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INTRODUCTION: A range of nonpharmaceutical public health interventions has been introduced in many countries following the rapid spread of Covid-19 since 2020, including recommendations or mandates for the use of face masks or coverings in the community. While the effectiveness of face masks in reducing Covid-19 transmission has been extensively discussed, scant attention has been paid to the lived experience of those wearing face masks. METHOD: Drawing on 40 narrative interviews with a purposive sample of people in the United Kingdom, with a particular focus on marginalised and minoritized groups, our paper explores experiences of face mask use during the pandemic. RESULTS: We find that face masks have a range of societal, health and safety impacts, and prompted positive and negative emotional responses for users. We map our findings onto Lorenc and Oliver's framework for intervention risks. We suggest that qualitative data offer particular insights into the experiences of public health interventions, allowing the potential downsides and risks of interventions to be more fully considered and informing public health policies that might avoid inadvertent harm, particularly towards marginalised groups. PATIENT OR PUBLIC CONTRIBUTION: The study primarily involved members of the public in the conduct of the research, namely through participation in interviews (email and telephone). The conception for the study involved extensive discussions on social media with a range of people, and we received input and ideas from presentations we delivered on the preliminary analysis.

Peer reviewed: True, Acknowledgements: This paper was produced using CUREd data. We gratefully acknowledge the contribution of the NHS Trusts in the Yorkshire and the Humber region which provided the original data to the University of Sheffield Connected Health Cities Study. Connected Health Cities is a Northern Health Science Alliance (NHSA)-led programme funded by the Department of Health and Social Care and delivered by a consortium of academic and NHS organisations across the north of England. Graham Martin is based in The Healthcare Improvement Studies Institute (THIS Institute), University of Cambridge. THIS Institute is supported by the Health Foundation, an independent charity committed to bringing about better health and healthcare for people in the UK. CUREd data were provided in anonymised form; this paper has been screened to ensure patient confidentiality is maintained. We would like to thank Jamie Mills, Neil Prockter and the Emergency Care for Frail Older People (ECOP) team for their valuable assistance and comments. We thank the editor and reviewers for their insightful comments on previous versions of the manuscript., Background and objectiveCare for older patients in the ED is an increasingly important issue with the ageing society. To better assess the quality of care in this patient group, we assessed predictors for three outcomes related to ED care: being seen and discharged within 4 hours of ED arrival; being admitted from ED to hospital and reattending the ED within 30 days. We also used these outcomes to identify better-performing EDs.MethodsThe CUREd Research Database was used for a retrospective observational study of all 1 039 251 attendances by 368 754 patients aged 75+ years in 18 type 1 EDs in the Yorkshire and the Humber region of England between April 2012 and March 2017. We estimated multilevel logit models, accounting for patients’ characteristics and contact with emergency services prior to ED arrival, time variables and the ED itself.ResultsPatients in the oldest category (95+ years vs 75–80 years) were more likely to have a long ED wait (OR=1.13 (95% CI=1.10 to 1.15)), hospital admission (OR=1.26 (95% CI=1.23 to 1.29)) and ED reattendance (OR=1.09 (95% CI=1.06 to 1.12)). Those who had previously attended (3+ vs 0 previous attendances) were more likely to have long wait (OR=1.07 (95% CI=1.06 to 1.08)), hospital admission (OR=1.10 (95% CI=1.09 to 1.12)) and ED attendance (OR=3.13 (95% CI=3.09 to 3.17)). Those who attended out of hours (vs not out of hours) were more likely to have a long ED wait (OR=1.33 (95% CI=1.32 to 1.34)), be admitted to hospital (OR=1.19 (95% CI=1.18 to 1.21)) and have ED reattendance (OR=1.07 (95% CI=1.05 to 1.08)). Those living in less deprived decile (vs most deprived decile) were less likely to have any of these three outcomes: OR=0.93 (95% CI=0.92 to 0.95), 0.92 (95% CI=0.90 to 0.94), 0.86 (95% CI=0.84 to 0.88). These characteristics were not strongly associated with long waits for those who arrived by ambulance. Emergency call handler designation was the strongest predictor of long ED waits and hospital admission: compared with those who did not arrive by ambulance; ORs for these outcomes were 1.18 (95% CI=1.16 to 1.20) and 1.85 (95% CI=1.81 to 1.89) for those designated less urgent; 1.37 (95% CI=1.33 to 1.40) and 2.13 (95% CI=2.07 to 2.18) for urgent attendees; 1.26 (95% CI=1.23 to 1.28) and 2.40 (95% CI=2.36 to 2.45) for emergency attendees; and 1.37 (95% CI=1.28 to 1.45) and 2.42 (95% CI=2.26 to 2.59) for those with life-threatening conditions. We identified two EDs whose patients were less likely to have a long ED, hospital admission or ED reattendance than other EDs in the region.ConclusionsAge, previous attendance and attending out of hours were all associated with an increased likelihood of exceeding 4 hours in the ED, hospital admission and reattendance among patients over 75 years. These differences were less pronounced among those arriving by ambulance. Emergency call handler designation could be used to identify those at the highest risk of long ED waits, hospital admission and ED reattendance.

Perry et al.’s study of a programme to reconfigure cancer surgery provision in Greater Manchester highlights the importance of accounting for history in making successful change. In this short commentary, I expand on some of Perry et al.’s key findings. I note the way in which those leading change in Greater Manchester combined formal expertise in change management with sensitivity to local context, enhancing their approach to change through attention to details around relationships, events and assumptions that might otherwise have derailed the process. I identify lessons for others in how best to account for history in leading change, highlighting in particular the need to attempt to access and understand forms of history that may be suppressed, difficult-to-articulate, or otherwise marginalised.

Background: Alcohol-related cirrhosis (AC) is responsible for 84% of liver related death in the UK. The only treatment available for AC is alcohol abstinence and reduction. Despite the availability of treatments for alcohol use disorder (AUD), the uptake among patients with AC poor. Little is known about the acceptability of these treatments in patients with AC or the barriers which may be contributing to poor uptake. The inpatient admission provides a unique opportunity for patients to be engaged. Research Questions: What is the experience of patients with AC in regard to available interventions for AUD? What do patients view as the barriers and facilitators to interventions for AUD? What outcomes do patients feel are important when evaluating these treatments? Methods: Semi-structured interviews with patients admitted to hospital with AC will be conducted. Interviewing patients admitted to hospital will allow those of most need to participate. A grounded theory approach and purposive sampling will be used to generate a rich and diverse qualitative dataset. Interviews will continue until data reaches saturation which is expected to be after approximately 30 patients. Impact: Gathering the views and experiences of patients will lead to recommendations on methods to improve the uptake of treatments. The insights gained will shape the development of new treatments or interventions. We will also be able to recommend preferred outcome measures for evaluating treatments to reduce alcohol intake in patients with AC. Funded by NIHR Doctoral Fellowship to Dr Christopher Oldroyd (NIHR 302571)

Supplemental Material for A qualitative study of the dynamics of access to remote antenatal care through the lens of candidacy by Lisa Hinton, Karolina Kuberska, Francesca Dakin, Nicola Boydell, Graham Martin, Tim Draycott, Cathy Winter, Richard J McManus, Lucy Chappell, Sanhita Chakrabarti, Elizabeth Howland, Janet Willars, and Mary Dixon-Woods in Journal of Health Services Research & Policy

Peer reviewed: True, Funder: Health Foundation; FundRef: https://doi.org/10.13039/501100000724, OBJECTIVE: The National Health Service (NHS) in England has introduced a range of policy measures aimed at fostering greater openness, transparency and candour about quality and safety. We draw on the findings of an evaluation of the implementation of these policies in NHS organisations, with the aim of identifying key implications for policy and practice. METHODS: We undertook a mixed-methods policy evaluation, comprising four substudies: a longitudinal analysis of data from surveys of NHS staff and service users; interviews with senior stakeholders in NHS provider organisations and the wider system; a survey of board members of NHS provider organisations and organisational case studies across acute, community and mental health, and ambulance services. RESULTS: Our findings indicate a mixed picture of progress towards improving openness in NHS organisations, influenced by organisational history and memories of past efforts, and complicated by organisational heterogeneity. We identify four features that appear to be necessary conditions for sustained progress in improving openness: (1) authentic integration into organisational mission is crucial in making openness a day-to-day concern; (2) functional and effective administrative systems are vital; (3) these systems must be leavened by flexibility and sensitivity in implementation and (4) a spirit of continuous inquiry, learning and improvement is required to avoid the fallacy that advancing openness can be reduced to a time-limited project. We also identify four persistent challenges in consolidating and sustaining improvement: (1) a reliance on goodwill and discretionary effort; (2) caring for staff, patients and relatives who seek openness; (3) the limits of values-driven approaches on their own and (4) the continued marginality of patients, carers and families. CONCLUSIONS: Variation in policy implementation offers important lessons on how organisations can better deliver openness, transparency and candour. These lessons highlight practical actions for policymakers, managers and senior clinicians.

BACKGROUND: Serious incident (SI) investigations aim to identify factors that caused or could have caused serious patient harm. This study aimed to use the Human Factors Analysis and Classification System (HFACS) to characterise the contributory factors identified in SI investigation reports. METHODS: We performed a content analysis of 126 investigation reports from a multi-site NHS trust. We used a HFACS-based framework that was modified through inductive analysis of the data. RESULTS: Using the modified HFACS framework, 'unsafe actions' were the most commonly identified hierarchical level of contributory factors in investigation reports, which were identified 282 times across 99 (79%) incidents. 'Preconditions to unsafe acts' (identified 223 times in 91 (72%) incidents) included miscommunication and environmental factors. Supervisory factors were identified 73 times across 40 (31%) incidents, and organisational factors 115 times across 59 (47%) incidents. We identified 'extra-organisational factors' as a new HFACS level, though it was infrequently described. CONCLUSIONS: Analysis of SI investigation reports using a modified HFACS framework allows important insights into what investigators view as contributory factors. We found an emphasis on human error but little engagement with why it occurs. Better investigations will require independence and professionalisation of investigators, human factors expertise, and a systems approach.

BACKGROUND: Resources for healthcare professionals, patients and those important to them relating to planning and coordinating treatment and care at the end of life are abundant, and can be difficult to navigate. However, they have not been systematically collated or catalogued in terms of their purpose, scope or intended audience. AIM: To collate, categorise and characterise advance care planning and end-of-life treatment and care (EoLT + C) resources directed towards healthcare professionals, patients and their families. METHODS: Rapid review and thematic synthesis of resources available in the United Kingdom. Google searches and reviews of websites belonging to selected organisations that develop and publish materials relating to EoLT + C, and advance care planning were used. Materials were included if they were intended for those over 18 living in the UK and pertained to five domains of EoLT + C: identifying those approaching end of life; accessing EoLT + C services; conducting important conversations about EoLT + C and preferences; advance care planning, including recording of preferences and plans; and ensuring that plans and preferences are accessed and used by health and social care services. RESULTS: 246 resources directed at healthcare professionals, patients and their families were identified, collated, catalogued and made internationally available for clinicians, researchers, patients and the public. 61 were classified as interactive, providing decision support in EoLT + C that went beyond simply providing information. Of these, there was notable content overlap among tools for identifying patients in their last year of life. There was variation in the development of tools across all domains of end-of-life care by geography and patient group. Few interactive resources integrated seamlessly with a digital interface or healthcare provider workflows. Incentives for the adoption of best-practice appeared rare. CONCLUSIONS: We present a repeatable and scalable approach to the cataloguing and characterisation of palliative care resources. The identified resources will be of benefit not only to those in the UK but to those in other countries, developing or evaluating their own resources for aiding professionals and patients to plan and deliver excellent treatment and care at the end of life., ZF, GM and FW are based in The Healthcare Improvement Studies Institute (THIS Institute), University of Cambridge. THIS Institute is supported by the Health Foundation, an independent charity committed to bringing about better health and healthcare for people in the UK.

The engineering of Majorana zero modes in topological superconductors, a paradigm for the realization of topological quantum computing and topology-based devices, has been hampered by the absence of materials with sufficiently large superconducting gaps. Recent experiments, however, have provided enthralling evidence for the existence of topological surface superconductivity in the iron-based superconductor FeSe0.45Te0.55 possessing a full s±-wave gap of a few meV. Here, we propose a mechanism for the emergence of topological superconductivity on the surface of FeSe0.45Te0.55 by demonstrating that the interplay between the s±-wave symmetry of the superconducting gap, surface magnetism, and a Rashba spin–orbit interaction gives rise to robust topological superconducting phases. Moreover, the proposed mechanism explains a series of experimentally observed hallmarks of topological superconductivity, such as the emergence of Majorana zero modes in the center of vortex cores and at the end of line defects, as well as of chiral Majorana edge modes along domain walls. We also propose that the spatial distribution of supercurrents near a domain wall is a characteristic signature measurable via a scanning superconducting quantum interference device that can distinguish between chiral Majorana edge modes and trivial in-gap states.

Background: People with dementia and other forms of cognitive impairment form a substantial proportion of patients admitted to hospitals, but problems in their care are persistent. One widely proposed improvement approach involves the use of systems using visual identifiers to help staff quickly recognise people with suspected dementia, with the goal of supporting more personalised care. The aim of this paper is to identify the identifier systems in use and staff perceptions of their strengths and weaknesses. Methods: We undertook an online survey of staff providing care for people with dementia in acute and mental health hospitals across the United Kingdom. The questionnaire covered different types of visual identifier systems for dementia. It used categorical and open‐response questions to access staff views of their use in practice. Responses were analysed using descriptive statistics, and the Framework approach for free‐text answers. Results: 162 responses were received from staff in at least 48 hospitals. Of these, 128 had direct experience of using visual identifier systems. They reported that multiple identifier systems are in use, including schemes with national scope and locally developed approaches. Most respondents reported that more than one system is in use in their hospital. Different types of identifier were seen to have different strengths and weaknesses. Respondents had a broadly positive view of identifiers, but highlighted risks including lack of reliable and consistent use (linked to competing pressures on staff time), lack of staff training, uncertainty about patient and family views, and unclear consent processes. Conclusions: Our study suggests that a wide range of identifier systems is in use in UK hospitals, with many hospitals using more than one. Further consideration should be given to ensuring that multiple perspectives—including those of patients and carers—are drawn on in optimising their design, resolving ethical issues and supporting implementation.

Background: Practical methods for facilitating process improvement are needed to support high quality, safe care. How best to specify (identify and define) process improvements – the changes that need to be made in a healthcare process – remains a key question. Methods for doing so collaboratively, rapidly and remotely offer much potential, but are under-developed. We propose an approach for engaging diverse stakeholders remotely in a consensus-building exercise to help specify improvements in a healthcare process, and we illustrate the approach in a case study. Methods: Organised in a five-step framework, our proposed approach is informed by a participatory ethos, crowdsourcing and consensus-building methods: (1) define scope and objective of the process improvement; (2) produce a draft or prototype of the proposed process improvement specification; (3) identify participant recruitment strategy; (4) design and conduct a remote consensus-building exercise; (5) produce a final specification of the process improvement in light of learning from the exercise. We tested the approach in a case study that sought to specify process improvements for the management of obstetric emergencies during the COVID-19 pandemic. We used a brief video showing a process for managing a post-partum haemorrhage in women with COVID-19 to elicit recommendations on how the process could be improved. Two Delphi rounds were then conducted to reach consensus. Results: We gathered views from 105 participants, with a background in maternity care (n = 36), infection prevention and control (n = 17), or human factors (n = 52). The participants initially generated 818 recommendations for how to improve the process illustrated in the video, which we synthesised into a set of 22 recommendations. The consensus-building exercise yielded a final set of 16 recommendations. These were used to inform the specification of process improvements for managing the obstetric emergency and develop supporting resources, including an updated video. Conclusions: The proposed methodological approach enabled the expertise and ingenuity of diverse stakeholders to be captured and mobilised to specify process improvements in an area of pressing service need. This approach has the potential to address current challenges in process improvement, but will require further evaluation.

Background: Practical methods for facilitating process improvement are needed to support high quality, safe care. How best to specify (identify and define) process improvements – the changes that need to be made in a healthcare process – remains a key question. Methods for doing so collaboratively, rapidly and remotely offer much potential, but are under-developed. We propose an approach for engaging diverse stakeholders remotely in a consensus-building exercise to help specify improvements in a healthcare process, and we illustrate the approach in a case study. Methods: Organised in a five-step framework, our proposed approach is informed by a participatory ethos, crowdsourcing and consensus-building methods: (1) define scope and objective of the process improvement; (2) produce a draft or prototype of the proposed process improvement specification; (3) identify participant recruitment strategy; (4) design and conduct a remote consensus-building exercise; (5) produce a final specification of the process improvement in light of learning from the exercise. We tested the approach in a case study that sought to specify process improvements for the management of obstetric emergencies during the COVID-19 pandemic. We used a brief video showing a process for managing a post-partum haemorrhage in women with COVID-19 to elicit recommendations on how the process could be improved. Two Delphi rounds were then conducted to reach consensus. Results: We gathered views from 105 participants, with a background in maternity care (n = 36), infection prevention and control (n = 17), or human factors (n = 52). The participants initially generated 818 recommendations for how to improve the process illustrated in the video, which we synthesised into a set of 22 recommendations. The consensus-building exercise yielded a final set of 16 recommendations. These were used to inform the specification of process improvements for managing the obstetric emergency and develop supporting resources, including an updated video. Conclusions: The proposed methodological approach enabled the expertise and ingenuity of diverse stakeholders to be captured and mobilised to specify process improvements in an area of pressing service need. This approach has the potential to address current challenges in process improvement, but will require further evaluation.

Background The Covid-19 pandemic has imposed extraordinary strains on healthcare workers. But, in contrast with acute settings, relatively little attention has been given to those who work in mental health settings. We aimed to characterise the experiences of those working in English NHS secondary mental health services during the first wave of the pandemic. Methods The design was a qualitative interview-based study. We conducted semi-structured, remote (telephone or online) interviews with 35 members of staff from NHS secondary (inpatient and community) mental health services in England. Analysis was based on the constant comparative method. Results Participants reported wide-ranging changes in the organisation of secondary mental health care and the nature of work in response to the pandemic, including pausing of all services deemed to be “non-essential”, deployment of staff across services to new and unfamiliar roles, and moves to remote working. The quality of participants’ working life was impaired by increasing levels of daily challenge associated with trying to provide care in trying and constrained circumstances, the problems of forging new ways of working remotely, and constraints on ability to access informal support. Participants were confronted with difficult dilemmas relating to clinical decision-making, prioritisation of care, and compromises in ability to perform the therapeutic function of their roles. Other dilemmas centred on trying to balance the risks of controlling infection with the need for human contact. Many reported features of moral injury linked to their perceived failures in providing the quality or level of care that they felt service users needed. They sometimes sought to compensate for deficits in care through increased advocacy, taking on additional tasks, or making exceptions, but this led to further personal strain. Many experienced feelings of grief, helplessness, isolation, distress, and burnout. These problems were compounded by sometimes poor communication about service changes and by staff feeling that they could not take time off because of the potential impact on others. Some reported feeling poorly supported by organisations. Conclusions Mental health workers faced multiple adversities during the pandemic that were highly consequential for their wellbeing. These findings can help in identifying targets for support.

ObjectivesTo explore the experiences of service users, carers and staff seeking or providing secondary mental health services during the COVID-19 pandemic.DesignQualitative interview study, co-designed with mental health service users and carers.MethodsWe conducted semi-structured, telephone or online interviews with a purposively constructed sample; a peer researcher with lived experience conducted and analysed interviews with service users. Analysis was based on the constant comparison method.SettingNHS secondary mental health services in England between June and August 2020.ParticipantsOf 65 participants, 20 had either accessed or needed to access English secondary mental healthcare during the pandemic; 10 were carers of people with mental health difficulties; 35 were members of staff working in NHS secondary mental health services during the pandemic.ResultsExperiences of remote care were mixed. Some service users valued the convenience of remote methods in the context of maintaining contact with familiar clinicians. Most participants commented that a lack of non-verbal cues and the loss of a therapeutic ‘safe space’ challenged therapeutic relationship building, assessments, and identification of deteriorating mental wellbeing. Some carers felt excluded from remote meetings and concerned that assessments were incomplete without their input. Like service users, remote methods posed challenges for clinicians who reported uncertainty about technical options and a lack of training. All groups expressed concern about intersectionality exacerbating inequalities and the exclusion of some service user groups if alternatives to remote care are lost.ConclusionsWhilst remote mental healthcare is likely to become increasingly widespread in secondary mental health services, our findings highlight the continued importance of a tailored, personal approach to decisions about remote mental healthcare. Further research should focus on which types of consultations best suit face-to-face interaction, and for whom and why, and which can be provided remotely and by which medium.ARTICLE SUMMARYStrengths and limitations of this studyStrengths include its qualitative approach in speaking to a large sample of participants with varied mental health difficulties, carers, and a diverse range of mental healthcare staff.Its novelty lies in a deep exploration of the views and experiences of remote mental healthcare during a pandemic.The methods are strengthened by the involvement of experts-by-experience and the use of peer research methods.We did not adopt a narrative method; the interviews were one-off conversations so we could not explore change as the pandemic progressed and people may have become accustomed to remote care.The study used remote methods to comply with UK lockdown regulations; this will have excluded some groups without the ability to engage remotely.

Additional file 2: Supplement 2. Interactive bar charts of ratings across the three stakeholder groups as presented to participants in the second Delphi round.

Additional file 1: Supplement 1. Synthesis process of the 912 responses to the recommendation task.

Meiotic crossovers reshuffle genetic material and are essential for accurate chromosome segregation. Crossovers are a product of meiotic recombination, a complex and highly regulated process, which occurs through the co-ordinated induction and repair of DNA double strand breaks. In the majority of sexually reproducing eukaryotes, the synaptonemal complex (a tripartite ultrastructure compromised of two closely apposed lateral elements adjoined by rod like transverse filaments) is installed between homologs during prophase I; this is essential for normal crossover formation. Using cytological techniques, fluorescent marker assays and novel CRISPR/Cas9 derived mutants the roles of the Arabidopsis thaliana transverse filament protein (ZYP1) were investigated. Additionally, this work also examined a candidate meiotic regulatory protein, the general transcription factor subunit TFIIFb2.This thesis reveals that in the absence of ZYP1, homologs are completely asynaptic yet chromosomes extensively and intimately align during prophase I. Furthermore, zyp1 retains near wild-type fertility and in the vast majority of cases homologs successfully and accurately crossover, though infrequently the obligate crossover is lost. This work shows that in zyp1 mutants HEI10 foci (a cytological marker of class I crossovers), counted at diplotene, are increased by ~2 fold compared to the wild type. Similarly, map lengths measured using fluorescently tagged lines were increased by ~1.5 fold in zyp1 compared to the wild-type. Despite this increase in recombination, zyp1 provides no rescue when crossed to msh5, instead zyp1 msh5 mutants show ~50% fewer chiasmata than msh5 single mutants, indicating that increased crossovers derive from the ZMM dependant class I pathway. In summary, this work reveals that zyp1 is an essential regulator of crossover control. Firstly, zyp1 is required to ensure all chromosomes receive an obligate crossover. Secondly, zyp1 is essential for the normal imposition of crossover interference which limits the occurrence of ZMM derived double crossovers.

Background: Acute gallstone disease is the highest volume Emergency General Surgical presentation in the UK. Recent data indicate wide variations in the quality of care provided across the country, with national guidance for care delivery not implemented in most UK hospitals. Against this backdrop, the Royal College of Surgeons of England set up a 13-hospital quality improvement collaborative (Chole-QuIC) to support clinical teams to reduce time to surgery for patients with acute gallstone disease requiring emergency cholecystectomy. Methods: Prospective, mixed-methods process evaluation to answer the following: (1) how was the collaborative delivered by the faculty and received, understood and enacted by the participants; (2) what influenced teams’ ability to improve care for patients requiring emergency cholecystectomy? We collected and analysed a range of data including field notes, ethnographic observations of meetings, and project documentation. Analysis was based on the framework approach, informed by Normalisation Process Theory, and involved the creation of comparative case studies based on hospital performance during the project. Results: Chole-QuIC was delivered as planned and was well received and understood by participants. Four hospitals were identified as highly successful, based upon a substantial increase in the number of patients having surgery in line with national guidance. Conversely, four hospitals were identified as challenged, achieving no significant improvement. The comparative analysis indicate that six inter-related influences appeared most associated with improvement: (1) achieving clarity of purpose amongst site leads and key stakeholders; (2) capacity to lead and effective project support; (3) ideas to action; (4) learning from own and others’ experience; (5) creating additional capacity to do emergency cholecystectomies; and (6) coordinating/managing the patient pathway. Conclusion: Collaborative-based quality improvement is a viable strategy for emergency surgery but success requires the deployment of effective clinical strategies in conjunction with improvement strategies. In particular, achieving clarity of purpose about proposed changes amongst key stakeholders was a vital precursor to improvement, enabling the creation of additional surgical capacity and new pathways to be implemented effectively. Protected time, testing ideas, and the ability to learn quickly from data and experience were associated with greater impact within this cohort.

As the Covid-19 crisis deepens, some researchers have argued for the widespread routine use of face masks in community settings, despite acknowledged gaps in the evidence base for the effectiveness of such a measure. We argue that such calls are premature, and risk neglecting important potential harms and negative consequences, known and unknown. We identify potential unintended consequences at multiple levels, from individual-behavioural to macrosocial, and suggest that it is far from clear that the benefits of widespread uptake of face masks, whether encouraged or enforced by public authorities, outweigh the downsides. Finally, we make the case for caution in communicating unequivocal messages about the scientific evidence for face mask use to policy, practitioner and public audiences, given continued scientific disagreement on the question.

Additional file 1. Quality checklist results for the assessment of risk of bias.

Additional file 2. Unit costs applied for valuation of resource use.

Additional file 5. Other reasons given for not wanting to attend SSME if invited.

Additional file 7. Summary of the findings for each feasibility objective.

Additional file 1. Ethnographic interview topic guides.

Additional file 4. Other reasons given for not attending SSME.

Additional file 1.

Additional file 3. Summary of extracted continuous primary care data by practice.

Additional file 6. Case examples demonstrating impact.

Atomic manipulation and interface engineering techniques have provided an intriguing approach to custom-designing topological superconductors and the ensuing Majorana zero modes, representing a paradigm for the realization of topological quantum computing and topology-based devices. Magnet-superconductor hybrid (MSH) systems have proven to be experimentally suitable to engineer topological superconductivity through the control of both the complex structure of its magnetic layer and the interface properties of the superconducting surface. Here, we demonstrate that two-dimensional MSH systems containing a magnetic skyrmion lattice provide an unprecedented ability to control the emergence of topological phases. By changing the skyrmion radius, which can be achieved experimentally through an external magnetic field, one can tune between different topological superconducting phases, allowing one to explore their unique properties and the transitions between them. In these MSH systems, Josephson scanning tunneling spectroscopy spatially visualizes one of the most crucial aspects underlying the emergence of topological superconductivity, the spatial structure of the induced spin–triplet correlations.

BACKGROUND AND OBJECTIVES: A clinical trial in 93 National Health Service hospitals evaluated a quality improvement programme for emergency abdominal surgery, designed to improve mortality by improving the patient care pathway. Large variation was observed in implementation approaches, and the main trial result showed no mortality reduction. Our objective therefore was to evaluate whether trial participation led to care pathway implementation and to study the relationship between care pathway implementation and use of six recommended implementation strategies. METHODS: We performed a hospital-level time-series analysis using data from the Enhanced Peri-Operative Care for High-risk patients trial. Care pathway implementation was defined as achievement of >80% median reliability in 10 measured care processes. Mean monthly process performance was plotted on run charts. Process improvement was defined as an observed run chart signal, using probability-based 'shift' and 'runs' rules. A new median performance level was calculated after an observed signal. RESULTS: Of 93 participating hospitals, 80 provided sufficient data for analysis, generating 800 process measure charts from 20 305 patient admissions over 27 months. No hospital reliably implemented all 10 processes. Overall, only 279 of the 800 processes were improved (3 (2-5) per hospital) and 14/80 hospitals improved more than six processes. Mortality risk documented (57/80 (71%)), lactate measurement (42/80 (53%)) and cardiac output guided fluid therapy (32/80 (40%)) were most frequently improved. Consultant-led decision making (14/80 (18%)), consultant review before surgery (17/80 (21%)) and time to surgery (14/80 (18%)) were least frequently improved. In hospitals using ≥5 implementation strategies, 9/30 (30%) hospitals improved ≥6 care processes compared with 0/11 hospitals using ≤2 implementation strategies. CONCLUSION: Only a small number of hospitals improved more than half of the measured care processes, more often when at least five of six implementation strategies were used. In a longer term project, this understanding may have allowed us to adapt the intervention to be effective in more hospitals.

Background Acute gallstone disease is the highest volume Emergency General Surgical presentation in the UK. Recent data indicate wide variations in the quality of care provided across the country, with national guidance for care delivery not implemented in most UK hospitals. Against this backdrop, the Royal College of Surgeons of England set up a 13-hospital quality improvement collaborative (Chole-QuIC) to support clinical teams to reduce time to surgery for patients with acute gallstone disease requiring emergency cholecystectomy. Methods Prospective, mixed-methods process evaluation to answer the following: (1) how was the collaborative delivered by the faculty and received, understood and enacted by the participants; (2) what influenced teams’ ability to improve care for patients requiring emergency cholecystectomy? We collected and analysed a range of data including field notes, ethnographic observations of meetings, and project documentation. Analysis was based on the framework approach, informed by Normalisation Process Theory, and involved the creation of comparative case studies based on hospital performance during the project. Results Chole-QuIC was delivered as planned and was well received and understood by participants. Four hospitals were identified as highly successful, based upon a substantial increase in the number of patients having surgery in line with national guidance. Conversely, four hospitals were identified as challenged, achieving no significant improvement. The comparative analysis indicate that six inter-related influences appeared most associated with improvement: (1) achieving clarity of purpose amongst site leads and key stakeholders; (2) capacity to lead and effective project support; (3) ideas to action; (4) learning from own and others’ experience; (5) creating additional capacity to do emergency cholecystectomies; and (6) coordinating/managing the patient pathway. Conclusion Collaborative-based quality improvement is a viable strategy for emergency surgery but success requires the deployment of effective clinical strategies in conjunction with improvement strategies. In particular, achieving clarity of purpose about proposed changes amongst key stakeholders was a vital precursor to improvement, enabling the creation of additional surgical capacity and new pathways to be implemented effectively. Protected time, testing ideas, and the ability to learn quickly from data and experience were associated with greater impact within this cohort.

OBJECTIVES: Quality improvement (QI) may help to avert or mitigate the risks of suboptimal care, but it is often poorly reported in the healthcare literature. We aimed to identify the influences on reporting QI in the area of perioperative care, with a view to informing improvements in reporting QI across healthcare. DESIGN: Qualitative interview study. SETTING: Healthcare and academic organisations in Australia, Europe and North America. PARTICIPANTS: Stakeholders involved in or influencing the publication, writing or consumption of reports of QI studies in perioperative care. RESULTS: Forty-two participants from six countries took part in the study. Participants included 15 authors (those who write QI reports), 12 consumers of QI reports (practitioners who apply QI research in practice), 11 journal editors and 4 authors of reporting guidelines. Participants identified three principal challenges in achieving high-quality QI reporting. First, the broad scope of QI reporting-ranging from small local projects to multisite research across different disciplines-causes uncertainty about where QI work should be published. Second, context is fundamental to the success of a QI intervention but is difficult to report in ways that support replication and development. Third, reporting is adversely affected by both proximal influences (such as lack of time to write up QI) and more distal, structural influences (such as norms about the format and content of biomedical research reporting), leading to incomplete reporting of QI findings. CONCLUSIONS: Divergent terminology and understandings of QI, along with existing reporting norms and the challenges of capturing context adequately yet succinctly, make for challenges in reporting QI. We offer suggestions for improvement.

Recent advances in the development of Josephson scanning tunneling spectroscopy (JSTS) have opened a new path for the exploration of unconventional superconductors. We demonstrate that the critical current I_{c}, measured via JSTS, images the spatial form of the superconducting order parameter in d_{x^{2}-y^{2}}-wave superconductors around defects and in the Fulde-Ferrell-Larkin-Ovchinnikov state. Moreover, we show that I_{c} probes the existence of phase-incoherent superconducting correlations in the pseudogap region of the cuprate superconductors, thus providing unprecedented insight into its elusive nature. These results provide the missing theoretical link between the experimentally measured I_{c} and the spatial structure of the superconducting order parameter.

PURPOSE: Employee voice plays an important role in organizational intelligence about patient safety hazards and other influences on quality of patient care. The authors report a case study of an academic medical center that aimed to understand barriers to voice and make improvements in identifying and responding to transgressive or disruptive behaviors. METHOD: The case study focused on an improvement effort at Johns Hopkins Medicine that sought to improve employee voice using a two-phase approach of diagnosis and intervention. Confidential interviews with 67 individuals (20 senior leaders, 47 frontline personnel) were conducted during 2014 to diagnose causes of employee reluctance to give voice about behavioral concerns. A structured intervention program to encourage voice was implemented, 2014-2016, in response to the findings. RESULTS: The diagnostic interviews identified gaps between espoused policies of encouraging employee voice and what happened in practice. A culture of fear pervaded the organization that, together with widespread perceptions of futility, inhibited personnel from speaking up about concerns. The intervention phase involved four actions: sharing the interview findings; coordinating and formalizing mechanisms for identifying and dealing with disruptive behavior; training leaders in encouraging voice; and building capacity for difficult conversations. CONCLUSIONS: The problems of giving voice are widely known across the organizational literature but are difficult to address. This case study offers an approach that includes diagnostic and intervention phases that may be helpful in remaking norms, facilitating employee voice, and improving organizational response. It highlights specific actions that are available for other organizations to adapt and test.

OBJECTIVES: The prominence given to issues of patient safety in health care organizations varies, but little is known about how or why this variation occurs. We sought to compare and contrast how three English hospitals came to identify, prioritize and address patient safety issues, drawing on insights from the sociological and political science literature on the process of problem definition. METHODS: In-depth qualitative fieldwork, involving 99 interviews, 246 hours of ethnographic observation, and document collection, was carried out in three case-study hospitals as part of a wider mixed-methods study. Data analysis was based on the constant comparative method. RESULTS: How problems of patient safety came to be recognized, conceptualized, prioritized and matched to solutions varied across the three hospitals. In each organization, it took certain ‘triggers’ to problematize safety, with crises having a particularly important role. How problems were constructed – and whose definitions were prioritized in the process – was highly consequential for organizational response, influencing which solutions were seen as most appropriate, and allocation of responsibility for implementing them. CONCLUSIONS: A process of problem definition is crucial to raising the profile of patient safety and to rendering problems amenable to intervention. How problems of patient safety are defined and constructed is highly consequential, influencing selection of solutions and their likely sustainability.

The possible realization of Majorana fermions as quasiparticle excitations in condensed matter physics has created much excitement. Most recent studies have focused on Majorana bound states which can serve as topological qubits. More generally, akin to elementary particles, Majorana fermions can propagate and display linear dispersion. These excitations have not yet been directly observed, and can also be used for quantum information processing. One route to realizing this is in a line junction between two phase-shifted superconductors coupled to topological surface states. Recent theory indicates that in iron-based superconductors, a particular type of crystalline defect, i.e., a domain wall (DW) between two regions with a half-unit cell shift between them, should create a $\pi$-phase shift in the superconducting order parameter. Combined with recent data showing topological surface states in FeSe$_x$Te$_{1-x}$ we find that this is the ideal system to realize helical 1D-dispersing Majorana modes. Here we report scanning tunneling spectroscopic (STS) measurements of crystalline DWs in FeSe$_{0.45}$Te$_{0.55}$. By analyzing large-area superconducting gap maps, we identify the gap in the topological surface state, demonstrating that our sample is an effective Fu-Kane proximitized topological system. We further locate DWs across which the atoms shift by half a unit cell. STS data on these DWs reveal a flat density of states inside the superconducting gap, a hallmark of linearly dispersing modes in 1D. This unique signature is absent in DWs in the related superconductor, FeSe which is not in the topological phase. Our combined data are consistent with the observation of dispersing Majorana states at a $\pi$-phase shift DW in a proximitized topological material.

Recent advances in the development of Josephson scanning tunneling spectroscopy (JSTS) have opened a new path for the exploration of unconventional superconductors. We demonstrate that the critical current I_{c}, measured via JSTS, images the spatial form of the superconducting order parameter in d_{x^{2}-y^{2}}-wave superconductors around defects and in the Fulde-Ferrell-Larkin-Ovchinnikov state. Moreover, we show that I_{c} probes the existence of phase-incoherent superconducting correlations in the pseudogap region of the cuprate superconductors, thus providing unprecedented insight into its elusive nature. These results provide the missing theoretical link between the experimentally measured I_{c} and the spatial structure of the superconducting order parameter.

Motivated by recent experiments, we investigate Josephson scanning tunneling spectroscopy in an s-wave superconductor. We demonstrate that the spatial oscillations in the superconducting order parameter induced by defects can be spatially imaged through local measurements of the critical Josephson current, providing unprecedented insight into the nature of superconductivity. The spatial form of the Josephson current reflects the nature of the defects, and can be used to probe defect-induced phase transitions from an $S=0$ to an $S=1/2$ ground state., Comment: main text plus supplemental information

Care pathways are a prominent feature of efforts to improve healthcare quality, outcomes and accountability, but sociological studies of pathways often find professional resistance to standardisation. This qualitative study examined the adoption and adaptation of a novel pathway as part of a randomised controlled trial in an unusually complex, non-linear field - emergency general surgery - by teams of surgeons and physicians in six theoretically sampled sites in the UK. We find near-universal receptivity to the concept of a pathway as a means of improving peri-operative processes and outcomes, but concern about the impact on appropriate professional judgement. However, this concern translated not into resistance and implementation failure, but into a nuancing of the pathways-as-realised in each site, and their use as a means of enhancing professional decision-making and inter-professional collaboration. We discuss our findings in the context of recent literature on the interplay between managerialism and professionalism in healthcare, and highlight practical and theoretical implications.

Topic guide for interviews with frontline staff. (DOCX 157 kb)

Formal metrics for monitoring the quality and safety of healthcare have a valuable role, but may not, by themselves, yield full insight into the range of fallibilities in organizations. ‘Soft intelligence’ is usefully understood as the processes and behaviours associated with seeking and interpreting soft data—of the kind that evade easy capture, straightforward classification and simple quantification—to produce forms of knowledge that can provide the basis for intervention. With the aim of examining current and potential practice in relation to soft intelligence, we conducted and analysed 107 in-depth qualitative interviews with senior leaders, including managers and clinicians, involved in healthcare quality and safety in the English National Health Service. We found that participants were in little doubt about the value of softer forms of data, especially for their role in revealing troubling issues that might be obscured by conventional metrics. Their struggles lay in how to access softer data and turn them into a useful form of knowing. Some of the dominant approaches they used risked replicating the limitations of hard, quantitative data. They relied on processes of aggregation and triangulation that prioritised reliability, or on instrumental use of soft data to animate the metrics. The unpredictable, untameable, spontaneous quality of soft data could be lost in efforts to systematize their collection and interpretation to render them more tractable. A more challenging but potentially rewarding approach involved processes and behaviours aimed at disrupting taken-for-granted assumptions about quality, safety, and organizational performance. This approach, which explicitly values the seeking out and the hearing of multiple voices, is consistent with conceptual frameworks of organizational sensemaking and dialogical understandings of knowledge. Using soft intelligence this way can be challenging and discomfiting, but may offer a critical defence against the complacency that can precede crisis., Highlights • There are calls for greater use of ‘soft’ intelligence around quality and safety. • Little research examines the challenges and opportunities soft data present. • Our study in the English NHS found clinicians and managers saw utility in soft data. • But dominant approaches to interpretation risked obscuring their greatest value. • Soft data might better be used to disrupt understanding and challenge consensus.

The Institute of Medicine encouraged the pursuit and development of potential reduced-exposure products, tobacco products that substantially reduce exposure to one or more tobacco toxicants and can reasonably be expected to reduce the risk of one or more specific diseases or other adverse health effects. One approach to reducing smoke toxicant yields is to dilute the smoke with glycerol. We report chemical, biological and human exposure data related to experimental cigarettes containing up to 60% of a novel glycerol containing "tobacco-substitute" sheet. Analysis of mainstream smoke from experimental cigarettes showed reductions in yields of most measured constituents, other than some volatile species. In vitro toxicological tests showed reductions in the activity of smoke particulates in proportion to their glycerol content. Human exposure to nicotine was reduced by a mean of 18% as determined by filter studies and by 14% using 24h urinary biomarker analysis. Smoke particulate exposures were reduced by a mean of 29% in filter studies and NNK exposure by similar amounts based on urinary 4-(methylnitrosamino)-1-(3-pyridyl)-1-butanol concentrations. These results show that reducing exposure to some smoke toxicants is possible using a tobacco-substitute sheet, although some smoke toxicants, and the sensory attributes of the smoke, remain as technical challenges.