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Background Female genital mutilation is an important UK health-care challenge. There are no health benefits of female genital mutilation, and it is associated with lifelong physical, psychological and sexual impacts. The annual cost to the NHS to care for survivors is £100M. Deinfibulation may improve the health and well-being of some women, but there is no consensus on the optimal timing of surgery for type 3 survivors. UK care provision is reportedly suboptimal. Objectives We aimed to explore the views of survivors, men and health-care professionals on the timing of deinfibulation surgery and NHS service provision. Methods This was a qualitative study informed by the Sound of Silence framework. This framework is useful for researching sensitive issues and the health-care needs of marginalised populations. A total of 101 interviews with 44 survivors, 13 men and 44 health-care professionals were conducted, supplemented by two workshops with affected communities (participants, n = 10) and one workshop with stakeholders (participants, n = 30). Data were analysed using a hybrid framework method. Results There was no clear consensus between groups on the optimal timing of deinfibulation. However, within groups, survivors expressed a preference for deinfibulation pre pregnancy; health-care professionals preferred antenatal deinfibulation, with the caveat that it should be the survivor’s choice. There was no consensus among men. There was agreement that deinfibulation should take place in a hospital setting and be undertaken by a suitable health-care professional. Decision-making around deinfibulation was complex. Deficiencies in professionals’ awareness, knowledge and understanding resulted in impacts on the provision of appropriate care. Although there were examples of good practice and positive care interactions, in general, service provision was opaque and remains suboptimal, with deficiencies most notable in mental health. Deinfibulation reportedly helps to mitigate some of the impacts of female genital mutilation. Interactions between survivors and health-care professionals were disproportionately framed around the law. The way in which services are planned and provided often silences the perspectives and preferences of survivors and their families. Limitations Only a minority of the interviews were conducted in a language other than English, and the recruitment of survivors was predominantly through maternity settings, which meant that some voices may not have been heard. The sample of men was relatively small, limiting interpretation. Conclusions In general, service provision remains suboptimal and can silence the perspectives and preferences of survivors. Deinfibulation services need to be widely advertised and information should highlight that the procedure will be carried out in hospital by suitable health-care professionals and that a range of time points will be offered to facilitate choice. Future services should be developed with survivors to ensure that they are clinically and culturally appropriate. Guidelines should be updated to better reflect the needs of survivors and to ensure consistency in service provision. Future work Research is needed to (1) map female genital mutilation service provision; (2) develop and test effective education to address deficits in awareness and knowledge for affected communities and health-care professionals; and (3) develop, monitor and evaluate clinically and culturally competent female genital mutilation services. Trial registration Current Controlled Trials ISRCTN14710507. Funding This project was funded by the National Institute for Health and Care Research (NIHR) Health Technology Assessment Programme and will be published in full in Health Technology Assessment; Vol. 27, No. 3. See the NIHR Journals Library website for further project information.

Reconstructing environments around archaeological sites is complicated by past land management practices and regional-scale climate proxies that can be contradictory and are often located at a distance from the sites themselves. Here we explore environmental information from fossil snail shells which, even when few in number on an archaeological site, may prove invaluable in constructing site-specific data. The palaeoecology of fossil snails and the stable isotopic composition of their shell carbonate can provide context-specific information on vegetation, water availability, and relative humidity during the occupation of a site. We studied terrestrial and aquatic snails from two later Neolithic archaeological sites in the Jordanian badia, Wadi al-Qattafi and Wisad Pools. At specific archaeological site-scale our study highlights the importance of aquatic snails in the reconstruction of semi-arid environments. At Wisad pools rare aquatic snails in contexts dating between ~8.0 and ~7.6 ka demonstrate episodes of wetness; moreover, their shell isotopic compositions indicate that local watercourses were well established, corroborating previous findings that during this period the immediate environs of Wisad Pools were host to C3 plant species more typical of the Mediterranean zone. Moreover, the δ18O signal in these snail shells allow tentative reconstruction of rainwater isotopic compositions and identify the effects of evaporation. Such fine-grained environmental information is much less evident from the terrestrial snail-shell data alone, showing that an ensemble of snail-shell data can be highly sensitive to environmental differentials across an archaeological site. Finally, at a regional palaeoclimate-scale our Wisad Pools snail-shell stable isotope data are consistent with a sustained, Rapid Climate Change (RCC)-driven wetness between 8.6 and 7.6 ka concurrent with cold and wet conditions in the wider Levant.

India boasts a rich sporting heritage dating back thousands of years. Despite its rich sporing culture, India only began developing its own sporting ecosystem in 1954 with the creation of the All-India Council of Sports (AICS) in 1954, shortly after gaining independence from the United Kingdom in 1947. However, in the seven decades that have passed, the systematisation and development of sport of India has been relatively slow and internationally India have had limited success on the elite stage. The aim of this profile is to provide a detailed insight into the vast sporting ecosystem in India by exploring the policies, enablers, and barriers in relation to sport participation, elite sport, and the use of sport across the nation to tackle non-sporting objectives. Following an introduction highlighting the key demographics and sporting culture in India, the profile moves onto outline the state led provision of sport in India, including how sport is organised and funded. Next, the significance of the commercial sport sector in India is highlighted, followed by a section detailing the growth of the not-for-profit sector. Finally, the profile highlights the current public policy priorities and challenges, which include elite sport success, tackling inactivity and poor governance in sport before offering some concluding observations.

The COVID-19 pandemic led to increases in family violence in Australia and elsewhere. In response, organisations in the domestic and family violence (DFV) sector, had to adapt to the emerging public health measures and worked collaboratively to protect the most vulnerable in the community. These services, including courts, rapidly transformed their methods of service delivery that are likely to continue for some time. But what have been the implications/impacts of these rapid changes on the DFV service sector in Australia? How have these impacts informed the future needs of the DFV sector? And what is needed to strengthen this community sector of the future? This article reports on the findings of a national research project examining the impacts of COVID-19 on the DFV service sector and the adaptations and innovations that emerged in response. The study highlights that the surge in demand for services put pressure on an already overwhelmed workforce/service sector and provided an opportunity for front line workers to contribute to building a robust sector to respond to future crisis events. These findings have significant implications for future DFV sector service delivery, and for the social work profession as a whole.

Vaccine-induced immune thrombotic thrombocytopenia (VITT) is a severe prothrombotic complication of adenoviral vaccines, including the ChAdOx1 nCoV-19 (Vaxzevria) vaccine. The putative mechanism involves formation of pathological anti–platelet factor 4 (PF4) antibodies that activate platelets via the low-affinity immunoglobulin G receptor FcγRIIa to drive thrombosis and thrombocytopenia. Functional assays are important for VITT diagnosis, as not all detectable anti-PF4 antibodies are pathogenic, and immunoassays have varying sensitivity. Combination of ligand binding of G protein–coupled receptors (protease-activated receptor-1) and immunoreceptor tyrosine–based activation motif–linked receptors (FcγRIIa) synergistically induce procoagulant platelet formation, which supports thrombin generation. Here, we describe a flow cytometry–based procoagulant platelet assay using cell death marker GSAO and P-selectin to diagnose VITT by exposing donor whole blood to patient plasma in the presence of a protease-activated receptor-1 agonist. Consecutive patients triaged for confirmatory functional VITT testing after screening using PF4/heparin ELISA were evaluated. In a development cohort of 47 patients with suspected VITT, plasma from ELISA-positive patients (n = 23), but not healthy donors (n = 32) or individuals exposed to the ChAdOx1 nCov-19 vaccine without VITT (n = 24), significantly increased the procoagulant platelet response. In a validation cohort of 99 VITT patients identified according to clinicopathologic adjudication, procoagulant flow cytometry identified 93% of VITT cases, including ELISA-negative and serotonin release assay–negative patients. The in vitro effect of intravenous immunoglobulin (IVIg) and fondaparinux trended with the clinical response seen in patients. Induction of FcγRIIa-dependent procoagulant response by patient plasma, suppressible by heparin and IVIg, is highly indicative of VITT, resulting in a sensitive and specific assay that has been adopted as part of a national diagnostic algorithm to identify vaccinated patients with platelet-activating antibodies.

Aims Behaviour modification and mood management are essential to recovery after a cardiac event. Recent times have seen a major shift to remote delivery of cardiac services. This study assessed behavioural and psychological outcomes of the Back on Track online self-management programme, comparing the programme undertaken alone (self-directed) vs. with telephone support (supported). Relevance for people with depression was also assessed. Methods and results Participants with cardiac conditions (n = 122) were randomly assigned to self-directed or supported groups and given access to the online programme for 2 months. The programme addressed depression, anxiety, physical activity, and healthy eating. Supported group participants also received two telephone sessions facilitated by a trained counsellor to further enhance their self-management skills and engagement with the online modules. The Patient Health Questionnaire-9, Generalized Anxiety Disorder-7, and Active Australia Survey and Diet Quality Tool were administered at baseline, 2, and 6 months. χ2 tests were used to compare self-directed and supported groups. Cochrane’s Q tests assessed changes over time in depression, anxiety, and physical activity (PA) and healthy diet guideline achievement. Participants in both groups showed reduced depression rates (self-directed, P < 0.05) and increased PA after programme completion (both groups, P < 0.05). Amongst those classified as depressed at baseline, significantly fewer were classified as depressed over time (P < 0.001) and significantly more were achieving the PA guidelines (P < 0.01) compared to those who were not depressed at baseline. Conclusions The Back on Track telehealth programme was effective in assisting with behavioural and emotional recovery after a cardiac event. The programme may be particularly beneficial for those who are depressed early in their recovery period. Trial Registration Australian New Zealand Clinical Trials Registry: ACTRN12620000102976.

Outdoor and nature experiences including play have been shown to be beneficial for children's physical, cognitive, social and emotional development. Parents/carers play an important role in encouraging or impeding their child's access to the outdoor environment and participation in outdoor play. The COVID-19 pandemic and associated restrictions on free movement and social interactions placed an unprecedented pressure on families to manage the drastic change in their daily routines. This paper reports findings from two combined data sets generated in 2020 during the COVID-19 pandemic and provides a deeper understanding of the interconnected nature of how contextual factors influence parenting processes and outcomes relating to young children's outdoor and nature experiences and subsequent child health. Findings have the potential to inform the messaging of existing outdoor play policies and the content of new interventions aiming to promote the exposure of children to the natural outdoor environment.

The early post-natal period is a critical period in women's infant feeding journeys, often marked by high levels of unintended breastfeeding cessation. Previous research has argued that infant feeding should be perceived within a complex system whereby factors operating at different ecological levels (i.e., individual, social/community networks, cultural/institutional) interact to affect individual behaviors. However, currently, more work needs to be done to implement an ecological approach in breastfeeding programs. We adopted a complex-systems lens approach to explore how multi-level factors—individual, mother-infant dyad, health service, family and social networks, and wider community infrastructure—interacted with women's motivations and experiences of breastfeeding. We undertook a secondary analysis of 24 women's interviews; all the women had a strong antenatal intention to breastfeed and were expecting their first baby. The interviews were collected during the UK-based Assets-based feeding help Before and After birth (ABA) feasibility trial when their infant was aged between 4 and 21 weeks. Categorical content analysis was used to explore the interrelationships between key factors and to identify different infant feeding typologies. Two different typologies emerged: “disappointed” (n = 7) and “by hook or by crook” (n = 17). “Disappointed” women had stopped breastfeeding early; women classified as “by hook or by crook” continued breastfeeding despite facing challenges. Sociodemographic, social, and service level differences between the typologies were noted. “Disappointed” women were more likely to be younger, White-British, to have considered mixed-feeding antenatally and experienced negative breastfeeding support from healthcare professionals and personal networks. Infants of “disappointed” women were more likely to have received unexpected “top-ups” and to be perceived as having infant feeding difficulties. Women classified as “by hook or by crook” were just as likely as “disappointed” women to experience birth-related complications, but demonstrated more proactive help-seeking behaviors, had positive experiences of personal/professional support and accessed wider support. While further research is needed to consolidate and/or refute the typologies, the ecological approach shifts the focus away from mothers' decisions to consider the multi-level factors that need to be in place to enable women to breastfeed successfully. Further work to encourage help-seeking behaviors and toward improving facilities, support, and services is needed.

Objective: To explore the views of female genital mutilation (FGM) survivors, men, and healthcare professionals (HCPs) on the timing of deinfibulation surgery and NHS service provision. Design: Qualitative study informed by the sound of silence framework. Setting: Survivors and men were recruited from three FGM prevalent areas of England. HCPs and stakeholders were from across the UK. Sample: 44 survivors, 13 men and 44 HCPs. 10 participants at two community workshops and 30 stakeholders at a national workshop. Methods: Hybrid framework analysis of 101 interviews and three workshops. Results: There was no consensus across groups on the optimal timing of deinfibulation for survivors who wished to be deinfibulated. Within group, survivors expressed a preference for deinfibulation pre-pregnancy and HCPs antenatal deinfibulation. There was no consensus for men. Participants reported that deinfibulation should take place in a hospital setting and be undertaken by a suitable HCP. Decision making around deinfibulation was complex but for those who underwent surgery it helped to mitigate FGM impacts. Whilst there were examples of good practice, in general, FGM service provision was sub-optimal. Conclusion: Deinfibulation services need to be widely advertised. Information should highlight that the procedure can be carried out at different time points, according to preference, and in a hospital by suitable HCPs. Future services should ideally be developed with survivors, to ensure that they are clinically and culturally appropriate. Guidelines would benefit from being updated to reflect the needs of survivors and to ensure consistency in provision. Study registration number ISRCTN 14710507

Background The UK has low levels of breastfeeding initiation and continuation, with evident socioeconomic disparities. To be inclusive, peer-support interventions should be woman-centred rather than breastfeeding-centred. Assets-based approaches to public health focus on the positive capabilities of individuals and communities, rather than their deficits and problems. The Assets-based feeding help Before and After birth (ABA) intervention offers an assets-based approach based on behaviour change theory. Objective To investigate the feasibility of delivering the ABA infant feeding intervention in a randomised controlled trial. Design This was an individually randomised controlled feasibility trial; women were randomised in a 1 : 1 ratio to either the intervention group or the comparator (usual care) group. Setting Two separate English sites were selected because they had an existing breastfeeding peer support service, relatively high levels of socioeconomic disadvantage and low rates of breastfeeding. Participants Women aged ≥ 16 years who were pregnant with their first child, irrespective of feeding intention (n = 103), were recruited by researchers in antenatal clinics. Interventions Proactive, woman-centred support, using an assets-based approach and including behaviour change techniques, was provided by an infant-feeding helper (a breastfeeding peer supporter trained in the ABA intervention) and delivered through face-to-face contact, telephone conversations and text messages. The intervention commenced at around 30 weeks’ gestation and could continue until 5 months postnatally. Main outcome measures The main outcome measures were feasibility of intervention delivery with the requisite intensity and duration; acceptability to women, infant-feeding helpers and maternity services; and feasibility of a future randomised controlled trial. Outcomes included recruitment rates and follow-up rates at 3 days, 8 weeks and 6 months postnatally, and outcomes for a future full trial were collected via participant questionnaires. A mixed-methods process evaluation included qualitative interviews with women, infant-feeding helpers and maternity services; infant-feeding helper logs; and audio-recordings of antenatal contacts to check intervention fidelity. Results Of the 135 eligible women approached, 103 (76.3%) agreed to participate. The study was successful in recruiting teenagers (8.7%) and women living in areas of socioeconomic disadvantage (37.3% resided in the most deprived 40% of small areas in England). Postnatal follow-up rates were 68.0%, 85.4% and 80.6% at 3 days, 8 weeks and 6 months, respectively. Feeding status at 8 weeks was obtained for 95.1% of participants. Recruitment took place from February 2017 until August 2017. It was possible to recruit and train existing peer supporters to the infant-feeding helper role. The intervention was delivered to most women with relatively high fidelity. Among the 50 women in the intervention group, 39 received antenatal visits and 40 received postnatal support. Qualitative data showed that the intervention was acceptable. There was no evidence of intervention-related harms. Limitations Birth notification delays resulted in delays in the collection of postnatal feeding status data and in the offer of postnatal support. In addition, the intervention needs to better consider all infant-feeding types and did not adequately accommodate women who delivered prematurely. Conclusion It is feasible to deliver the intervention and trial. Future work The intervention should be tested in a fully powered randomised controlled trial. Trial registration Current Controlled Trials ISRCTN14760978. Funding This project was funded by the National Institute for Health Research (NIHR) Public Health Research programme and will be published in full in Public Health Research; Vol. 8, No. 7. See the NIHR Journals Library website for further project information.

ObjectivesUK general practice has radically altered in response to COVID-19. The general practice nursing team has been central to these changes. To help learn from COVID-19 and maintain a sustainable nursing workforce, general practice should reflect on their support needs and perceptions of organisational strategies. This study aimed to explore primary care nurses’ and healthcare assistants’ experiences and perceptions of general practice, and the changes made to it, during the pandemic.DesignExploratory qualitative study using semistructured interviews. Interview data were analysed using Braun and Clarke’s ‘codebook’ thematic analysis.SettingGeneral practices in the Midlands, South East and South West England. Interviews were conducted in February and March 2021, as England began to unlock from its third national lockdown.ParticipantsPractice nurses (n=12), healthcare assistants (n=7), advanced nurse practitioners (n=4) and nursing associates (n=1) recruited using convenience and snowball sampling.ResultsThree themes were identified. Difficult changes describes dramatic changes made to general practice at the onset of the pandemic, creating confusion and anxiety. Dealing with change characterises how negative emotions were intensified by fear of infection, problematic government guidance, personal protective equipment (PPE) shortages and friction with doctors; but could be mitigated through effective practice communication, peer support and individual coping strategies. An opportunity for improvement highlights certain changes (eg, the increased use of telehealth) that participants believed could be adopted long term to improve efficiency.ConclusionGeneral practice should learn from the COVID-19 pandemic to nurture the clinical role and resilience of nurses and healthcare assistants in the postpandemic ‘new normal’. Robust PPE provision could enable them to undertake their patient-facing duties safely and confidently. Judicious implementation of telehealth could help preserve the practical and caring nature of nursing. Improving channels of communication and interprofessional collaboration could help realise their potential within the primary care team.

Background The COVID-19 pandemic has rapidly changed general practice in the UK. Research is required to understand how General Practitioners (GPs) and GP trainees adjusted to these changes, so that beneficial changes might be sustained, and Primary Health Care (PHC) can be prepared for future challenges. This study explored the experiences and perspectives of GP and GP trainees during the pandemic. Methods Remote, semi-structured interviews (n = 21) were conducted with GPs (n = 11) and GP trainees (n = 10), recruited from across the UK using convenience and purposive sampling. Interviews were audio-recorded and transcribed verbatim. Interview data were analysed with an inductive thematic approach. Results Five overarching themes were identified: (1) ‘Thrown in at the deep end’; (2) Telemedicine: ‘it needs to be a happy balance’; (3) Delayed referrals and ‘holding’ patients; (4) The Covid Cohort–training in Covid; (5) Suggestions and lessons for the future of general practice’. GPs reported a turbulent and uncertain time of major changes to PHC. They described the benefits of technology in general medicine, particularly telemedicine, when used in a balanced manner, highlighting the need for accompanying teaching and guidelines, and the importance of patient preferences. Key tools to help GPs manage patients with delayed referrals to Secondary Care were also identified. Conclusion Several key changes to general practice occurred as a result of the COVID-19 pandemic, including a rapid uptake of telemedicine. The pandemic exposed the strengths and limitations of normal general practice and highlighted the importance of workplace camaraderie. These findings contribute to the evidence base used to adapt PHC infrastructures as we emerge from the pandemic.

BACKGROUND After a cardiac event, a large majority of patients with cardiac conditions do not achieve recommended behavior change targets for secondary prevention. Mental health issues can also impact the ability to engage in health behavior change. There is a need for innovative, flexible, and theory-driven eHealth programs, which include evidence-based strategies to assist patients with cardiac conditions with their recovery, especially in behavioral and emotional self-management. OBJECTIVE The aim of this study is to determine the short- and longer-term behavioral and emotional well-being outcomes of the Back on Track web-based self-management program. In addition, this study will test whether there is enhanced benefit of providing one-on-one telephone support from a trained lifestyle counselor, over and above benefit obtained through completing the web-based program alone. METHODS People who have experienced a cardiac event in the previous 12 months and have access to the internet will be eligible for this study (N=120). Participants will be randomly assigned to one of the two study conditions: either “self-directed” completion of the Back on Track program (without assistance) or “supported” completion of the Back on Track program (additional 2 telephone sessions with a lifestyle counselor). All participants will have access to the web-based Back on Track program for 2 months. Telephone sessions with the supported arm participants will occur at approximately 2 and 6 weeks post enrollment. Measures will be assessed at baseline, and then 2 and 6 months later. Outcome measures assessed at all 3 timepoints include dietary intake, physical activity and sitting time, smoking status, anxiety and depression, stage of change, and self-efficacy in relation to behavioral and emotional self-management, quality of life, and self-rated health and well-being. A demographic questionnaire will be included at baseline only and program acceptability at 2 months only. RESULTS Recruitment began in May 2020 and concluded in August 2021. Data collection for the 6-month follow-up will be completed by February 2022, and data analysis and publication of results will be completed by June 2022. A total of 122 participants were enrolled in this study. CONCLUSIONS The Back on Track trial will enable us to quantify the behavioral and emotional improvements obtained and maintained for patients with cardiac conditions and, in particular, to compare two modes of delivery: (1) fully self-directed delivery and (2) supported by a lifestyle counselor. We anticipate that the web-based Back on Track program will assist patients in their recovery and self-management after an acute event, and represents an effective, flexible, and easily accessible adjunct to center-based rehabilitation programs. CLINICALTRIAL Australian New Zealand Clinical Trials Registry ACTRN12620000102976; http://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=378920&isReview=true INTERNATIONAL REGISTERED REPORT DERR1-10.2196/34534

Important heritage sites along the African coast are at risk from the threats associated with rising sea levels. Here, we quantify the exposure of natural and cultural heritage sites in Africa to coastal flooding and erosion in the 21st century. We develop a comprehensive database of 284 coastal African Heritage Sites (AHS), composed of 213 natural and 71 cultural heritage sites, which is then combined with coastal flooding and erosion projections to assess exposure to coastal extreme events for a moderate (RCP4.5) and high (RCP8.5) greenhouse gas emissions scenario. We find that 56 AHS are presently at risk from a 100-year extreme sea-level event, with a total exposed heritage area of 2,222 km2. Most of the currently exposed AHS are located in Northern and Western Africa. By mid-century, the number of exposed AHS is projected to increase more than 3 times to reach 191 and 198 under moderate and high emissions respectively. In the second half of the century, the number of exposed sites stabilizes, but the median exposed area increases to 6.6 to 8.5 times the present-day value, under moderate and high emissions, respectively. Mitigation from high to moderate emissions will reduce the end-century median exposed area and number of very highly exposed sites by 20% and 25% respectively.

Background and objectives Fluid overload and intradialytic hypotension are associated with cardiovascular events and mortality in patients on hemodialysis. We investigated associations between hemodialysis facility practices related to fluid volume and intradialytic hypotension and patient outcomes. Design, setting, participants, & measurements Data were analyzed from 10,250 patients in 273 facilities across 12 countries, from phase 4 of the Dialysis Outcomes and Practice Patterns Study (DOPPS; 2009–2012). Cox regression models (shared frailty) were used to estimate associations between facility practices reported by medical directors in response to the DOPPS Medical Directors Survey and all-cause and cardiovascular mortality and hospitalization, and cardiovascular events, adjusting for country, age, sex, dialysis vintage, predialysis systolic BP, cardiovascular comorbidities, diabetes, body mass index, smoking, residual kidney function, dialysis adequacy, and vascular access type. Results Of ten facility practices tested (chosen a priori ), having a protocol that specifies how often to assess dry weight in most patients was associated with lower all-cause (hazard ratio [HR], 0.78; 99% confidence interval [99% CI], 0.64 to 0.94) and cardiovascular mortality (HR, 0.72; 99% CI, 0.55 to 0.95). Routine orthostatic BP measurement to assess dry weight was associated with lower all-cause hospitalization (HR, 0.86; 99% CI, 0.77 to 0.97) and cardiovascular events (HR, 0.85; 99% CI, 0.73 to 0.98). Routine use of lower dialysate temperature to limit or prevent intradialytic hypotension was associated with lower cardiovascular mortality (HR, 0.76; 99% CI, 0.58 to 0.98). Routine use of an online volume indicator to assess dry weight was associated with higher all-cause hospitalization (HR, 1.19; 99% CI, 1.02 to 1.38). Routine use of sodium modeling/profiling to limit or prevent intradialytic hypotension was associated with higher all-cause mortality (HR, 1.36; 99% CI, 1.14 to 1.63), cardiovascular mortality (HR, 1.34; 99% CI, 1.04 to 1.73), and cardiovascular events (HR, 1.21; 99% CI, 1.03 to 1.43). Conclusions Hemodialysis facility practices relating to the management of fluid volume and intradialytic hypotension are associated with patient outcomes.

Background Childhood obesity is an urgent worldwide concern associated with increased morbidity in adulthood. Healthcare professionals (HCPs) are well placed to influence childhood obesity trends and implement interventions. English-language studies regarding HCPs’ perceptions of childhood obesity are limited to high-income countries. Peru is an upper-middle-income country with regional disparities in childhood obesity prevalence. This qualitative study aims to explore HCPs’ perceptions of childhood obesity in Iquitos, Peru, where prevalence is relatively low. Methods Twenty-one HCPs with child healthcare experience were purposively recruited from two primary healthcare centres. Semi-structured, individual interviews were conducted with a translator and audio recorded. Transcribed data were analysed using thematic analysis. Results Eight themes were identified and divided into four categories: (1) HCPs’ perceptions and attitudes towards childhood obesity (level of concern regarding childhood obesity, perceived consequences of childhood obesity); (2) Factors which HCPs perceive to be important in the development of childhood obesity (parental factors, contextual factors); (3) HCPs’ perceptions of their role in childhood obesity prevention and management (educating parents about childhood obesity, regular monitoring of child growth); and (4) Barriers and facilitators in childhood obesity prevention and management (in healthcare, in schools). Conclusions HCPs had a low level of concern regarding childhood obesity in Iquitos and prioritised undernutrition. Parental factors were perceived to be the most influential in the development of childhood obesity. HCPs perceived themselves to have minimal influence due to prevailing positive views of excess weight and difficulties engaging parents. Educating parents about childhood obesity was felt to be essential to prevention and management although regular monitoring of child growth and home healthcare visits were viewed as useful additional measures. This study can help to inform the development of targeted public health strategies which are sensitive to local contexts and could prevent the upward childhood obesity trends evident elsewhere in Peru.

This article proposes that the Pre-Pottery Neolithic A (PPNA) hunter-forager-cultivator introductions to Cyprus from the northern Levant had a much more enduring impact on the Cypriot Aceramic Neol...

This pilot study attempts to document the potential of Prehistoric human bone and teeth collagen from Cyprus (9th-2nd mill. BC), for isotopic analysis and palaeodietary reconstruction. We sampled archaeological human skeletons and some faunal remains coming from six sites located in different locations, with different burial modes. The analysis of carbon and nitrogen elemental compositions and stable isotope ratios (δ13C, δ15N), indicate an extremely poor preservation of collagen, probably in relationship with burying conditions. Although very few individuals were successfully analysed, stable isotope data from this study allow a discussion on different protein food resources intake by humans in comparison with some other published data in the Near East (Greece, Cyprus, Turkey) from the Neolithic to the Bronze Age. These diachronic data provide documentations for future studies, including palaeodietary and environmental field research.

Background After a cardiac event, a large majority of patients with cardiac conditions do not achieve recommended behavior change targets for secondary prevention. Mental health issues can also impact the ability to engage in health behavior change. There is a need for innovative, flexible, and theory-driven eHealth programs, which include evidence-based strategies to assist patients with cardiac conditions with their recovery, especially in behavioral and emotional self-management. Objective The aim of this study is to determine the short- and longer-term behavioral and emotional well-being outcomes of the Back on Track web-based self-management program. In addition, this study will test whether there is enhanced benefit of providing one-on-one telephone support from a trained lifestyle counselor, over and above benefit obtained through completing the web-based program alone. Methods People who have experienced a cardiac event in the previous 12 months and have access to the internet will be eligible for this study (N=120). Participants will be randomly assigned to one of the two study conditions: either “self-directed” completion of the Back on Track program (without assistance) or “supported” completion of the Back on Track program (additional 2 telephone sessions with a lifestyle counselor). All participants will have access to the web-based Back on Track program for 2 months. Telephone sessions with the supported arm participants will occur at approximately 2 and 6 weeks post enrollment. Measures will be assessed at baseline, and then 2 and 6 months later. Outcome measures assessed at all 3 timepoints include dietary intake, physical activity and sitting time, smoking status, anxiety and depression, stage of change, and self-efficacy in relation to behavioral and emotional self-management, quality of life, and self-rated health and well-being. A demographic questionnaire will be included at baseline only and program acceptability at 2 months only. Results Recruitment began in May 2020 and concluded in August 2021. Data collection for the 6-month follow-up will be completed by February 2022, and data analysis and publication of results will be completed by June 2022. A total of 122 participants were enrolled in this study. Conclusions The Back on Track trial will enable us to quantify the behavioral and emotional improvements obtained and maintained for patients with cardiac conditions and, in particular, to compare two modes of delivery: (1) fully self-directed delivery and (2) supported by a lifestyle counselor. We anticipate that the web-based Back on Track program will assist patients in their recovery and self-management after an acute event, and represents an effective, flexible, and easily accessible adjunct to center-based rehabilitation programs. Trial Registration Australian New Zealand Clinical Trials Registry ACTRN12620000102976; http://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=378920&isReview=true International Registered Report Identifier (IRRID) DERR1-10.2196/34534

We are deeply saddened by the loss of our close friend and colleague, Carole McCartney, whom we knew for more than 30 years, and whose work has had a profound impact on our understanding of the pre...

Objective Oral anticoagulant (OAC) prescription for stroke prevention in atrial fibrillation (AF) patients frequently does not follow current guidelines, with underuse in patients at high risk of stroke and substantial overuse in those at low risk. This review aims to systematically evaluate the effectiveness of interventions to improve appropriate OAC prescription in eligible AF patients for stroke prevention. Methods Systematic review of controlled and uncontrolled studies published up to July 2017 with interventions designed to improve appropriate OAC prescription for stroke prevention in eligible AF patients (according to risk assessment tool or guidelines). Categorization of intervention types was pre-specified. The main outcome was change in proportion of eligible AF patients prescribed OACs for stroke prevention. Results Twenty studies conducted in 392 settings were included (cluster randomized controlled trials, controlled trials and uncontrolled before-after designs; n = 29,868 patients at baseline). Fifteen studies reported significant improvements in appropriate prescription of OACs in AF patients. All interventions with a persuasive element (8/8); all studies targeting health care professional (HCP) education or guideline/protocol implementation (7/7); and all medical care programs (4/4) achieved significant increases in appropriate OAC prescription. Computerized decision support interventions (3/5) and reviews of prescribing (2/4) were less likely to report significant improvements in appropriate OAC prescription. Conclusion Interventions designed to improve appropriate prescription of OACs in eligible AF patients for stroke prevention can be effective. Successful approaches include education of HCPs; implementation of local guidelines; interdisciplinary medical care programs educating both HCPs and patients and persuasive interventions utilizing peer-group experts. Protocol registration: PROSPERO (CRD42016039654).

OBJECTIVE: To assess the effectiveness of a school and family based healthy lifestyle programme (WAVES intervention) compared with usual practice, in preventing childhood obesity.DESIGN: Cluster randomised controlled trial.SETTING: UK primary schools from the West Midlands.PARTICIPANTS: 200 schools were randomly selected from all state run primary schools within 35 miles of the study centre (n=980), oversampling those with high minority ethnic populations. These schools were randomly ordered and sequentially invited to participate. 144 eligible schools were approached to achieve the target recruitment of 54 schools. After baseline measurements 1467 year 1 pupils aged 5 and 6 years (control: 28 schools, 778 pupils) were randomised, using a blocked balancing algorithm. 53 schools remained in the trial and data on 1287 (87.7%) and 1169 (79.7%) pupils were available at first follow-up (15 month) and second follow-up (30 month), respectively.INTERVENTIONS: The 12 month intervention encouraged healthy eating and physical activity, including a daily additional 30 minute school time physical activity opportunity, a six week interactive skill based programme in conjunction with Aston Villa football club, signposting of local family physical activity opportunities through mail-outs every six months, and termly school led family workshops on healthy cooking skills.MAIN OUTCOME MEASURES: The protocol defined primary outcomes, assessed blind to allocation, were between arm difference in body mass index (BMI) z score at 15 and 30 months. Secondary outcomes were further anthropometric, dietary, physical activity, and psychological measurements, and difference in BMI z score at 39 months in a subset.RESULTS: Data for primary outcome analyses were: baseline, 54 schools: 1392 pupils (732 controls); first follow-up (15 months post-baseline), 53 schools: 1249 pupils (675 controls); second follow-up (30 months post-baseline), 53 schools: 1145 pupils (621 controls). The mean BMI z score was non-significantly lower in the intervention arm compared with the control arm at 15 months (mean difference -0.075 (95% confidence interval -0.183 to 0.033, P=0.18) in the baseline adjusted models. At 30 months the mean difference was -0.027 (-0.137 to 0.083, P=0.63). There was no statistically significant difference between groups for other anthropometric, dietary, physical activity, or psychological measurements (including assessment of harm).CONCLUSIONS: The primary analyses suggest that this experiential focused intervention had no statistically significant effect on BMI z score or on preventing childhood obesity. Schools are unlikely to impact on the childhood obesity epidemic by incorporating such interventions without wider support across multiple sectors and environments.TRIAL REGISTRATION: Current Controlled Trials ISRCTN97000586.

With a population of over 20 million, the central African nation of Cameroon has over\ud 200 ethnic groups speaking over 230 languages. Its triple colonial heritage makes it a\ud unique nation, fused with many political, economic and social complexities. This\ud country profile provides a review of how sport is organised and governed and begins\ud with an overview of the democratic and postcolonial past it has witnessed since\ud independence was gained in 1961. Sport is popular in Cameroon, and its development\ud is largely led by the central government. The profile begins with a discussion of the\ud key sport policy developments in recent years and in particular the rise in the\ud popularity of football over other sporting codes, and how this intersects positively\ud and negatively with politics. Next, the organisation and structure of sport in Cameroon\ud are outlined, specifically school sport, elite sport and disability sports provision. The\ud profile notes a small yet emergent non-state-led sector, which uses sport for development\ud purposes, which is driven in the main by international organisations and donors.\ud Finally, the key priorities and associated challenges for Cameroon sport are discussed,\ud including the desire to grow the nation’s sporting infrastructure in order to host\ud international sports competitions.

This paper presents the results of a petrographic study conducted on a selection of 88 Cypriot ceramic Neolithic vessels, originating at seven sites, representing various geographic regions on the island. The study is aimed at determining their place of origin and disclosing details about the technology of their production. All the vessels studied were found to be locally made on the island. There are, however, indications that there was restricted movement of ceramic vessels within defined regions of the island. In addition, a clear distinction between the production technologies of coarse ware and painted ware was observed, reflecting island-wide shared technological traditions. However, even within these seemingly uniform technological traditions, regional variations can be observed. These observations support previous interpretations suggesting a division between ‘northern’ and ‘southern’ social groups on the island during the Ceramic Neolithic period.

Background The trial results of BD FocalPoint™ GS computer assisted screening(FP) of BD SurePath® liquid based cervical cytology slides (SP) were published in Diagnostic Cytopathology in 2012.1 Method The FP-reviewed SP slides were compared to conventional cervical Pap smears (CON) in a split sample of 2198 routine specimens. In all 47 confirmed high grade (HG) cases, FP either selected fields of view (FOV) containing cells suspicious or diagnostic of HG (46/47), or prompted full screening of the slide (1/47) leading to detection of the HG lesion. In this study for the HG cases which were reported initially as negative (NEG) or low grade (LG), the original slides were reviewed to determine the reasons for the false negative reporting and to identify features characteristic of a HG pattern. Results Indicators of a high risk pattern for HG Squamous Intraepithelial lesions (HSIL) included the recognition of pale abnormal immature metaplastic cells. Indicators of a high risk pattern for HG Glandular Intraepithelial lesion (AIS) were single columnar cells with the nucleus occupying the widest area of the cell. Pavemented sheets of glandular cells and isolated mitoses were additional clues to the diagnosis. In endocervical and endometrial adenocarcinomas tumour diathesis tends to be absent in SurePath slides. Single cells with ingested neutrophils and obscured eccentric nuclei were another clue to the detection of endometrial adenocarcinoma. Conclusion These morphological features are illustrated to help identify HSIL and HG glandular lesions when viewing the FOV presented by the FocalPointTM GS technology. Diagn. Cytopathol. 2015;43:870–878. © 2015 Wiley Periodicals, Inc.

Schools are increasingly recognized as an ideal setting for interventions to tackle childhood obesity. A better understanding of the views of key stakeholders would help to engage schools and inform the feasibility of such interventions in practice. This meta-synthesis of 18 qualitative studies explores the views of parents, school staff, school governors, school nurses and students on the role of the primary school in preventing childhood obesity. Six categories emerged: 'School as a key setting'; 'What schools should be doing to promote healthy eating (HE)'; 'What schools should be doing to promote physical activity (PA)'; 'General barriers'; 'Barriers to promoting HE at school'; and 'Barriers to promoting PA at school'. Thirty-seven finer-level themes emerged within these categories. Stakeholders agreed on the key role of the primary school as a setting for obesity prevention, the importance of schools providing and promoting opportunities for HE and PA, and the need for schools to work with parents. Some perceived barriers could be overcome at school level, e.g. using unhealthy foods as rewards/fundraisers or withholding PA for bad behaviour. Leadership and guidance from government were considered to be needed to counteract other observed barriers, particularly regarding school canteens, support for parents and time for PA.

During the Middle Pre-pottery Neolithic B in the southern Levant the use of lime plaster in both ritual and domestic contexts increased significantly relative to previous periods. Its properties of whiteness, purity, plasticity and antisepsis would have made it a natural choice for decorating, and through the act of colouring disparate categories of objects were linked together. Plaster appears to have transcended its own inherent value as a material due to its interconnectedness with mortuary ritual. Because of its ubiquity, this socially ascribed value was accessible to everyone. This article will claim that plaster, and the act of plastering both ritual and domestic contexts played a key role in the creation and maintenance of community cohesion and social well-being.

BD FocalPoint GS™ computer-assisted screening of BD SurePath® liquid-based cervical cytology slides (SP + FP) was compared with screening an accompanying conventional cervical Papanicolaou (Pap) smear (CON) in a split sample trial of 2,198 routine specimens. The rate of unsatisfactory specimens in the SP + FP arm was 0.2% compared with 4.1% in the conventional Pap smear, a significant reduction. There was no statistically significant difference between SP + FP and CON for the detection of histologically confirmed high-grade (HG) lesions in the routine split sample specimens (n = 9). To further test the sensitivity of SP + FP for HG lesions, 38 SurePath slides from confirmed HG cases, without an accompanying CON, were interpolated among the routine smears. In every one of the 47 confirmed HG cases, either HG cells were present in the microscope fields selected by FocalPointGS™ for review by the screening cytologist (46 of 47), or full screening of the slide was indicated by the FocalPointGS™ (1 of 47), confirming the effectiveness of SP + FP technology for primary screening. In a small number of cases, the screening cytologist did not recognize the abnormality even though on review HG cells were present in fields selected by FocalPointGS™. The overall detection rate was 93% for HG squamous lesions; 89% for known HG endocervical glandular lesions; and 91% for known endometrial carcinoma. In conclusion, the SP + FP detected 100% of HG abnormalities in the trial set; significantly reduced the rate of unsatisfactory specimens; and improved the overall screening rate of detection of HG abnormalities particularly of glandular lesions when compared with other screening technologies.

Western Sahara has one of the last remaining unexplored prehistories on the planet. The new research reported here reveals a sequence of Holocene occupation beginning in a humid period around 9000 bp, superceded around 5000 bp by an arid phase in which the land was mainly given over to pastoralism and monumental burial. The authors summarise the flint and pottery assemblage and classify the monuments, looking to neighbouring cultures in Niger, Libya and Sudan.

Objective To determine whether providing previous cytology and histology findings alters the accuracy of conventional cervical cytology reading or changes reading times. Study Design Each of 9 cytologists read 9 batches of 8 routinely referred Pap smears (total, 648 slides), with history (H) and without history (NH), at an interval of no less than 4 weeks. Each batch was read blind to the result of reading under the other strategy and to histology. Histologic cervical intraepitbelial neoplasia 2 or more severe was the reference standard. Accuracy of reading was assessed across all thresholds using receiver operating characteristic (ROC) curves and by sensitivity and specificity at a cytology threshold of possible low grade squamous intraepithelial lesion (consistent with atypical squamous cells of undermined significance). Results Areas under the ROC curve, sensitivities and specificities were similar if read with or without history, except for 1 reader for whom reading with history increased the area under the ROC curve from 0.716 to 0.833 (increase of 0.117, p = 0.017) and the sensitivity from 0. 57 to 0.79 (increase of 0.22, p = 0. 014), without any significant change in specificity. Accuracy varied between subgroups defined by age and by the severity and timing of previous abnormalities, but the results of the comparison of accuracy in H and NH did not vary by subgroup. Mean reading times were 8.2 (H) and 7.9 (NH) minutes per slide, a difference of 0.34 minutes (p=0.083). Differences in mean batch times (H-NH) between readers ranged from -0.08 to 1.0 minutes, the largest difference being for the reader whose accuracy increased. Conclusion An accurate history might improve accuracy for some cytologists.

Sixty years after the excavations of Porphyrios Dikaios at the prehistoric site, Kalavasos Kokkinoyia in Cyprus, recent excavations are revealing new information on the poorly understood transition from the Late Neolithic period to the Early Chalcolithic period (ca 4000-3900 cal. BC). Kalavasos Kokkinoyia features at least two anomalous traits: an extensive chamber and tunnel complex and the complete absence of any animal or botanical remains. These features set the site apart from other sites of the Late Neolithic and Early Chalcolithic periods in Cyprus. This paper summarises recent findings at Kalavasos Kokkinoyia in the wider context of Cyprus in the late 5th and early 4th millennia BC and poses some questions regarding the nature of site diversity at this time.

Schools are seen as important contributors to obesity prevention, yet face barriers in fulfilling this function. This qualitative study investigates headteacher views on the primary school role in preventing obesity. Semi-structured interviews were held with 22 headteachers from ethnically and socio-economically diverse schools in the West Midlands, UK. Data analysis was conducted using the framework approach. Two over-arching categories were identified: 'School roles and responsibilities' and 'Influencing factors'. Participants agreed that although schools contribute towards obesity prevention in many ways, a moral responsibility to support children's holistic development was the principal motivator, rather than preventing obesity per se. The perceived impact on learning was a key driver for promoting health. Parents were believed to have the main responsibility for preventing obesity, but barriers were identified. Whilst headteachers recognized the advantageous position of schools in offering support to parents, opinion varied on the degree to which schools could and should take on this role. Headteachers serving more deprived areas reported adopting certain responsibilities that elsewhere were fulfilled by parents, and were more likely to view working with families on healthy lifestyles as an important school function. Several factors were perceived as barriers to schools doing more to prevent obesity, including academic pressure, access to expert support and space. In conclusion, school leaders need more support, through resources and government policy, to enable them to maximize their role in obesity prevention. Additionally, school-based obesity prevention should be an integral part of the education agenda rather than bolt-on initiatives.

Paul Thomas Anderson's film Magnolia (1999) is striking for its implications of gender address and enunciation. Somewhat akin to Pirandello's Six Characters in Search of an Author—which displaces "fictional characters" into the "real" world—Magnolia displaces film narrative to television text and shifts from the normative masculine viewing position to a feminine one. Magnolia is symptomatic of a crisis in masculinity and interrogates cultural texts such as cop shows, quiz shows, and infomercials. Read as soap opera, Magnolia is a subversive cultural product, an indictment of paradigms of male hegemony and power, and a critique of the media systems of film and television.