCTs, small sample sizes, and a lack of diversity in study populations. Future high-quality RCTs are needed to examine the long-term effects of CWI, its impact on diverse health outcomes, and optimal CWI protocols. PROSPERO (ID: CRD42024500591).

BackgroundStrokes are becoming more common, and with improving survival rates, the prevalence of stroke survivors has increased. Almost half of chronic stroke survivors are cognitively impaired, and healthcare services are struggling to manage these patients, leaving some feeling "abandoned". Several systematic reviews have investigated the effect of physical exercise and cognition-orientated interventions on post-stroke cognitive impairment, and have produced conflicting findings, making it difficult for clinicians and guideline producers to make evidence-based decisions. This overview of reviews aims to provide a comprehensive overview of systematic reviews investigating the effect of physical exercise and cognition-orientated interventions on post-stroke cognitive function, assess methodological quality and certainty of evidence, and identify sources of discordance between these reviews.MethodsEight databases-Embase, Medline, CINAHL, Psycinfo, SPORTDiscus, The Cochrane Database of Systematic reviews, Epistemonikos, and Scopus-plus grey literature sources will be searched. The eligibility criteria include systematic reviews of trials that included an adult stroke population and investigated physical exercise and/or cognition-orientated interventions. Only reviews that assessed at least one of the DSM-5 neurocognitive domains will be included. Screening, data extraction, and quality appraisal will be conducted by two independent reviewers. Methodological quality, certainty of evidence, and primary study overlap will be assessed using the AMSTAR-2, GRADE, and GROOVE tools, respectively. Interventions will be grouped into exercise, cognition-orientated, and combined interventions, and findings will be synthesised narratively. Heterogeneity assessment will be conducted to identify factors causing discordance between reviews.DiscussionThe findings of this overview will allow decision makers to make evidence-based decisions, stratified by methodological quality and certainty of evidence. Heterogeneity assessment may identify factors causing discordance between systematic reviews, which could inform the design of future studies.Trial registrationRegistration: PROSPERO CRD42024534179.

BackgroundAccurate assessment of cardiovascular disease (CVD) risk is crucial for effective prevention and resource allocation. However, few CVD risk estimation tools consider social determinants of health (SDoH), despite their known impact on CVD risk. We aimed to estimate 10-year CVD risk in the Eastern Caribbean Health Outcomes Research Network Cohort Study (ECS) across multiple risk estimation instruments and assess the association between SDoH and CVD risk.MethodsFive widely used CVD risk estimation tools (Framingham and WHO laboratory, both laboratory and non-laboratory-based, and ASCVD) were applied using data from ECS participants aged 40-74 without a history of CVD. SDoH variables included educational attainment, occupational status, household food security, and perceived social status. Multivariable logistic regression models were used to compare differences in the association between selected SDoH and high CVD risk according to the five instruments.FindingsAmong 1,777 adult participants, estimated 10-year CVD risk varied substantially across tools. Framingham non-lab and ASCVD demonstrated strong agreement in categorizing participants as high risk. Framingham non-lab categorized the greatest percentage as high risk, followed by Framingham lab, ASCVD, WHO lab, and WHO non-lab. Fifteen times more people were classified as high risk by Framingham non-lab compared with WHO non-lab (31% vs 2%). Mean estimated 10-year risk in the sample was over 2.5 times higher using Framingham non-lab vs WHO non-lab (17.3% vs 6.6%). We found associations between food insecurity, those with the lowest level compared to the highest level of education, and non-professional occupation and increased estimated CVD risk.InterpretationOur findings highlight significant discrepancies in CVD risk estimation across tools and underscore the potential impact of incorporating SDoH into risk assessment. Further research is needed to validate and refine existing risk tools, particularly in ethnically diverse populations and resource-constrained settings, and to develop race- and ethnicity-free risk estimation models that consider SDoH.

Cholera continues to cause many outbreaks in low and middle-income countries due to inadequate water, sanitation, and hygiene services. We describe a protracted cholera outbreak in Nairobi City County, Kenya in 2017. We reviewed the cholera outbreak line lists from Nairobi City County in 2017 to determine its extent and factors associated with death. A suspected case of cholera was any person aged >2 years old who had acute watery diarrhea, nausea, or vomiting, whereas a confirmed case was where Vibrio cholerae was isolated from the stool specimen. We summarized cases using means for continuous variables and proportions for categorical variables. Associations between admission status, sex, age, residence, time to care seeking, and outbreak settings; and cholera associated deaths were assessed using odds ratio (OR) with 95% confidence interval (CI). Of the 2,737 cholera cases reported, we analyzed 2,347 (85.7%) cases including 1,364 (58.1%) outpatients, 1,724 (73.5%) not associated with mass gathering events, 1,356 (57.8%) male and 2,202 (93.8%) aged ≥5 years, and 35 deaths (case fatality rate: 1.5%). Cases were reported from all the Sub Counties of Nairobi City County with an overall county attack rate of 50 per 100,000 people. Vibrio cholerae Ogawa serotype was isolated from 78 (34.8%) of the 224 specimens tested and all isolates were sensitive to tetracycline and levofloxacin but resistant to amikacin. The odds of cholera-related deaths was lower among outpatient cases (aOR: 0.35; [95% CI: 0.17-0.72]), age ≥5 years old (aOR: 0.21 [95% CI: 0.09-0.55]), and mass gathering events (aOR: 0.26 [95% CI: 0.07-0.91]) while threefold higher odds among male (aOR: 3.04 [95% CI: 1.30-7.13]). Nairobi City County experienced a protracted and widespread cholera outbreak with a high case fatality rate in 2017.

The objective of this study was to identify the prevalence and correlates of phosphatidylethanol (PEth) levels suggestive of unhealthy alcohol use among women living with and without HIV who self-reported no or low-risk drinking. We analyzed data from a cross-sectional study among women enrolled in the San Francisco Bay Area site of the Women's Interagency HIV Study (WIHS). Between October 2017 and March 2018, PEth was tested from dried blood spots in 192 women enrolled in the San Francisco site of the WIHS. Using multivariable logistic regression, we identified the correlates of PEth levels suggestive of unhealthy alcohol use (>50 ng/ml) among the 168 women who reported no or low-risk drinking ( 1 (aOR = 3.10, 95% CI = 1.18-8.13), higher high-density lipoprotein levels (aOR = 1.31 per 10 mg/dL increase, 95% CI = 1.01-1.70), and consuming a greater number of drinks per week in the past six months (aOR = 1.40, 95% CI = 1.10-1.78). Nearly a third of women in this study had PEth levels suggestive of unhealthy alcohol use and potentially under-reported their use. To optimize alcohol related health care, there is a need to consider approaches to improve ascertainment of unhealthy alcohol use, especially among Black/African American women and those living with liver disease, so that interventions can be initiated.

Following confirmation of the first case of the ongoing U.S. HPAI H5N1 epizootic in commercial poultry on February 8, 2022, the virus has continued to devastate the U.S. poultry sector and the pathogen has since managed to cross over to livestock and a few human cases have also been reported. Efficient outbreak management benefits greatly from timely detection and proper identification of the pathways of virus introduction and spread. In this study, we used changes in mortality rates as a proxy for HPAI incidence in a layer, broiler and turkey flock together with diagnostic test results to infer within-flock HPAI transmission dynamics. Mathematical modeling techniques, specifically the Approximate Bayesian Computation algorithm in conjunction with a stochastic within-flock HPAI transmission model were used in the analysis. The time window of HPAI virus introduction into the flock (TOI) and the adequate contact rate (ACR) were estimated. Then, using the estimated TOI together with the day when the first HPAI positive sample was collected from the flock, we calculated the most likely time to first positive sample (MTFPS) which reflects the time to HPAI detection. The estimated joint (i.e., all species combined) median of the MTFPS for different flocks was six days, the joint median most likely ACR was 6.8 newly infected birds per infectious bird per day, the joint median R0 was 13 and the joint median number of test days per flock was two. These results were also grouped by species and by epidemic phase and discussed accordingly. We conclude that this findings from this and other related studies are beneficial for the different stakeholders in outbreak management. We recommend that combining TOI analysis with complementary approaches such as phylogenetic analyses is critically important for improved understanding of disease transmission pathways. The estimated parameters can also be used to parametrize mathematical models that can guide the design of surveillance protocols, risk analyses of HPAI spread, and emergency preparedness for HPAI outbreaks.

Many maternal and neonatal deaths can be avoided if quality healthcare is provided. To this end, the South African National Department of Health implemented a quality improvement (QI) programme (2018-2022) to improve maternal and neonatal health services in 21 public health facilities. This study sought to identify good practices aimed at improving QI teams' performance by identifying optimal facility-level contextual factors and implementation processes. We purposively selected 14 facilities of the 21 facilities for a longitudinal qualitative process evaluation. We interviewed 17 team leaders, 47 members, and five QI advisors who provided technical support to the teams. The data were analysed using framework analysis. We choose the Consolidated Framework for Implementation Research as framework given that it explicates contexts and processes that shape programme implementation. Six quality improvement teams were assessed as well-performing, and eight as less well-performing. This research conceptualises a 'life course lens' for setting up and managing a QI team. We identified eight good practices, six related to implementation processes, and two contextual variables that will optimise team performance. The two most impactful practices to improve the performance of a QI team were (i) selecting healthcare workers with quality improvement-specific characteristics, and (ii) appointing advisors whose interpersonal skills match their technical quality improvement competencies.

Brain metastasis leads to increased mortality and is a major site of relapse for several cancers, yet the molecular mechanisms of brain metastasis are not well understood. In this study, we established and characterized a new leukemic cell line, FIA10, that metastasizes into the central nervous system (CNS) following injection into the tail vein of syngeneic mice. Mice injected with FIA10 cells developed neurological symptoms such as loss of balance, tremor, ataxic gait and seizures, leading to death within 3 months. Histopathology coupled with PCR analysis clearly showed infiltration of leukemic FIA10 cells into the brain parenchyma of diseased mice, with little involvement of bone marrow, peripheral blood and other organs. To define pathways that contribute to CNS metastasis, global transcriptome and proteome analysis was performed on FIA10 cells and compared with that of the parental stem cell line FDCP-Mix and the related FIA18 cells, which give rise to myeloid leukemia without CNS involvement. 188 expressed genes (RNA level) and 189 proteins were upregulated (log2 ratio FIA10/FIA18 ≥ 1) and 120 mRNAs and 177 proteins were downregulated (log2 ratio FIA10/FIA18 ≤ 1) in FIA10 cells compared with FIA18 cells. Major upregulated pathways in FIA10 cells revealed by biofunctional analyses involved immune response components, adhesion molecules and enzymes implicated in extracellular matrix remodeling, opening and crossing the blood-brain barrier (BBB), molecules supporting migration within the brain parenchyma, alterations in metabolism necessary for growth within the brain microenvironment, and regulators for these functions. Downregulated RNA and protein included several tumor suppressors and DNA repair enzymes. In line with the function of FIA10 cells to specifically infiltrate the brain, FIA10 cells have acquired a phenotype that permits crossing the BBB and adapting to the brain microenvironment thereby escaping immune surveillance. These data and our model system FIA10 will be valuable resources to study the occurrence of brain metastases and may help in the development of potential therapies against brain invasion.

Globally, Indigenous children have historical and contemporary connections with government child protection services that have caused significant harm to their long-term health and wellbeing. Innovative, culturally secure and recovery focussed service provision is required. This paper describes a research protocol that has been designed by Indigenous researchers led by Indigenous Elders, to explore culturally secure care planning and service delivery in out-of-home care agencies in Australia. Using participatory action research methods, we will collect data using a variety of forums, including focus groups and semi-structured interviews. These data will explore the challenges for out-of-home care agencies in providing culturally secure care-planning, cultural activity and resources, and explore solutions to address factors that influence health and can assist to redress social inequities for Indigenous children. We aim to recruit approximately 100 participants for the qualitative study and 40 participants for the quantitative survey. Study participants will initially be recruited using purposive sampling, and as the study progresses will be recruited using a mixture of purposive and convenience sampling techniques. The rich data that this study is expected to yield, will inform ways to collect cultural information about Indigenous children and ways to provide cultural connections and activities that will have benefit to Indigenous children and families, and a broad range of social services.

IntroductionEach person having access to needed health services, of sufficient quality, and without suffering financial hardship, defined as universal health coverage (UHC) by the World Health Organization, is critical to improve population health, particularly for vulnerable populations. UHC requires multisectoral collaboration and good governance, and this will require buy-in of key stakeholders; but their views are under-documented. The aim of this stakeholder analysis was to explore the awareness and perceptions of UHC by health care workers (HCWs) in Uganda.MethodsA mixed-methods study was conducted based on primary data from HCWs including an online QualtricsXM survey of 274 HCWs (from a database of persons who had received training at an academic institution), 23 key informant semi-structured interviews, and one eight-person focus group discussion. Data was collected from February to April 2022. Microsoft Excel and R Programme were used for quantitative analyses and NVivo version 12 for qualitative analyses.ResultsHCWs attributed a high level of importance to UHC in Uganda. Participants discussed national communication and management practices, organisational roles, health financing and power dynamics, health care demand and the impact of and learnings from COVID-19. Four main themes-each with related sub-themes-emerged from the interview data providing insights into: (1) communication, (2) organisation, (3) power, and (4) trust.ConclusionThere is a critical need for better communication of UHC targets by policymakers to improve understanding at a grassroots level. Results indicated that ensuring trust among the population through transparency in metrics and budgets, strong accountability measures, awareness of local cultural sensitivities, sensitisation of the UHC concept and community inclusion will be essential for a multisectoral roll out of UHC. Further provision of quality health services, a harmonisation of efforts, increased domestic health financing and investment of HCWs through fair remuneration will need to underpin the delivery of UHC.

BackgroundTo assess factors associated with perceived changes in physical and mental health and with delays in seeking healthcare during the second and third COVID-19 lockdowns in England (2020-2021).MethodsAn online survey of Million Women Study participants collected data on 44,523 women, mean age 76 (SD = 4), October 2020-May 2021. These data were linked to data collected prospectively on Million Women Study participants at recruitment in median year 1998 and at re-surveys in 2011-2013, as well as to hospital admission data from 2017-2019.ResultsOf 40,821 participants with complete data on the outcomes of interest, 28% reported worse physical health and 26% worse mental health. After adjustment for age, region, education and survey period, poor/fair self-rated health (adjusted OR 2.71, 95% CI 2.52-2.91), having been told to shield (1.92, 1.79-2.05), obesity (2.17, 2.04-2.31) and other measures of poor health prior to the outbreak were all strongly related to worse physical health, as was being an informal carer (1.47, 1.38-1.56) and having a COVID-19 infection (1.64, 1.53-1.77). Depression (2.31, 2.06-2.58), poor/fair self-rated health (1.98, 1.84-2.13) and being an informal carer (1.69, 95% CI 1.58-1.80) were the factors most strongly related to worse mental health. Having poor/fair self-rated health (2.22, 2.05-2.40), obesity (1.58, 1.47-1.70) and being an informal carer (1.45, 1.34-1.56) were all strongly related to delaying seeking medical care. These associations remained essentially unchanged after exclusion of participants who had a COVID-19 infection.ConclusionsIn a large sample of older women in England, just over a quarter reported a deterioration in their physical and mental health during the national lockdowns. In addition to the expected effect of a COVID-19 infection on physical health, the groups who were most likely to report such a deterioration were those with pre-existing morbidity and those who were caring for others as informal carers.

IntroductionThe incidence of varicella in Canada has decreased by almost 99% since vaccination was introduced. However, variation in the timing and eligibility of vaccination programs across the country has resulted in some cohorts being under-vaccinated and therefore potentially susceptible to infection.MethodsWe used nationally representative specimens from the Biobank of Statistics Canada's Canadian Health Measures Survey (CHMS) as well as residual specimens from Ontario collected between 2009-2014 to estimate population immunity across age-groups and geography, and identify any groups at increased risk of varicella infection.ResultsThe weighted proportion of specimens with antibody levels above the threshold of protection was 93.6% (95% CI: 92.4, 95.0). Protection was lowest among those aged 3-5 years (54.3%; 95% CI: 47.3, 61.4), but increased with age. Individuals born outside Canada had more than twice the odds of varicella susceptibility than those born in Canada (aOR: 2.7; 95% CI: 1.4, 5.0; p = 0.004). There were no differences by sex or geography within Canada, and there were no statistically significant differences when Ontario CHMS sera were compared to Ontario residual sera, apart from in participants aged 12-19 year age-group, for whom the CHMS estimate (91.2%; 95% CI: 86.7, 95.7) was significantly higher (p = 0.03) than that from residual specimens (85.9%, 95% CI: 81.1, 90.8).DiscussionVaricella immunity in Canada is changing. Children appear to have low population immunity, placing them at greater risk of infection and at increased risk of severe disease as they age. Our results underscore the importance of performing periodic serosurveys to monitor further population immunity changes as the proportion of vaccine-eligible birth-cohorts increases, and to continually assess the risk of outbreaks.

BackgroundDementia with Lewy bodies (DLB) is one of the most common degenerative dementias, but research on end-of-life experiences for people with DLB and their caregivers is limited.MethodDyads of individuals with moderate-advanced DLB and their primary informal caregivers were recruited from specialty clinics, advocacy organizations, and research registries and followed prospectively every 6 months. The current study examines results of caregiver study visits 3 months after the death of the person with DLB. These visits included the Last Month of Life survey, study-specific questions, and a semi-structured interview querying end-of-life experiences.ResultsIndividuals with DLB (n = 50) died 3.24 ± 1.81 years after diagnosis, typically of disease-related complications. Only 44% of caregivers reported a helpful conversation with clinicians regarding what to expect at the end of life in DLB. Symptoms commonly worsening prior to death included: cognition and motor function, ADL dependence, behavioral features, daytime sleepiness, communication, appetite, and weight loss. Almost 90% of participants received hospice care, but 20% used hospice for ConclusionMost caregivers of individuals who died with DLB reported positive end-of-life experiences. However, the study identified multiple opportunities for improvement relating to clinician counseling of patients/families, support/hospice referrals, and monitoring individuals with DLB to identify approaching end of life. Future research should quantitatively identify changes that herald end of life in DLB and develop tools that can assist clinicians in evaluating disease stage to better inform counseling and timely hospice referrals.Trial registrationTrial registration information: NCT04829656.

BackgroundAlmost half of all women in the US experience intimate partner violence (IPV) in their lifetime. The US Preventive Services Task Force recommends IPV screening paired with intervention for women of reproductive age. We aim to understand clinical practices and policies that are beneficial, detrimental, or insufficient to support survivors of IPV in a safety-net healthcare system.MethodsWe sampled 45 women who were 18-64 years old, had experienced IPV within the prior year and were patients in the San Francisco Health Network. We conducted in-depth, semi-structured interviews to elicit their perspectives on disclosing IPV and obtaining support within the healthcare system. We analyzed our data using thematic analysis and grounded theory practices informed by ecological systems theory.FindingsWe identified four themes regarding factors that impeded or facilitated discussing and addressing IPV across interpersonal and systemic levels relating to relationship-building, respect, autonomy and resources. (1) Interpersonal barriers included insufficient attention to relationship-building, lack of respect or concern for survivor circumstances, and feeling pressured to disclose IPV or to comply with clinicians' recommended interventions. (2) Interpersonal facilitators consisted of patient-centered IPV inquiry, attentive listening, strength-based counseling and transparency regarding confidentiality. (3) Systemic barriers such as visit time limitations, clinician turn-over and feared loss of autonomy from involvement of governmental systems leading to separation from children or harm to partners, negatively affected interpersonal dynamics. (4) Systemic facilitators involved provision of resources through IPV universal education, on-site access to IPV services, and community partnerships.ConclusionsWomen experiencing IPV in our study reported that relationship-building, respect, autonomy, and IPV-related resources were essential components to providing support, promoting safety, and enabling healing in the healthcare setting. Successful trauma-informed transformation of healthcare systems must optimize interpersonal and systemic factors that improve survivor wellbeing while eliminating barriers.

BackgroundCommunity-based peer support (CBPS) groups have been effective in facilitating access to and retention in the healthcare system for patients with HIV/AIDS, cancer, diabetes, and other communicable and non-communicable diseases. Given the high incidence of morbidity that results from traumatic injuries, and the barriers to reaching and accessing care for injured patients, community-based support groups may prove to be similarly effective in this population.ObjectivesThe objective of this review is to identify the extent and impact of CBPS for injured patients.EligibilityWe included primary research on studies that evaluated peer-support groups that were solely based in the community. Hospital-based or healthcare-professional led groups were excluded.EvidenceSources were identified from a systematic search of Medline / PubMed, CINAHL, and Web of Science Core Collection.Charting methodsWe utilized a narrative synthesis approach to data analysis.Results4,989 references were retrieved; 25 were included in final data extraction. There was a variety of methodologies represented and the groups included patients with spinal cord injury (N = 2), traumatic brain or head injury (N = 7), burns (N = 4), intimate partner violence (IPV) (N = 5), mixed injuries (N = 5), torture (N = 1), and brachial plexus injury (N = 1). Multiple benefits were reported by support group participants; categorized as social, emotional, logistical, or educational benefits.ConclusionsCommunity-based peer support groups can provide education, community, and may have implications for retention in care for injured patients.

BackgroundCardiovascular disease (CVD) prevalence is high in Ghana-but awareness, prevention, and treatment is sparse, particularly in rural regions. The nurse-led Community-based Health Planning and Services program offers general preventive and primary care in these areas, but overlooks CVD and its risk factors.MethodsWe conducted in-depth interviews with 30 community members (CM) in rural Navrongo, Ghana to understand their knowledge and beliefs regarding the causes and treatment of CVD and the potential role of community nurses in rendering CVD care. We transcribed audio records, coded these data for content, and qualitatively analyzed these codes for key themes.ResultsCMs described CVD as an acute, aggressive disease rather than a chronic asymptomatic condition, believing that CVD patients often die suddenly. Yet CMs identified causal risk factors for CVD: not only tobacco smoking and poor diet, but also emotional burdens and stressors, which cause and exacerbate CVD symptoms. Many CMs expressed interest in counseling on these risk factors, particularly diet. However, they felt that nurses could provide comprehensive CVD care only if key barriers (such as medication access and training) are addressed. In the interim, many saw nurses' main CVD care role as referring to the hospital.ConclusionsCMs would like CVD behavioral education from community nurses at local clinics, but feel the local health system is now too fragile to offer other CVD interventions. CMs believe that a more comprehensive CVD care model would require accessible medication, along with training for nurses to screen for hypertension and other cardiovascular risk factors-in addition to counseling on CVD prevention. Such counseling should build upon existing community beliefs and concerns regarding CVD-including its behavioral and mental health causes-in addition to usual measures to prevent CVD mortality such as diet changes and physical exercise.

Introduction As part of the Harbnger-2 project, this study aimed to discover the impact of the COVID-19 pandemic on junior researchers’ work-life, career prospects, research and publishing practices and networking. Methods An online international survey of 800 early career researchers (ECRs) was conducted in 2022. A questionnaire was developed based on three rounds of interviews and distributed using multiple channels including publishers, social media, and direct email to ECRs. Results The impact of the pandemic on career prospects, morale, job security, productivity, ability to network and collaborate, and quality and speed of peer review has on the whole been more negative than positive. A quarter of ECRs shifted their research focus to pandemic-related topics and half of those who did, benefited largely due to increased productivity and impact. The majority worked remotely/from home and more than two-thirds of those who did so benefitted from it. While virtual or hybrid conferences have been embraced by the majority of ECRs, around a third still preferred face-to-face only conferences. The use of library online platforms, Sci-Hub, ResearchGate, Google Scholar and smartphone to search and access full-text papers increased. ECRs prioritised journals with fast submission procedures for the publishing of their papers and spent more time on increasing the visibility of their research. Fees were a problem for publishing open access. Conclusion Although, generally, the pandemic negatively impacted many aspects of ECRs’ work-life, certain research areas and individuals benefited from being more appreciated and valued, and, in some cases, resulted in increased resources, better productivity and greater impact. Changes, such as the use of digital technologies and remote working created new opportunities for some ECRs. While continuing work flexibility and hybrid conferences might benefit some ECRs, institutions should also take measures to help those ECRs whose career and productivity have been adversely impacted.

COVID-19 and associated public health policies have significantly disrupted the lives of both adults and children. Experiences of COVID-positive adults are well described but less is known about the experiences of families of children who receive a positive diagnosis, and the impact of public health policies on this experience. This study aimed to develop a framework to understand the lived experience of families with a child testing positive for COVID-19. We applied a qualitative study design, using grounded theory. The study took place in Melbourne, Australia between July and December 2020, during the first major Australian COVID-19 wave. Parents of children 0–18 years tested at a walk-in clinic at a paediatric tertiary referral hospital were invited to participate. Two interviewers jointly undertook in-depth interviews with parents of children who tested positive. Interviews were transcribed and two analysts used an inductive, critical realist analysis approach with NVivo and a virtual whiteboard. Results are presented incorporating a stratified reality (empirical, actual, real). Families described seven sequential stages of the COVID-19 positive testing journey: COVID-19 close to home; time to be tested; waiting for the test result; receiving the result; dealing with the diagnosis; coping with isolation; and moving forward/looking back. Our findings highlight how public health policies and messages targeting the general (adult) public were experienced by families. We provide a framework that families move through when their child tests positive for COVID-19. Within each phase, we report unmet needs and identify strategies to improve future pandemic planning for parents and children.

IntroductionAsthma has substantial and increasing health and economic burden worldwide. This study aimed to estimate healthcare expenditure and determine the factors that increase expenditure in Australians with poorly controlled asthma.MethodsIndividuals ≥18 years of age with poorly controlled asthma, as determined by a score ≥1.5 on the Asthma Control Questionnaire, were included in the study. Healthcare utilization costs from medical services and medications were estimated over an average follow-up of 12 months from administratively linked data: the Medicare Benefits Schedule and Pharmaceutical Benefits Scheme. A generalized linear model with gamma distribution and log link was used to predict participants' key baseline characteristics associated with variations in healthcare costs.ResultsA total of 341 participants recruited through community pharmacies were included. The mean (standard deviation, SD) age of participants was 56.6 (SD 17.6) years, and approximately 71% were females. The adjusted average monthly healthcare expenditure per participant was $AU386 (95% CI: 336, 436). On top of the average monthly costs, an incremental expenditure was found for each year increase in age ($AU4; 95% CI: 0.78, 7), being unemployed ($AU201; 95% CI: 91, 311), one unit change in worsening quality of life ($AU35; 95% CI: 9, 61) and being diagnosed with depression and anxiety ($AU171; 95% CI: 36, 306).ConclusionsIn a cohort of Australian patients, characterized by poor asthma control and co-morbidities individuals impose substantial economic burden in terms of Medicare funded medical services and medications. Programs addressing strategies to improve the quality of life and manage co-morbid anxiety and depression and encourage asthma patients' engagement in clinically tolerable jobs, may result in significant cost savings to the health system.

IntroductionThe aim of this study is to explore outcomes currently reported in physiotherapy trials for bronchiectasis and investigate the level of consistency in outcome reporting. This mapping of outcomes will be used to inform the development of a core outcome set (COS) for physiotherapy research in bronchiectasis. Outcomes reported in randomised clinical trials (RCTs) and RCT protocols were reviewed and evaluated. We included trials with physiotherapy as the main intervention, including pulmonary rehabilitation, exercise prescription, airway clearance, positive expiratory pressure devices, breathing training, self-management plans, and home exercise program. Medline, CINAHL, Scopus, Cochrane Central Register of Controlled Trials (CENTRAL), and the physiotherapy evidence database (PEDro) were searched from inception using a prespecified search strategy. Records including adult patients with bronchiectasis were included. Outcomes were listed verbatim and categorised into domains based on a pre-specified system, frequency of reporting and sources of variation were inspected.ResultsOf 2158 abstracts screened, 37 trials (1202 participants) and 17 trial protocols were identified. Eighteen different physiotherapy techniques were investigated. A total of 331 outcomes were reported. No single outcome was reported by all trials. The most reported outcomes were lung function (27 trials, 50%), health related quality of life (26 trials, 48.1%), and dyspnoea (18 trials, 33.3%). A list of 104 unique outcomes covering 23 domains was created. Trials focus on physiological outcomes, mainly those related to respiratory system functions. Outcomes related to functioning and life impact are often neglected.ConclusionOutcome reporting in physiotherapy research for bronchiectasis was found to be inconsistent in terms of choosing and defining outcomes. Developing a core outcome set in this area of research is needed to facilitate aggregation of future trial results in systematic reviews that will in turn inform the strength of evidence for the effectiveness of physiotherapy. Outcome choice should include all stakeholders, including patients.Trial registrationThis study is registered in the PROSPERO registry under the number CRD42021266247.

BackgroundThe COVID-19 pandemic caused disruptions across healthcare systems globally exposing the precarious state of patient engagement across all levels of healthcare. While evidence is emerging to describe how engagement was affected across various settings, insights about how some organizations at the policy and practice level of healthcare were able to sustain or adapt patient engagement activities is lacking.ObjectiveThis paper addresses the following research question: "How were healthcare, government, and patient partner organizations able to sustain or adapt patient engagement activities during the COVID-19 pandemic?"MethodsA qualitative descriptive study was conducted to understand how patient engagement activities were maintained or adapted in a variety of healthcare, government, and patient partner organizations in Canada throughout the pandemic. This analysis was part of a larger qualitative, multiple case study where one-to-one interviews were conducted with organizational leaders, managers and patient partners.ResultsThe following themes were identified as key aspects of maintaining or adapting patient engagement activities: 1) having an embedded organizational culture of patient engagement; 2) adapting patient engagement activities to focus on COVID-19 response efforts; 3) having patient partners who exercised leadership and advocacy to support patient care and experiences during the pandemic; and 4) leveraging virtual technology as a communication tool to engage patient partners.ConclusionThis paper highlights important insights that may be useful to other health care organizations on how to sustain or adapt patient engagement activities during a healthcare crisis. Having patient engagement embedded within an organization's culture supported by, but not limited to, infrastructure, resources, investments in dedicated staff and patient partner leadership, and communication strategies and tools enabled continued patient engagement activities during the pandemic.

Background Ten percent of the school-aged population have speech, language, and communication needs (SLCN) that impact access to the curriculum. Successful implementation of classroom-based SLCN interventions can reduce barriers to learning, thereby improving educational outcomes for this vulnerable population. The challenges of implementing innovations in educational settings are well-documented, yet limited studies have addressed such considerations when developing, and piloting universal level SLCN interventions for use in Irish schools. Methods A qualitative exploratory study was undertaken to establish the acceptability, feasibility, and appropriateness of a universal level SLCN intervention. An advisory panel of teachers (n = 8) and children with SLCN (n = 2) were engaged as co-researchers in the study. The Communication Supporting Classrooms Observation Tool, developed as part of the Better Communication Project in the UK, was trialled across a diverse sample of school settings (n = 5). Semi-structured interviews were conducted with school practitioners and school leaders, and a deductive content analysis was undertaken using the domains of the Consolidation Framework for Implementation Research. Discussion The observation tool was viewed as acceptable with suggested additions. Integrating use of the tool within existing data-informed, school self-evaluation processes aimed at supporting school improvement was noted as a potential means of supporting implementation. A knowledge gap in relation to school-based models of support for SLCN was identified which may negatively impact implementation. An implementation strategy targeting coherence, cognitive engagement and contextual integration is indicated if the tool is to be normalised into routine practice in Irish classrooms. Implementation needs appeared to vary at the school level. Conclusions The importance of early-stage exploration to guide implementation planning with regards to developing and testing universal level interventions for SLCN in schools is highlighted. Engaging an advisory panel provides important insights to guide implementation decisions. Findings suggest an adaptive design is required when planning implementation studies targeting classroom setting.

Holocene-era range expansions are relevant to understanding how a species might respond to the warming and drying climates of today. The harsh conditions of North American deserts have phylogenetically structured desert bat communities but differences in flight capabilities are expected to affect their ability to compete, locate, and use habitat in the face of modern climate change. A highly vagile but data-deficient bat species, the spotted bat (Euderma maculatum), is thought to have expanded its range from central Mexico to western Canada during the Holocene. With specimens spanning this latitudinal extent, we examined historical demography, and used ecological niche modeling (ENM) and phylogeography (mitochondrial DNA), to investigate historic biogeography from the rear to leading edges of the species' range. The ENM supported the notion that Mexico was largely the Pleistocene-era range, whereas haplotype pattern and Skyline plots indicated that populations expanded from the southwestern US throughout the Holocene. This era provided substantial gains in suitable climate space and likely facilitated access to roosting habitat throughout the US Intermountain West. Incongruent phylogenies among different methods prevented a precise understanding of colonization history. However, isolation at the southern-most margin of the range suggests a population was left behind in Mexico as climate space contracted and are currently of unknown status. The species appears historically suited to follow shifts in climate space but differences in flight behaviors between leading edge and core-range haplogroups suggest range expansions could be influenced by differences in habitat quality or climate (e.g., drought). Although its vagility could facilitate response to environmental change and thereby avoid extinction, anthropogenic pressures at the core range could still threaten the ability for beneficial alleles to expand into the leading edge.

Otoliths (ear stones) of the inner ears of teleost fishes, which develop independently from the skeleton and are functionally associated with hearing and the sense of equilibrium, have significantly contributed to contemporary understanding of teleost fish systematics and evolutionary diversity. The sagittal otolith is of particular interest, since it often possesses distinctive morphological features that differ significantly among species, and have been shown to be species- and genus-specific, making it an informative taxonomic tool for ichthyologists. The otolith morphology of the Caspian Sea gobiids has not been thoroughly studied yet, with data available for only a few species. The aim of the present paper is to examine the qualitative and quantitative taxonomic and phylogenetic information in the sagittal otoliths of these species. A total of 118 otoliths representing 30 gobiid species (including 53.5% of the Caspian gobiofauna) in three gobiid lineages (i.e., Gobius, Pomatoschistus, and Acanthogobius) and 11 genera (i.e., all Ponto-Caspian gobiid genera except Babka) were analysed at taxonomic levels using an integrated descriptive and morphometric approach. The results indicated high taxonomic efficiency of otolith morphology and morphometry at taxonomic levels for the Ponto-Caspian gobiids. Our qualitative and quantitative otolith data also (i) support the monophyly of neogobiin gobies, (ii) along with other morphological and ecological data, offer a new perspective on the systematics of Neogobius bathybius, (iii) suggest the reassignment of Hyrcanogobius bergi to the genus Knipowitschia, and (iv) question the phylogenetic integrity of the four phenotypic groups previously defined in the tadpole-goby genus Benthophilus; however, more studies are needed to complete these evaluations and confirm our otolith study findings.

ImportanceSARS-CoV-2 infection can result in ongoing, relapsing, or new symptoms or other health effects after the acute phase of infection; termed post-acute sequelae of SARS-CoV-2 infection (PASC), or long COVID. The characteristics, prevalence, trajectory and mechanisms of PASC are ill-defined. The objectives of the Researching COVID to Enhance Recovery (RECOVER) Multi-site Observational Study of PASC in Adults (RECOVER-Adult) are to: (1) characterize PASC prevalence; (2) characterize the symptoms, organ dysfunction, natural history, and distinct phenotypes of PASC; (3) identify demographic, social and clinical risk factors for PASC onset and recovery; and (4) define the biological mechanisms underlying PASC pathogenesis.MethodsRECOVER-Adult is a combined prospective/retrospective cohort currently planned to enroll 14,880 adults aged ≥18 years. Eligible participants either must meet WHO criteria for suspected, probable, or confirmed infection; or must have evidence of no prior infection. Recruitment occurs at 86 sites in 33 U.S. states, Washington, DC and Puerto Rico, via facility- and community-based outreach. Participants complete quarterly questionnaires about symptoms, social determinants, vaccination status, and interim SARS-CoV-2 infections. In addition, participants contribute biospecimens and undergo physical and laboratory examinations at approximately 0, 90 and 180 days from infection or negative test date, and yearly thereafter. Some participants undergo additional testing based on specific criteria or random sampling. Patient representatives provide input on all study processes. The primary study outcome is onset of PASC, measured by signs and symptoms. A paradigm for identifying PASC cases will be defined and updated using supervised and unsupervised learning approaches with cross-validation. Logistic regression and proportional hazards regression will be conducted to investigate associations between risk factors, onset, and resolution of PASC symptoms.DiscussionRECOVER-Adult is the first national, prospective, longitudinal cohort of PASC among US adults. Results of this study are intended to inform public health, spur clinical trials, and expand treatment options.RegistrationNCT05172024.

BackgroundBronchiectasis is a chronic respiratory disease characterised by airways widening and recurrent infections, resulting in episodes of chronic cough, sputum expectoration, and dyspnoea. This leads to deterioration in daily function, repeated hospital admissions and poor quality of life. The prevalence and mortality related to bronchiectasis is increasing worldwide with growing economic burden on healthcare systems. Physiotherapy for bronchiectasis aims to decrease accumulation of sputum, dyspnoea, and improve exercise capacity and daily function. A robust evidence base to support physiotherapy in bronchiectasis is currently lacking. This is partly because of inconsistency and poor reporting of outcomes in available studies. A core outcome set is the minimum acceptable group of outcomes that should be used in clinical trials for a specific condition. This decreases research waste by improving consistency and reporting of key outcomes and facilitates the synthesis of study outcomes in systematic reviews and guidelines. The aim of the study is therefore to develop a core outcome set and outcome measurement set for physiotherapy research in adults with bronchiectasis. This will ensure outcomes important to key stakeholders are consistently used and reported in future research.Methods and analysisThis project will use the COMET Initiative and COSMIN guidelines of core outcome set development and will include three phases. In the first phase, a comprehensive list of outcomes will be developed using systematic review of reported outcomes and qualitative interviews with patients and physiotherapists. Then consensus on key outcomes will be established in phase two using a Delphi survey and a consensus meeting. Finally, in phase three, we will identify appropriate instruments to measure the core outcomes by evaluating the psychometric properties of available instruments and a stakeholders' meeting to establish consensus.EthicsThe study was reviewed and has received ethical approval from the health-related Research Ethics Committee- Edge Hill University (ETH2021-0217).RegistrationThis study is registered with the COMET database. https://www.comet-initiative.org/Studies/Details/1931. The full systematic review protocol is registered in PROSPERO under the number CRD42021266247.

BackgroundShoulder and neck pain (SNP) is common in office workers and represents a serious public health problem given its detrimental impact on quality of life, physical functioning, personal finances, employers, and the health care system. Management with painkillers has adverse implications such as tolerance, addiction, and opioid abuse. Safe, sustainable, cost-effective, and evidence-based solutions are urgently needed. The non-invasive, painless, non-infectious, and safe modality of low-level laser acupuncture (LLLA) has shown promise for SNP management.ObjectiveThe overarching aim of this study is to provide evidence of the feasibility and therapeutic efficacy of LLLA for office workers with SNP.MethodsThis is a pilot, single-blind, double-armed, randomised controlled trial on the feasibility and therapeutic efficacy of a two-week LLLA therapy for office workers with SNP, aged 18 to 65 years. Each of the two study groups will contain 35 participants: the intervention group will receive LLLA from a licensed acupuncturist at the researchers' university clinic (10-20 min/session, 3 sessions/week) for two weeks; the control group will receive usual care without painkillers. Outcomes will be measured at baseline, throughout the two-week intervention, and at trial end. Surveys including open-ended questions will be completed. The primary outcome of this study is to evaluate the feasibility of a two-week LLLA therapy for office workers with SNP, as measured by recruitment and completion rates, patient safety, and treatment adherence and compliance. Participants' attitudes, motivation, and challenges to participation, intervention non-compliance, and experience of participating in the trial will be investigated via qualitative data. The secondary outcome is to evaluate the therapeutic efficacy of LLLA on SNP using the visual analogue scale (VAS) and the Short-Form McGill Pain Questionnaire (SF-MPQ); the work productivity and activity assessment (WPAI:SHP); 12-Item Short Form Survey (SF-12) for quality of life assessment; and the past 3-month out-of-pocket (OOP) cost for prescription and non-prescription SNP therapy, which is an indicative of the economic burden of SNP on patients and health care systems. This study was approved by Edith Cowan University's Human Research Ethics Committee (No. 2021-02225-WANG).ResultsData collection will commence in December 2021 with anticipated completion by December 2022.ConclusionsSafe, sustainable, cost-effective, evidence-based interventions are needed to minimise the negative implications of SNP in office workers. LLLA is a promising modality in managing SNP. However, more consolidated evidence is required to provide insight regarding the effectiveness of LLLA. This study is expected to contribute to the challenging work of reducing the burden of SNP in office workers.Trial registrationAustralian New Zealand Clinical Trials Registry (ANZCTR): ACTRN12621000426886p; https://www.anzctr.org.au/ACTRN12621000426886p.aspx.

The objective of this study was to identify the correlates of being at risk of clinical depression and examine the role of syndemic factors among marginally housed and homeless transitional age youth (TAY). From 2017–2018, 100 TAY between the ages of 18 and 24 in San Francisco were recruited from Larkin Street Youth Services into a cross-sectional study. Participants completed surveys on mental health, substance use, and HIV risk behaviors. A syndemic score ranging from 0–3 was calculated by summing dichotomous measures of moderate or severe anxiety in the past two weeks, PTSD symptoms in the past month and polysubstance use in the past three months. We used modified Poisson regression with robust error variances to identify the correlates of being at risk of clinical depression in the past week, all primary effects measures were modeled separately. Among 100 participants, the average age was 21 (SD = 1.7), 67% were male, 38% were Multiracial, 54% identified as gay, lesbian, bisexual or pansexual, 13% were unstably housed, 50% were homeless and 23% were living with HIV. The majority (74%) were at risk of clinical depression, 51% had symptoms of moderate or severe anxiety, 80% exhibited symptoms of PTSD and 33% reported polysubstance use. After controlling for age in years, gender, race/ethnicity and sexual orientation, factors independently associated with being at risk of clinical depression were; symptoms of moderate or severe anxiety (adjusted risk ratio [aRR] = 1.62, 95% confidence interval [CI] = 1.23–2.12, P

Background Skin colonization with coagulase-negative staphylococci (CoNS) is generally beneficial, but recent investigations suggest its association with flares and atopic dermatitis (AD) severity. However, this relationship remains unclear. Objective To assess patterns of staphylococcal colonization and biofilm formation in toddlers with and without AD from rural and urban South African settings. Methods We conducted a cross-sectional study of AD-affected and non-atopic AmaXhosa toddlers from rural Umtata and urban Cape Town, South Africa. CoNS isolates were recovered from lesional, nonlesional skin samples and the anterior nares of participants. Identification of the staphylococci was achieved by MALDI-TOF mass spectrometry. The microtiter plate assay assessed in-vitro biofilm formation. Results CoNS and S. aureus commonly co-colonized nonlesional skin among cases (urban: 24% vs. 3%, p = 0.037 and rural 21% vs. 6%, pConclusion CoNS colonization is associated with AD and disease severity and may be implicated in AD exacerbations. Studies are needed to understand their underlying pathological contribution in AD pathogenesis.

Zika virus (ZIKV) is a positive-sense RNA flavivirus and can cause serious neurological disorders including microcephaly in infected fetuses. As a mosquito-borne arbovirus, it enters the bloodstream and replicates in various organs. During pregnancy, it can be transmitted from the blood of the viremic mother to the fetus by crossing the placental barrier. Monocytes and macrophages are considered the earliest blood cell types to be infected by ZIKV. As a first line defense, these cells are crucial components in innate immunity and host responses and may impact viral pathogenesis in humans. Previous studies have shown that ZIKV infection can activate inflammasomes and induce proinflammatory cytokines in monocytes. In this report, we showed that ZIKV could infect and induce cell death in human and murine macrophages. In addition to the presence of cleaved caspase-3, indicating that apoptosis was involved, we identified the cleaved caspase-1 and gasdermin D (GSDMD) as well as increased secretion of IL-1β and IL-18. This suggests that the inflammasome was activated and that may lead to pyroptosis in infected macrophages. The pyroptosis was NLRP3-dependent and could be suppressed in the macrophages treated with shRNA to target and knockdown caspase-1. It was also be inhibited by an inhibitor for caspase-1, indicating that the pyroptosis was triggered via a canonical approach. Our findings in this study demonstrate a concomitant occurrence of apoptosis and pyroptosis in ZIKV-infected macrophages, with two mechanisms involved in the cell death, which may have potentially significant impacts on viral pathogenesis in humans.

As one of the main knowledge producers, researchers can play an important role in contributing to efforts that bridge the gap between knowledge, policy and practice. However, for researchers to play this role, they need knowledge translation (KT) capacities that many typically lack. Furthermore, research has confirmed that little is known on KT training approaches for LMICs researchers and their effectiveness. This paper seeks to contribute to filling this knowledge gap on KT training approaches for LMIC researchers by assessing the effectiveness of a training and mentorship intervention to build African researchers' KT capacity. We conducted KT training and mentorship for 23 early and mid-career researchers from 20 universities in sub-Saharan Africa. This comprised a 5-day intense residential training workshop, followed by a 6-months mentorship. A pre- and post-training test was used to assess the immediate effect of the workshop. The intermediate effect of the training following a 6-month mentorship was assessed by the number of researchers who completed policy briefs during this period and those who participated in the webinar series conducted during this period. Overall, the aggregate average point change in the self-reported learning between the pre-training and the post-training survey was 1.9, which demonstrated the effectiveness of the training workshop. This was confirmed by a 33.7% increase in the aggregate average percentage of participants that responded correctly to questions assessing topics covered in the training between the pre-training and the post-training survey. During the mentorship period, 19 of the 23 researchers prepared and submitted complete drafts of their policy briefs within two months after the training. Fewer (4) researchers revised and submitted final policy briefs. More than half of the trained researchers participated in the webinars conducted in the first three months of the mentorship, whereas less than half of the researchers participated in the webinars conducted in the last three months. KT training and mentorship can be an effective intervention for addressing researchers' KT capacity gaps. For sustainability, KT training and mentorship need to be integrated in graduate training programmes in universities so that future LMIC researchers leave training institutions with the KT capacities they need for influencing policy and programme decisions and actions.

Wind energy is a growing source of renewable energy with a 3-fold increase in use globally over the last decade. However, wind turbines cause bat mortality, especially for migratory species. The southwest United States has high bat species diversity and is an important area for migratory species, although little is known about their seasonal distribution. To examine potential risk to bats in areas proposed for wind energy development, we characterized bat occupancy spatially and temporally across northern Arizona, identifying use during summer when bats are reproductively active and fall during the migratory season. Our objectives were to determine occupancy of migratory species and species of greatest conservation need and develop a probability of occupancy map for species to identify areas of potential conflict with wind energy development. We selected 92 sites in 10 clusters with potential for development and used acoustic detectors to sample bats in the summer and fall of 2016 and 2017 for 6 nights per site per year. We predicted response of migratory bat species and species of special concern to 9 landscape variables using Program MARK. During summer, higher densities of forest on the landscape resulted in a higher probability of occupancy of migratory species such as hoary bats (Lasiurus cinereus), silver-haired bats (Lasionycteris noctivagans), big free-tailed bats (Nyctinomops macrotis), and species of conservation need such as spotted bats (Euderma maculatum). During the fall, higher concentration of valleys on the landscape predicted occupancy of hoary bats, big free-tailed bats, and spotted bats. High bat occupancy in the fall was also associated with higher elevation and close proximity to forests. We recommend that wind turbines be placed in open, flat grasslands away from forested landscapes and concentrations of valleys or other topographic variation.

The opioid crisis is a growing public health emergency and increasing resources are being directed towards overdose education. Simulation has emerged as a novel strategy for training overdose response, yet little is known about training non-clinicians in bystander resuscitation. Understanding the perspectives of individuals who are likely to experience or witness opioid overdose is critical to ensure that emergency response is effective. The Surviving Opioid Overdose with Naloxone Education and Resuscitation (SOONER) study evaluates the effectiveness of a novel naloxone education and distribution tool among people who are non-clinicians and likely to witness opioid overdose. Participants' resuscitation skills are evaluated using a realistic overdose simulation as the primary outcome of the trial. The purpose of our study is to describe the experience of participants with the simulation process in the SOONER study. We employed a semi-structured debriefing interview and a follow up qualitative interview to understand the experience of participants with simulation. A qualitative content analysis was performed using data from 21 participants who participated in the SOONER study. Our qualitative analysis identified 5 themes and 17 subthemes which described the experience of participants within the simulation process. These themes included realism, valuing practical experience, improving self-efficacy, gaining new perspective and bidirectional learning. Our analysis found that simulation was a positive and empowering experience for participants in the SOONER trial, most of whom are marginalized in society. Our study supports the notion that expanding simulation-based education to non-clinicians may offer an acceptable and effective way of supplementing current opioid overdose education strategies. Increasing the accessibility of simulation-based education may represent a paradigm shift whereby simulation is transformed from a primarily academic practice into a patient-based community resource.

Circular shell rings along the South Atlantic Coast of North America are the remnants of some of the earliest villages that emerged during the Late Archaic (5000-3000 BP). Many of these villages, however, were abandoned during the Terminal Late Archaic (ca 3800-3000 BP). We combine Bayesian chronological modeling with mollusk shell geochemistry and oyster paleobiology to understand the nature and timing of environmental change associated with the emergence and abandonment of circular shell ring villages on Sapelo Island, Georgia. Our Bayesian models indicate that Native Americans occupied the three Sapelo shell rings at varying times with some generational overlap. By the end of the complex's occupation, only Ring III was occupied before abandonment ca. 3845 BP. Ring III also consists of statistically smaller oysters harvested from less saline estuaries compared to earlier occupations. Integrating shell biochemical and paleobiological data with recent tree ring analyses shows a clear pattern of environmental fluctuations throughout the period in which the rings were occupied. We argue that as the environment became unstable around 4300 BP, aggregation at villages provided a way to effectively manage fisheries that are highly sensitive to environmental change. However, with the eventual collapse of oyster fisheries and subsequent rebound in environmental conditions ca. post-3800 BP, people dispersed from shell rings, and shifted to non-marine subsistence economies and other types of settlements. This study provides the most comprehensive evidence for correlations between large-scale environmental change and societal transformations on the Georgia coast during the Late Archaic period.

Just a decade ago Vision and Change in Undergraduate Biology Education: A Call to Action was released, catalyzing several initiatives to transform undergraduate life sciences education. Among these was the Partnership for Undergraduate Life Sciences Education (PULSE), a national organization commissioned to increase the adoption of Vision and Change recommendations within academic life sciences departments. PULSE activities have been designed based on the recognition that life sciences departments and faculty are embedded within institutions of higher education which, similar to other large organizations, are complex systems composed of multiple, interconnected subsystems. The organizational change research suggests that effecting large-scale changes (e.g., undergraduate STEM education transformation) may be facilitated by applying systems thinking to change efforts. In this paper we introduce the approach of systems thinking as a professional development tool to empower individual STEM faculty to effect department-level transformation. We briefly describe a professional development experience designed to increase life sciences faculty members' understanding of systems thinking, present evidence that faculty applied a systems thinking approach to initiate department-level change, and discuss the degree to which transformation efforts were perceived to be successful. Though focused on faculty in the life sciences, our findings are broadly transferable to other efforts seeking to effect change in undergraduate STEM education.

Objective During the COVID-19 pandemic, the unemployment rate in the United States peaked at 14.8% in April 2020. We examined patterns in unemployment following this peak in counties with rapid increases in COVID-19 incidence. Method We used CDC aggregate county data to identify counties with rapid increases in COVID-19 incidence (rapid riser counties) during July 1–October 31, 2020. We used a linear regression model with fixed effect to calculate the change of unemployment rate difference in these counties, stratified by the county’s social vulnerability (an indicator compiled by CDC) in the two months before the rapid riser index month compared to the index month plus one month after the index month. Results Among the 585 (19% of U.S. counties) rapid riser counties identified, the unemployment rate gap between the most and least socially vulnerable counties widened by 0.40 percentage point (pConclusion The widened unemployment gap after COVID-19 incidence rapid rise between the most and least socially vulnerable counties suggests that it may take longer for socially and economically disadvantaged communities to recover. Loss of income and benefits due to unemployment could hinder behaviors that prevent spread of COVID-19 (e.g., seeking healthcare) and could impede response efforts including testing and vaccination. Addressing the social needs within these vulnerable communities could help support public health response measures.

The spectral bat (Vampyrum spectrum), the largest bat species in the Americas, is considered Near Threatened by the International Union for Conservation of Nature and is listed as a species of special concern or endangered in several countries throughout its range. Although the species is known as carnivorous, data on basic ecology, including habitat selection and primary diet items, are limited owing to its relative rarity and difficulty in capturing the species. Leveraging advances in DNA metabarcoding and using radio-telemetry, we present novel information on the diet and movement of V. spectrum based on locations of a radio-collared individual and fecal samples collected from its communal roost (three individuals) in the Lowland Dry Forest of southern Nicaragua. Using a non-invasive approach, we explored the diet of the species with genetic markers designed to capture a range of arthropods and vertebrate targets from fecal samples. We identified 27 species of vertebrate prey which included birds, rodents, and other bat species. Our evidence suggested that V. spectrum can forage on a variety of species, from those associated with mature forests to forest edge-dwellers. Characteristics of the roost and our telemetry data underscore the importance of large trees for roosting in mature forest patches for the species. These data can inform conservation efforts for preserving both the habitat and the prey items in remnants of mature forest required by Vampyrum spectrum to survive in landscape mosaics.