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BACKGROUND Poor cardiorespiratory fitness (CRF) is a cardinal feature of post-treatment primary lung cancer. The most effective exercise therapy regimen to improve CRF has not been determined. METHODS In this parallel-group factorial randomized controlled trial, lung cancer survivors with poor CRF (below age-sex sedentary values) were randomly allocated to receive 48 consecutive supervised sessions thrice weekly of (i) aerobic training (AT)-cycle ergometry at 55% to >95% of peak oxygen consumption (VO2 peak); (ii) resistance training (RT)-lower and upper extremity exercises at 50-85% of maximal strength; (iii) combination training (CT)-AT plus RT; or (iv) stretching attention control (AC) for 16 weeks. The primary endpoint was change in CRF (VO2 peak, mL O2 ·kg-1 ·min-1 ). Secondary endpoints were body composition, muscle strength, patient-reported outcomes, tolerability (relative dose intensity of exercise), and safety. Analysis of covariance determined change in primary and secondary endpoints from baseline to post-intervention (Week 17) with adjustment for baseline values of the endpoint and other relevant clinical covariates. RESULTS Ninety patients (65 ± 9 years; 66% female) were randomized (AT, n = 24; RT, n = 23; CT, n = 20; and AC, n = 23) of the planned n = 160. No serious adverse events were observed. For the overall cohort, the lost-to-follow-up rate was 10%. Mean attendance was ≥75% in all groups. In intention-to-treat analysis, VO2 peak increased 1.1 mL O2 ·kg-1 ·min-1 [95% confidence interval (CI): 0.0, 2.2, P = 0.04] and 1.4 mL O2 ·kg-1 ·min-1 (95% CI: 0.2, 2.5, P = 0.02) in AT and CT, respectively, compared with AC. There was no difference in VO2 peak change between RT and AC (-0.1 mL O2 ·kg-1 ·min-1 , 95% CI: -1.2, 1.0, P = 0.88). Favourable improvements in maximal strength and body composition were observed in RT and CT groups compared with AT and AC groups (Ps

Background\ud The risk of transmission of SARS-CoV-2 from aerosols generated by medical procedures is a cause for concern.\ud \ud Aim\ud To evaluate the evidence for aerosol production and transmission of respiratory infection associated with procedures that involve airway suctioning or induce coughing/sneezing.\ud \ud Methods\ud The review was informed by PRISMA guidelines. Searches were conducted in PubMed for studies published between January 1st, 2003 and October 6th, 2020. Included studies examined whether nasogastric tube insertion, lung function tests, nasendoscopy, dysphagia assessment, or suctioning for airway clearance result in aerosol generation or transmission of SARS-CoV-2, SARS-CoV, MERS, or influenza. Risk of bias assessment focused on robustness of measurement, control for confounding, and applicability to clinical practice.\ud \ud Findings\ud Eighteen primary studies and two systematic reviews were included. Three epidemiological studies found no association between nasogastric tube insertion and acquisition of respiratory infections. One simulation study found low/very low production of aerosols associated with pulmonary lung function tests. Seven simulation studies of endoscopic sinus surgery suggested significant increases in aerosols but findings were inconsistent; two clinical studies found airborne particles associated with the use of microdebriders/drills. Some simulation studies did not use robust measures to detect particles and are difficult to equate to clinical conditions.\ud \ud Conclusion\ud There was an absence of evidence to suggest that the procedures included in the review were associated with an increased risk of transmission of respiratory infection. In order to better target precautions to mitigate risk, more research is required to determine the characteristics of medical procedures and patients that increase the risk of transmission of SARS-CoV-2.

Increasing competition in hospitality is one of the industry challenges, which depends mainly on human capital. Thus, this research investigated the relationship between human resources practices, employee motivation, and online hotel reviews. Hypotheses were tested using two-phase survey data collected from 308 respondents corresponding to 154 dyads of frontline employees and human resources managers from hotels located in Brazil and England. Quantitative online hotel review ratings were collected from the surveyed hotels as performance indicators. Partial least squares structural equation modeling was used to examine the data collected. Employee intrinsic motivation negatively influenced online hotel review ratings. The online hotel review overall ratings were positively affected by extrinsic motivation. Likewise, human resources practices had a strong influence on the online hotel review service ratings. This study presented some insights to hospitality organizations, identifying relationships among three important topics on hotel management. This information can help hoteliers develop better competitive strategies, using human resources to increase online hotel review ratings, considered critical hotel performance indicators.

Summary Background Islatravir is a nucleoside reverse transcriptase translocation inhibitor in development for the treatment and prevention of HIV-1 infection. We aimed to assess the efficacy and safety of islatravir-based regimens for the treatment of HIV-1. Methods We did a phase 2b, randomised, double-blind, comparator-controlled, dose-ranging trial at 24 clinics or hospitals in four countries (Chile, France, the UK, and the USA). Treatment-naive adults (≥18 years) with plasma HIV-1 RNA concentrations of at least 1000 copies per mL, CD4 T-cell counts of at least 200 cells per mL, and a calculated creatinine clearance of at least 50 mL/min (all within 60 days before study treatment) were eligible for inclusion. Participants were randomly assigned (1:1:1:1) with a block size of four via an interactive voice and web response system to receive oral treatment with one of three doses of islatravir (0·25 mg, 0·75 mg, or 2·25 mg) plus doravirine (100 mg) and lamivudine (300 mg) or to doravirine (100 mg) plus lamivudine (300 mg) plus tenofovir disoproxil fumarate (TDF; 300 mg) once daily with placebo (part 1). Treatment groups were stratified according to screening HIV-1 RNA concentration (≤100 000 copies per mL or >100 000 copies per mL). After at least 24 weeks of treatment, participants taking islatravir who achieved an HIV-1 RNA concentration lower than 50 copies per mL switched to a two-drug regimen of islatravir and doravirine (part 2). All participants and study investigators were masked to treatment in part 1; in part 2, the islatravir dose was masked to all participants and investigators, but the other drugs were given open label. The primary efficacy outcomes were the proportions of participants with an HIV-1 RNA concentration lower than 50 copies per mL at weeks 24 and 48 (US Food and Drug Administration snapshot approach). The primary safety outcomes were the number of participants experiencing adverse events and the number of participants discontinuing study drug owing to adverse events. All participants who received at least one dose of any study drug were included in the analyses. This trial is ongoing, but closed to enrolment of new participants; herein, we report study findings through 48 weeks of treatment. This trial is registered with ClinicalTrials.gov , NCT03272347 . Findings Between Nov 27, 2017, and April 25, 2019, 121 participants (mean age 31 years [SD 10·9], 112 [93%] male, 92 [76%] white, 27 [22%] with HIV-1 RNA concentration >100 000 copies per mL) were randomly assigned: 29 to the 0·25 mg, 30 to the 0·75 mg, and 31 to the 2·25 mg islatravir groups, and 31 to the doravirine, lamivudine, and TDF group. At week 24, 26 (90%) of 29 participants in the 0·25 mg islatravir group, 30 (100%) of 30 in the 0·75 mg islatravir group, and 27 (87%) of 31 in the 2·25 mg islatravir group achieved HIV-1 RNA concentrations lower than 50 copies per mL compared with 27 (87%) of 31 in the doravirine plus lamivudine plus TDF group (difference 2·8%, 95% CI –14·9 to 20·4, for the 0·25 mg islatravir group; 12·9%, –1·6 to 27·5, for the 0·75 mg islatravir group; and 0·3%, –17·9 to 18·5, for the 2·25 mg islatravir group). At week 48, these data were 26 (90%) of 29 in the 0·25 mg islatravir group, 27 (90%) of 30 in the 0·75 mg islatravir group, and 24 (77%) of 31 in the 2·25 mg islatravir group compared with 26 (84%) of 31 in the doravirine plus lamivudine plus TDF group (difference 6·1%, 95% CI –12·4 to 24·4, for the 0·25 mg islatravir group; 6·2%, –12·2 to 24·6, for the 0·75 mg islatravir group; and –6·1%, –27·1 to 14·8, for the 2·75 mg islatravir group). 66 (73%) of participants in the islatravir groups combined and 24 (77%) of those in the doravirine plus lamivudine plus TDF group reported at least one adverse event. Two participants in the 2·25 mg islatravir group and one participant in the doravirine plus lamivudine plus TDF group discontinued owing to an adverse event. No deaths were reported up to week 48. Interpretation Treatment regimens containing islatravir and doravirine showed antiviral efficacy and were well tolerated regardless of dose. Doravirine in combination with islatravir has the potential to be a potent two-drug regimen that warrants further clinical development. Funding Merck, Sharp, & Dohme Corp, a subsidiary of Merck & Co., Inc.

Purpose The COVID-19 pandemic has reformed global healthcare delivery. On 25 March 2020, Intercollegiate guidelines were published in the UK to promote safe surgical provision during the COVID-19 outbreak advocating non-operative management or avoidance of laparoscopy when surgery is essential. The effects of this on the investigation and management of appendicitis remain unknown. Methods We performed a multicentre, prospective, observational study from the start of the new guidelines to the 6th of May 2020. We included all patients referred to surgical teams with suspected appendicitis. A recent historical cohort was identified for comparison. The primary outcome was the impact of the COVID-19 pandemic on the use of non-operative management in appendicitis. Secondary outcomes included imaging, negative appendicectomy rate (NAR), length of stay (LOS) and 30-day complications. Results A total of 63/164 (38%) patients compared to 79/191 (41%) were diagnosed with appendicitis before and after the guidelines were introduced (p = 0.589). CT scanning increased (71/164 vs 105/191; p = 0.033) while ultrasound scanning decreased (71/164 vs 62/191; p = 0.037). Appendicitis was more likely to be managed non-operatively (11/63 vs 51/79; p

This pilot study evaluated the feasibility of investigating the effect of the erector spinae plane (ESP) block on the patient-centred outcomes of quality of recovery-15 (QoR-15), and brief pain inventory (BPI) in thoracic and breast surgery patients. In this randomized-controlled pilot trial, 82 patients undergoing video-assisted thoracoscopic surgery (n = 77) and mastectomy (n = 5) received either continuous ESP block with ropivacaine (ropivacaine group) or the same procedure with 0.9% saline (saline group). All patients received surgical intercostal block (thoracic surgery) or local anesthetic infiltration (breast surgery). Feasibility as the primary outcome was evaluated on recruitment (three patients per week), catheter retention (above 90% at 24 hr), and patient attrition (less than 10%). Secondary outcomes comprised of QoR-15, BPI, and opioid consumption. Recruitment rate was 1.8 patients per week. Catheters were retained in 77 patients (94%) at 24 hr. At three months, five patients were lost to follow-up (6%). At 24 hr compared with baseline, the ropivacaine group had a smaller decline in QoR-15 score (median difference, 14; 95% confidence interval [CI], 2 to 26; P = 0.02) and a smaller increase in BPI global score (median difference, 14; 95% CI, 0 to 24; P = 0.048). There was no difference in opioid consumption (P = 0.08). In this pilot study, the target recruitment rate was not met, but catheter retention and patient attrition rates were both satisfactory. A definitive trial with QoR-15 as the primary outcome would require 300 study participants. Australian New Zealand Clinical Trials Registry (ID12618000701224); registered 30 April 2018.

The heart and lungs are anatomically coupled through the pulmonary circulation and coexist within the sealed thoracic cavity, making the function of these systems highly interdependent. Understanding of the complex mechanical interactions between cardiac and pulmonary systems has evolved over the last century to appreciate that changes in respiratory mechanics significantly impact pulmonary hemodynamics and ventricular filling and ejection. Furthermore, given that the left and right heart share a common septum and are surrounded by the nondistensible pericardium, direct ventricular interaction is an important mediator of both diastolic and systolic performance. Although it is generally considered that cardiopulmonary interaction in healthy individuals at rest minimally affects hemodynamics, the significance during exercise is less clear. Adverse heart-lung interaction in respiratory disease is of growing interest as it may contribute to the pathogenesis of comorbid cardiovascular dysfunction and exercise intolerance in these patients. Similarly, heart failure represents a pathological uncoupling of the cardiovascular and pulmonary systems, whereby cardiac function may be impaired by the normal ventilatory response to exercise. Despite significant research contributions to this complex area, the mechanisms of cardiopulmonary interaction in the intact human and the clinical consequences of adverse interactions in common respiratory and cardiovascular diseases, particularly during exercise, remain incompletely understood. The purpose of this review is to present the key physiological principles of cardiopulmonary interaction as they pertain to resting and exercising hemodynamics in healthy humans and the clinical implications of adverse cardiopulmonary interaction during exercise in chronic obstructive pulmonary disease (COPD), pulmonary hypertension, and heart failure.

Objective: \ud To determine whether the attention problems in adults born very preterm/very low birth weight (VP/VLBW

OBJECTIVE To estimate the impact of vulvovaginal atrophy (VVA) on sexual function in a clinical population of postmenopausal women. METHODS Women 45 to 75 years old and more than 12 months after the last menstruation, who attended menopausal/gynecological centers in Italy and Spain, were included. Women with at least one VVA symptom completed the following questionnaires: Day-to-Day Impact of Vaginal Aging (DIVA), Female Sexual Function Index (FSFI), and Female Sexual Distress Scale revised (FSDS-R). A physical gynecological examination was performed to confirm the VVA diagnosis. Data were analyzed by chi-square and Student's t tests. RESULTS In all, 2,160 evaluable women were included in the study. VVA was confirmed in 90% of the included participants. The negative impact on sexual function was significantly higher in women with than in women without confirmed VVA, as evaluated with the sexual function component (DIVA-C) of the DIVA questionnaire (P = 0.013). Statistically significant differences (P

To determine whether cognitive performance from infancy to adulthood is affected by being born small for gestational age (SGA), and if this depends on the SGA reference used. Furthermore, to determine SGA's effect while considering the effects of very preterm/very low birthweight (VP/VLBW), socio-economic status (SES) and parent-infant relationship.A total of 414 participants (197 term-born, 217 VP/VLBW) of the Bavarian Longitudinal Study.Small for gestational age was classified using neonatal or fetal growth references. SES and the parent-infant relationship were assessed before the infant was 5 months old.Developmental (DQ) and intelligence (IQ) tests assessed cognitive performance on six occasions, from 5 months to 26 years of age.The fetal reference classified more infants as SGA (10th centile) than the neonatal reference (n = 138, 33% versus n = 75, 18%). Using linear mixed models, SGA was associated with IQ -8 points lower than appropriate for gestational age, regardless of reference used (95% CI -13.66 to -0.64 and 95% CI -13.75 to -1.98). This difference narrowed minimally into adulthood. Being VP/VLBW was associated with IQ -16 (95% CI -21.01 to -10.04) points lower than term-born participants. Low SES was associated with IQ -14 (95% CI -18.55 to -9.06) points lower than high SES. A poor parent-infant relationship was associated with IQ -10 points lower than those with a good relationship (95% CI -13.91 to -6.47).Small for gestational age is associated with lower IQ throughout development, independent of VP/VLBW birth, low SES or poor parent-child relationship. Social factors effects on IQ comparable to those of SGA and should be considered for interventions.Small for gestational age is associated with lower cognitive performance from infancy to adulthood.

CONTEXT There is a lack of research on individual perceptions of social experiences and social relationships among very preterm (VP) adults compared with term-born peers. OBJECTIVE To investigate self-perceived social functioning in adults born VP ( DATA SOURCES Two international consortia: Research on European Children and Adults born Preterm and Adults Born Preterm International Collaboration. STUDY SELECTION Cohorts with outcomes assessed by using the Adult Self-Report Adaptive Functioning scales (friends, spouse/partner, family, job, and education) in both groups. DATA EXTRACTION IPD from 5 eligible cohorts were collected. Raw-sum scores for each scale were standardized as z scores by using mean and SD of controls for each cohort. Pooled effect size was measured by difference (Δ) in means between groups. RESULTS One-stage analyses (1285 participants) revealed significantly lower scores for relationships with friends in VP/VLBW adults compared with controls (Δ −0.37, 95% confidence interval [CI]: −0.61 to −0.13). Differences were similar after adjusting for sex, age, and socioeconomic status (Δ −0.39, 95% CI: −0.63 to −0.15) and after excluding participants with neurosensory impairment (Δ −0.34, 95% CI: −0.61 to −0.07). No significant differences were found in other domains. LIMITATIONS Generalizability of research findings to VP survivors born in recent decades. CONCLUSIONS VP/VLBW adults scored their relationship with friends lower but perceived their family and partner relationships, as well as work and educational experiences, as comparable to those of controls.

Machine-learning (ML) techniques hold the potential of enabling efficient quantitative micrograph analysis, but the robustness of ML models with respect to real-world micrograph quality variations has not been carefully evaluated. We collected thousands of scanning electron microscopy (SEM) micrographs for molecular solid materials, in which image pixel intensities vary due to both the microstructure content and microscope instrument conditions. We then built ML models to predict the ultimate compressive strength (UCS) of consolidated molecular solids, by encoding micrographs with different image feature descriptors and training a random forest regressor, and by training an end-to-end deep-learning (DL) model. Results show that instrument-induced pixel intensity signals can affect ML model predictions in a consistently negative way. As a remedy, we explored intensity normalization techniques. It is seen that intensity normalization helps to improve micrograph data quality and ML model robustness, but microscope-induced intensity variations can be difficult to eliminate.

Background: Current exercise guidelines for clinical populations recommend an exercise therapy (ET) prescription of fixed intensity (moderate), duration (40–50 minutes per session), and volume (120–160 min/wk). A critical overarching element of exercise programming that has received minimal attention is dose scheduling. We investigated the tolerability and efficacy of 2 exercise training dose regimens on cardiorespiratory fitness and patient-reported outcomes in patients with posttreatment primary breast cancer. Methods: Using a parallel-group randomized trial, we randomly allocated 174 postmenopausal patients (2.8 years after adjuvant therapy) with impaired peak oxygen consumption (VO 2 peak) to 1 of 2 supervised exercise training interventions delivered with a standard linear (LET) (fixed dose intensity per session for 160 min/wk) or nonlinear (NLET) (variable dose intensity per session for ≈120 min/wk) schedule compared with a stretching attention control group for 16 consecutive weeks. Stretching was matched to exercise dosing arms on the basis of location, frequency, duration, and treatment length. The primary end point was change in VO 2 peak (mL O 2 ·kg −1 ·min −1 ) from baseline to after intervention. Secondary end points were patient-reported outcomes, tolerability, and safety. Results: No serious adverse events were observed. Mean attendance was 64%, 75%, and 80% for attention control, LET, and NLET, respectively. In intention-to-treat analysis, VO 2 peak increased 0.6±1.7 mL O 2 ·kg −1 ·min −1 ( P =0.05) and 0.8±1.8 mL O 2 ·kg −1 ·min −1 ( P =0.07) in LET and NLET, respectively, compared with attention control. Change in VO 2 peak ranged from −2.7 to 4.1 mL O 2 ·kg −1 ·min −1 and from −3.6 to 5.1 mL O 2 ·kg −1 ·min −1 in LET and NLET, respectively. Approximately 40% of patients in both exercise dosing regimens were classified as VO 2 peak responders (ie, Δ ≥1.32 mL O 2 ·kg −1 ·min −1 ). NLET improved all patient-reported outcomes compared with attention control. Conclusions: Short-term exercise training, independently of dosing schedule, is associated with modest improvements in cardiorespiratory fitness in patients previously treated for early-stage breast cancer. Clinical Trial Registration: URL: https://www.clinicaltrials.gov . Unique identifier: NCT01186367.

Objective This study aimed to determine the degree of left ventricular (LV) dysfunction and its determinants in adolescents with type 2 diabetes (T2D). We hypothesized that adolescents with T2D would display impaired LV diastolic function and that these cardiovascular complications would be exacerbated in youth exposed to maternal diabetes in utero. Methods Left ventricular structure and function, carotid artery intima media thickness and strain, and serum metabolomic profiles were compared between adolescents with T2D (n = 121) and controls (n = 34). Sub-group analyses examined the role of exposure to maternal diabetes as a determinant of LV or carotid artery structure and function among adolescents with T2D. Results Adolescents with T2D were 15.1 ± 2.5 years old, (65% female, 99% Indigenous), had lived with diabetes for 2.7 ± 2.2 years, had suboptimal glycemic control (HbA1c = 9.4 ± 2.6%) and 58% (n = 69) were exposed to diabetes in utero. Compared to controls, adolescents with T2D displayed lower LV diastolic filling (early diastole/atrial filling rate ratio [E/A] = 1.9 ± 0.6 vs 2.2 ± 0.6, P = 0.012), lower LV relaxation and carotid strain (0.12 ± 0.05 vs 0.17 ± 0.05, P = .03) and elevated levels of leucine, isoleucine and valine. Among adolescents with T2D, exposure to diabetes in utero was not associated with differences in LV diastolic filling, LV relaxation, carotid strain or branched chain amino acids. Conclusions Adolescents with T2D display LV diastolic dysfunction, carotid artery stiffness, and elevated levels of select branch chain amino acids; differences were not associated with exposure to maternal diabetes in utero.

Histological chorioamnionitis (HCA) is associated with preterm birth and adverse neonatal outcomes. We evaluated the rise in C-reactive protein (CRP) in preterm infants as a predictor of HCA severity and outcomes.Consecutive preterm infants, born January 2009 to January 2014 in the National Maternity Hospital, Dublin, under 32 weeks' gestation or1.5 kg birthweight, were included. Histological chorioamnionitis was staged as maternal inflammatory response, foetal inflammatory response and non-HCA.Preterm infants (n = 518) were included with a mean gestational age 28.5 ± 2.8 weeks, birthweight 1.1 ± 0.3 kg, and 53.5% were male. Histological chorioamnionitis was found in 25.4%. Histological chorioamnionitis was present in 93.7% when CRP 5 mg/L, 65.2% when CRP 1-5 mg/L and in 19.4% when CRP 1 mg/L. When both the immature to total neutrophil (IT) ratio was0.2 and the CRP 1 mg/L the positive predictive value and negative predictive value for HCA were 92.5% and 84.9%, respectively. Histological chorioamnionitis was associated with more resuscitation and respiratory distress syndrome (both P .001). A CRP 10 mg/L was associated with a foetal inflammatory response and increased early-onset sepsis.Higher early CRP was a surrogate predictor of HCA and correlated with the severity of HCA. Higher CRP and HCA were associated with adverse early outcomes.

In this manuscript we present a simple, inexpensive, non-microscope training model for microsurgery.

KEY POINTS The effect of combined inspiratory and expiratory muscle training on resting and reflexive cardiac function, as well as exercise capacity, in individuals with cervical spinal cord injury (SCI) is presently unknown. Six weeks of combined inspiratory and expiratory muscle training enhances both inspiratory and expiratory muscle strength in highly-trained athletes with cervical SCI with no significant effect on lung function. There was a significant decrease in left-ventricular filling and stroke volume at rest in response to 45° head-up tilt, which is irreversible by respiratory muscle training. Combined inspiratory and expiratory muscle training increased peak aerobic work rate and reduced end-expiratory lung volumes during exercise, which may have implications for left-ventricular filling during exercise. ABSTRACT To investigate the pulmonary, cardiovascular and exercise responses to combined inspiratory and expiratory respiratory muscle training (RMT) in athletes with tetraplegia, six wheelchair rugby athletes (five males and one female, aged 33 ± 5 years) completed 6 weeks of pressure threshold RMT, 2 sessions day-1 on 5 days week-1 . Resting pulmonary and cardiac function, exercise capacity, exercising lung volumes and field-based exercise performance were assessed at pre-RMT, post-RMT and after a 6-week no RMT period. RMT enhanced maximal inspiratory (pre- vs. post-RMT: -76 ± 15 to -106 ± 23 cmH2 O, P = 0.002) and expiratory (59 ± 26 to 73 ± 32 cmH2 O, P = 0.007) mouth pressures, as well as peak expiratory flow (6.74 ± 1.51 vs. 7.32 ± 1.60 L/s, P

Introduction Good handover is paramount for orientating on-call teams coming onto shift and maintaining patient safety. In our tertiary referral centre a pre-prepared list on our shared drive is used to handover vascular patients in the hospital. It was felt that there was insufficient information on the list and that inconsistencies / inaccuracies could compromise patient safety. Method We performed a full-cycle prospective audit using GMC/ RCSEng guidance as standards. Our list was audited over a period of 10 days 4/2/20-14/2/20. In addition, a questionnaire was sent around doctors of all grades to highlight areas of improvement and to gather ideas. The second cycle (17/2/20- 27/2/20) was then performed after introduction of a new list, which allowed more comprehensive information to be collected in a shared drive. Junior doctors on the team were briefed, and results collected with a second questionnaire. Results The new list showed statistically significant improvements in inclusion of key information as set out in the standards. These included presenting complaint ’92% from 57%,’ Diagnosis ’98% from 89%, clinical history 91% from 35%, significant results 86% from 13% and outstanding tasks 80% from 6.2%. (These were all significant p = 0.001 Mann-Whitney U.) Further information including antibiotics and VTE was included after feedback from department. 85% found the new list easier to navigate and 76% felt it reduced risk to patient safety. Conclusions Introduction of a revised handover list in a vascular tertiary referral centre resulted in significant improvements in adherence to RCSEng/ BMA standards and staff perceived benefit to patient safety.

Several hundred species are hunted for wild meat in the tropics, supporting the diets, customs, and livelihoods of millions of people. However, unsustainable hunting is one of the most urgent threats to wildlife and ecosystems worldwide and has serious ramifications for people whose subsistence and income are tied to wild meat. Over the past 18 years, although research efforts have increased, scientific knowledge has largely not translated into action. One major barrier to progress has been insufficient monitoring and evaluation, meaning that the effectiveness of interventions cannot be ascertained. Emerging issues include the difficulty of designing regulatory frameworks that disentangle the different purposes of hunting, the large scale of urban consumption, and the implications of wild meat consumption for human health. To address these intractable challenges, wepropose eight new recommendations for research and action for sustainable wild meat use, which would support the achievement of the United Nations Sustainable Development Goals., This article is primarily an output of the WILDMEAT Project and was funded by the United States Fish and Wildlife Service (AFR1732 Grant F17AP00421 Supplement 0001) and the United States Agency for International Development (USAID) (D.J.I., K.A., L.C., F.N.T., D.M.I.). This project also benefitted from funding from the UK Research and Innovation’s Global Challenges Research Fund (UKRI GCRF) Trade, Development and the Environment Hub project (project number ES/S008160/1) (E.J.M.G., C.S., L.C.). A.B.-L. is supported by a Juan de la Cierva Incorporación grant (IJCI-2017-31419) from the Spanish Ministry of Science, Innovation and Universities. H.R.E.B. is supported by the Brazilian National Council for Scientific and Technological Development (grant numbers 201475/2017-0 and 441435/2017-3). T.Q.M. is supported by the Wildlife Conservation Society Graduate Scholarship Program (Christensen Conservation Leaders Scholarship), the Wildlife Conservation Network Scholarship Program (Sidney Byers Scholarship), and the British Federation of Women Graduates (Funds for Women Graduates). R.N., J.E.F., L.C., and N.V.V. were funded by USAID as part of the Bushmeat Research Initiative of the CGIAR research program on Forests, Trees and Agroforestry. G.C. and J.M.R. are supported by Research England. C.D.G. acknowledges that he is an unpaid science advisory board member at Oceana. K.A. acknowledges that her husband is Minister of Water, Forests, Seas and Environment in Gabon and is responsible for policies concerning hunting management.

Daily ward rounds (WR) represent a fundamental part of the delivery of surgical care. It is an opportunity for the senior members of the team to review all aspects of the patient’s treatment pathway and decide on the most appropriate management plan going forward. The quality and effectiveness of a WR relies on good documentation. Not only from a medico-legal perspective but also as communication between multidisciplinary teams (MDT). Both in and out of hours, the information written on the WR directly influences decisions made and therefore patient safety. Furthermore, the introduction of the European Working Time Directive has created complex shift-based work patterns, in which the members of the WR are regularly rotating.1 Good documentation is the one constant that maintains effective continuity of care and is the base of good patient care. The General Medical Council (GMC) of the UK has clear guidance on what is expected to be documented in the doctor–patient interactions.2 Despite this, research continues to find a failure to reach these standards.3–7 In fact in a UK study of 432 surgeon–patient consultations, key information provided …

Travellers have high standards and regard restaurants as important travel attributes. In the tourism and hospitality industry, the use of developed tools (e.g., smartphones and location-based tablets) has been popularised as a way for travellers to easily search for information and to book venues. Qualitative research using semi-structured interviews based on the face-to-face approach was adopted for this study to examine how consumers’ restaurant selection processes are performed with the utilisation of social media on smartphones. Then, thematic analysis was adopted. The findings of this research show that the adoption of social media on smartphones is positively related with consumers’ gratification. More specifically, when consumers regard that process, content and social gratification are satisfied, their intention to adopt social media is fulfilled. It is suggested by this study that consumers’ restaurant decision-making process needs to be understood, as each stage of the decision-making process is not independent, all the stages of the restaurant selection process are organically connected and influence one another.

Importance: Birth before 32 weeks’ gestation (very preterm [VPT]) and birth weight below 1500 g (very low birth weight [VLBW]) have been associated with lower cognitive performance in childhood. However, there are few investigations of the association of neonatal morbidities and maternal educational levels with the adult cognitive performance of individuals born VPT or VLBW (VPT/VLBW). Objective: To assess differences in adult IQ between VPT/VLBW and term-born individuals and to examine the association of adult IQ with cohort factors, neonatal morbidities, and maternal educational level among VPT/VLBW participants. Data Sources: Systematic review of published data from PubMed and meta-analysis of individual participant data (IPD) of cohorts from 2 consortia (Research on European Children and Adults Born Preterm [RECAP] and Adults Born Preterm International Collaboration [APIC]). Study Selection: The meta-analysis included prospective longitudinal cohort studies that assessed the full-scale IQ of adults born VPT or VLBW and respective control groups comprising term-born adults. Data Extraction And Synthesis: The study followed the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) reporting guideline for analyses of individual participant data and identified 8 studies that provided data from 2135 adults (1068 VPT/VLBW and 1067 term-born participants) born between 1978 and 1995. Meta-analyses of IPD were performed using a 1-stage approach, treating VPT birth or VLBW and cohort as random effects. Main Outcomes And Measures: Full-scale IQ scores were converted to z scores within each cohort using the combined SD of VPT/VLBW participants and a control group of term-born participants, with scores centered on the mean of the control group. Results: A total of 426 records were identified and screened. After exclusions, 13 studies were included in the aggregate meta-analysis. The IPD meta-analysis included 8 of the 9 RECAP and APIC cohorts with adult IQ data. The mean (SD) age among the 8 IPD cohorts was 24.6 (4.3) years, and 1163 participants (54.5%) were women. In unadjusted analyses, VPT/VLBW participants had mean adult IQ scores that were 0.78 SD (95% CI, −0.90 to −0.66 SD) lower than term-born participants, equivalent to a difference of 12 IQ points. Among VPT/VLBW participants, lower gestational age (score difference per week of gestation, 0.11; 95% CI, 0.07-0.14), lower birth weight z scores (score difference per 1.0 SD, 0.21; 95% CI, 0.14-0.28), the presence of neonatal bronchopulmonary dysplasia (score difference, −0.16; 95% CI, −0.30 to −0.02) or any grade of intraventricular hemorrhage (score difference, −0.19; 95% CI, −0.33 to −0.05), and lower maternal educational level (score difference, 0.26; 95% CI, 0.17-0.35) were all significantly associated with lower IQ scores in adulthood. Conclusions And Relevance: In this IPD meta-analysis, lower gestational age, lower weight for gestational age, neonatal morbidities, and lower maternal educational levels were all important risk factors associated with lower IQ among young adults born VPT or VLBW.

Background and Aims Frailty is a measure of physiological reserve and the ability to respond to physiological stress. Increasing frailty predicts adverse health outcomes in patients with end stage renal disease (ESRD) Despite this, frailty is not routinely measured in clinical practice where clinician perception of frailty is used to inform decision making. The Clinical Frailty Scale (CFS) is a clinical judgement-based score that is a useful screening tool for frailty. Increasing frailty measured by CFS is predictive of adverse outcomes in patients with advanced chronic kidney disease (CKD) including falls, worsening disability, care home admissions, hospitalizations and ultimately mortality. It has been widely used in the assessment of patients with COVID-19 to help inform decisions regarding ceiling of care. This study aimed to assess the correlation between clinician perception of frailty and frailty as measured using the CFS. Method Frailty was assessed for all patients undergoing in centre hospital haemodialysis (n=53) in a single dialysis unit in Northern Ireland. A CFS score was calculated for all patients by a clinician who routinely uses the CFS in clinical practice. Patients with a score of 1-3 were classified as not frail, 4-5 as intermediately frail and 6-9 as frail. Nephrologists received basic education about frailty. They were then asked to categorize their patients as non-frail, intermediately frail or frail. The relationship between measured and perceived frailty was assessed using percent agreement. Participant characteristics of frail patients who were misclassified as intermediately frail or non-frail by clinicians were compared to those patients correctly classified as non-frail by clinicians. Fisher’s exact test was employed for categorical variables and t-tests were employed for pseudo normally distributed continuous variables. Results Of the 53 participants, the median age was 59 years (26-89). 41.5% were women. The median time on dialysis was 1.6 years. According to the CFS, 6 patients were categorised as non-frail, 30 patients as intermediately frail and 17 as frail. Among frail participants, 41% were correctly perceived as frail by their nephrologist. Among non-frail participants, 100% were correctly perceived as non-frail by their nephrologist. Among those who were frail according to the CFS, those misclassified as intermediately frail or non-frail, were younger (median age of those misclassified 49 years vs 62 years of those not mis-classified, P=0.03) but did not differ by sex (P=1), time on dialysis (P=0.39), presence of diabetes (P=0.30) or presence of vascular disease (P=1). Conclusion In this study of adult patients undergoing chronic haemodialysis, perceived frailty correlated with measured frailty using the CFS less than 50% of the time. This suggests that clinical perception is not an accurate surrogate for frailty status in this population group. Additionally, this study suggests that younger patients with ESRD are less likely to be correctly perceived as frail. Such misclassification could influence clinical decisions for treatment, including candidacy for kidney transplantation.

Changing behaviour is necessary to address many of the threats facing human populations. However, identifying behaviour change interventions likely to be effective in particular contexts as a basis for improving them presents a major challenge. The Human Behaviour-Change Project harnesses the power of artificial intelligence and behavioural science to organise global evidence about behaviour change to predict outcomes in common and unknown behaviour change scenarios.

Main text This bilateral SIM key comparison on calibration of gauge blocks by interferometry (SIM.L-K1.2007.1) was carried out between CENAM (México) and INTI (Argentina). Its scope is to support and maintain the claimed Calibration and Measurement Capability (CMC) by the participants, which regularly offer the service of gauge block calibration by optical interferometry. The comparison was held from first half of 2018 to second half of 2019, and involved the measurement of eleven steel gauge blocks-eight in the range of short gauge block and three in the range of long gauge block. The reference values for each nominal length were taken as the arithmetic mean. The results of both participants are in good agreement with the reference values for all the gauge blocks measured. This makes the present comparison exercise valid to provide evidence of the participants' competence. The results also provides evidence to support the CMC claims of the participants in gauge block calibration by optical interferometry and for those service that stems out of this key technique as required by the CIPM Mutual Recognition Arrangement (CIPM MRA). To reach the main text of this paper, click on Final Report. Note that this text is that which appears in Appendix B of the BIPM key comparison database kcdb.bipm.org/. The final report has been peer-reviewed and approved for publication by the CCL, according to the provisions of the CIPM Mutual Recognition Arrangement (CIPM MRA).

Augmented negative intrathoracic pressures (nITP) and dynamic hyperinflation (DH) are adverse breathing mechanics (ABM) associated with chronic obstructive pulmonary disease (COPD) that attenuate left ventricular (LV) preload and augment afterload. In COPD, hypertension (elevated systemic arterial load) commonly adds additional afterload to the LV. Combined ABM and hypertension may profoundly challenge ventricular-vascular coupling and attenuate stroke volume (SV), particularly if LV systolic reserve is limited. However, even in the healthy heart, the combined impact of ABM and systemic arterial loading on LV function and ventricular-vascular coupling has not been fully elucidated. Healthy volunteers (10 M/9 F, 24 ± 3 yr old) were challenged with mild (-10 cmH

BACKGROUND: Mayo type-IIA olecranon fractures are characterized by a transverse or short oblique fracture without articular comminution or ulnohumeral instability. Traditionally, these fractures are treated with a tension-band wiring technique. Despite good rates of fracture union, tension-band wiring is associated with a reoperation rate of 30% to 60%, usually for removal of prominent metalwork. The tension suture technique was developed as an alternative method of fixing Mayo type-IIA fractures using only high-tensile braided nonabsorbable number-2 sutures, with the aim of reducing the reoperation rate associated with tension-band wiring without compromising outcomes. The tension suture technique has subsequently become the only technique we use when treating these fractures. DESCRIPTION: The patient is positioned in the lateral decubitus position under general or regional anesthesia. A direct posterior approach is made, centered over the fracture. The fracture is identified, cleared of hematoma, and reduced with use of a large, pointed reduction clamp to provide interfragmentary compression. A 2.5-mm transverse drill hole is made through the ulna distal to the fracture site. Two sets of number-2 braided nonabsorbable sutures are utilized. The first sutures are passed lateral to medial through the drill hole and used to grasp the medial triceps insertion onto the proximal fragment, then passed back through the transverse drill hole from medial to lateral and used to grasp the lateral triceps insertion onto the proximal fragment. The suture ends are tensioned to remove slack and tied on the lateral aspect of the olecranon. The second sutures are then passed lateral to medial through the transverse drill hole but this time used to grasp the posterolateral triceps insertion on the proximal fragment, then re-passed through the transverse drill hole from medial to lateral, and finally used to grasp the posteromedial triceps insertion. The suture limbs are tensioned and tied on the lateral aspect of the ulna next to the first suture. The clamp is removed, and the construct is tested under full range of motion to ensure there is no evidence of gapping. Fluoroscopy is utilized to confirm reduction before the wound is irrigated and closed in a standard fashion. ALTERNATIVES: Mayo type-IIA fractures may be treated nonoperatively in frail or low-demand patients. Surgical treatment is traditionally performed with the tension-band wiring technique, but plate or intramedullary fixation may also be utilized. RATIONALE: This technique negates the metalwork-related complications associated with all other surgical techniques for this fracture type. EXPECTED OUTCOMES: In a recent study comparing the tension suture technique with tension-band wiring and plate fixation for Mayo type-IIA fractures, the tension suture technique had a significantly lower reoperation rate compared with tension-band wiring and a lower complication rate compared with plate fixation. IMPORTANT TIPS: The tension-suture technique is primarily for Mayo type-IIA fractures without ulnohumeral instability or marked articular comminution. Ensure the transverse tunnel in the ulna is at least 3 cm distal to the fracture site and 1 cm anterior to the dorsal cortex of the ulna in order to prevent fracture of the tunnel. Grasp as much of the triceps tendon as possible when placing the sutures through the proximal fragment to prevent pull-out. Tension and tie the sutures with the elbow semi-extended to prevent the construct slackening in elbow extension and to facilitate interfragmentary compression during flexion.

With each heartbeat, the right ventricle (RV) inputs blood into the pulmonary vascular (PV) compartment, which conducts blood through the lungs at low pressure and concurrently fills the left atrium (LA) for output to the systemic circulation. This overall hemodynamic function of the integrated RV-PV-LA unit is determined by complex interactions between the components that vary over the cardiac cycle but are often assessed in terms of mean pressure and flow. Exercise challenges these hemodynamic interactions as cardiac filling increases, stroke volume augments, and cycle length decreases, with PV pressures ultimately increasing in association with cardiac output. Recent cardiopulmonary exercise hemodynamic studies have enriched the available data from healthy adults, yielded insight into the underlying mechanisms that modify the PV pressure-flow relationship, and better delineated the normal limits of healthy responses to exercise. This review will examine hemodynamic function of the RV-PV-LA unit using the two-element Windkessel model for the pulmonary circulation. It will focus on acute PV and LA responses that accommodate increased RV output during exercise, including PV recruitment and distension and LA reservoir expansion, and the integrated mean pressure-flow response to exercise in healthy adults. Finally, it will consider how these responses may be impacted by age-related remodeling and modified by sex-related cardiopulmonary differences. Studying the determinants and recognizing the normal limits of PV pressure-flow relations during exercise will improve our understanding of cardiopulmonary mechanisms that facilitate or limit exercise.

Background Stair climbing can be a vigorous lifestyle physical activity, and is associated with healthier lipoprotein profiles, lower body weight and blood pressure, as well as higher aerobic fitness. The present analysis of data from a cohort of late middle-aged men and women examined the association between daily stair climbing and the metabolic syndrome. Methods Data from 782 (423 women) participants (mean (SD) age 58.3 (0.95) years in the Dutch Famine Birth Cohort Study (2002–2004) were used to examine the cross-sectional association between self-reported daily stair climbing and the metabolic syndrome. Stair climbing was assessed by the question ‘Do you climb stairs daily?’ and the metabolic syndrome was defined using the established five components relating to lipid fractions, blood glucose levels, blood pressure and abdominal obesity. Results Not climbing stairs daily was associated with an increased incidence of the metabolic syndrome (OR = 1.90, 95% CI = 1.23, 2.92, p = 0.004) and a greater number of its components (F1,780 = 8.48, p = 0.004): these associations were still evident after adjusting for a variety of potential confounders. Conclusions The most likely explanation for the current findings is that daily stair climbing may be protective against the metabolic syndrome. This result reinforces public health recommendations for increased stair climbing with evidence from physiological outcomes.

We compared cardiopulmonary responses to arm-ergometry in individuals with cervical spinal cord injury (C-SCI) and able-bodied controls. We hypothesized that individuals with C-SCI would have higher respiratory frequency (fb) but lower tidal volume (VT) at a given work rate and dynamically hyperinflate during exercise, whereas able-bodied individuals would not. Participants completed pulmonary function testing, an arm-ergometry test to exhaustion, and a sub-maximal exercise test consisting of four-minute stages at 20, 40, 60, and 80% peak work rate. Able-bodied individuals completed a further sub-maximal test with absolute work rate matched to C-SCI. During work rate matched sub-maximal exercise, C-SCI had smaller VT (main effect p

Background: Arteriovenous fistulae (AVF) are preferred for dialysis access but require accurate cannulation for effective dialysis. Evidence supports improvements in cannulation and complication rates using ultrasound guidance (USG) in cannulating other sites. This mixed methods, randomised controlled trial aimed to assess effects of USG during AVF cannulation. Methods: Participants with difficult to cannulate AVF had each cannulation event randomised to USG or standard technique (no USG). The primary outcome was the incidence and number of additional needle passes. Secondary outcomes included: the incidence and number of additional skin punctures; time to achieve two needle cannulation; pain associated with cannulation; local complications. Qualitative outcomes were assessed using patient and staff questionnaires. Results: Thirty-two participants had 346 cannulation events randomised (170 to USG and 176 to standard cannulation). USG resulted in a significant reduction in additional needle passes (72 vs 99 p = 0.007) and additional skin punctures (10 vs 25 p = 0.016.) but prolonged time to cannulation ( p > 0.001). There was no difference in pain score ( p = 0.705) or complications between groups. Questionnaires demonstrated that USG cannulation is acceptable to patients and staff. Conclusion: USG cannulation of AVF is more accurate and no more painful than non-image guided cannulation, but prolonged time to cannulation. Some of the excess time involved may be due to the trial being performed early in cannulating staff’s learning curve with the USG technique. Further work to elucidate which patients gain most benefit from USG cannulation and the effect of USG on cannulation complications and AVF patency is warranted.

Women with history of breast cancer (HBC) frequently suffer from vulvovaginal atrophy (VVA). European Vulvovaginal Epidemiology Survey (EVES) sub-analysis assesses the impact of HBC on VVA, sexual life and quality of life (QoL) in postmenopausal women.Women with at least one VVA symptom aged 45-75 years were included. EuroQol (EQ-5D-3L) and Day-to-Day Impact of Vaginal Aging (DIVA) questionnaires were filled to investigate QoL. VVA diagnosis was confirmed with objective gynecological examination. Comparison of postmenopausal women with and without HBC, and evaluation of treatment impact on VVA were performed.1985 postmenopausal women without HBC and 175 with HBC were included. VVA was confirmed in 90.4% of women without HBC and 91.4% of women with HBC. There were no differences in VVA symptoms severity or vulvovaginal discomfort between groups. However, women with HBC who had completed treatment and had surgery 11-20 years previously versus those without HBC presented significantly worse Vaginal Health Index scores, as well as a higher prevalence of VVA objective diagnosis, although their overall symptom severity score was lower. Health status and QoL comparisons were similar.Results support a similar burden in terms of VVA prevalence and symptoms, QoL and sexual function in postmenopausal women with and without HBC.

Background: Physical activity (PA) is a safe and effective strategy to help mitigate health challenges associated with breast cancer (BC) survivorship. However, the majority of BC survivors are not meeting the minimum recommended PA (≥150 min of moderate to vigorous intensity). Project MOVE was developed as a model for increasing PA that combined a) Microgrants: funds ($2000) awarded to applicant groups to develop and implement a PA initiative and b) Financial incentives: a reward ($500) for increasing group PA. The purpose of this paper was to provide an exploratory analysis of effectiveness of Project MOVE on PA behavior, PA motivation, and quality of life (QoL) in female BC survivors. The differential outcomes between women meeting and not meeting PA guidelines were also investigated. Methods: This pre-post test, preliminary trial included groups of adult (18+ years) self-identified female BC survivors, who were post-surgery and primary systemic chemo- and radiation therapy, and living in British Columbia, Canada. PA was assessed by accelerometry. PA motivation and QoL were assessed by self-report. Data were collected at baseline, 6-months, and 12-month time points. Repeated measures mixed ANOVAs were used to test changes in the main outcomes. Results: A total of 10 groups were awarded microgrants between May 2015 and January 2016. Groups comprised of 8 to 12 women with a total of 87 participants. A statistically significant increase was found between time points on weekly moderate to vigorous PA (p = .012). This was mediated by a significant interaction between those meeting PA guidelines and those not meeting guidelines at baseline by time points (p = .004), with those not meeting guidelines at baseline showing the greatest increase in MVPA. A statistically significant difference across time points was found for intrinsic motivation (p = .02), physical functioning (p

In the United States, there are a large number of incarcerated individuals, resulting in high numbers of previously incarcerated individuals out on parole undergoing reentry into society. An aging prison population translates to an older parolee population and increased incidence of kidney disease requiring either long-term dialysis or transplantation. This paper argues that due to challenges specific to the parolee population as well as societal biases and priorities, Transplant Centers and healthcare professionals face an ethical imperative to attend to the needs of parolees as a class and take steps to address challenges related to access to Centers for renal transplantation evaluation for this disadvantaged group. It will first review the regulatory context of kidney transplantation and highlight the specific ways it effects parolees. The paper will then discuss the broader social context of parolee reentry into society and barriers faced by parolees in this process. This ethical analysis examines the complexity of these issues, and deliberates on ways to balance the competing priorities of justice, respect for this patient population as individuals and as a disadvantaged class, and the societal interests regarding organ allocation and considerable economic burdens of end-stage renal disease on parolees, the justice system, and the public.

This study examined cerebral blood flow (CBF) and its regulation before and after a short-term periodized aerobic exercise training intervention in patients with chronic obstructive pulmonary disease (COPD). Twenty-eight patients with COPD (forced expiratory volume in 1 s/forced vital capacity < 0.7 and −1·mmHg−1, P = 0.02). After aerobic training, absolute peak O2 consumption increased in both groups, with a greater improvement in control subjects (1.7 ± 0.4 vs. 4.1 ± 0.2 ml·kg−1·min−1, respectively, P = 0.001). Despite these improvements in peak O2 consumption, there were no significant alterations in CBF or any measures of cerebrovascular function after exercise training in either group. In conclusion, patients with COPD have a blunted cerebrovascular response to hypocapnia, and 8 wk of aerobic exercise training did not alter cerebrovascular function despite significant improvements in cardiorespiratory fitness. NEW & NOTEWORTHY No study to date has investigated whether exercise training can alter resting cerebral blood flow (CBF) regulation in patients with chronic obstructive pulmonary disease (COPD). This study is the first to assess CBF regulation at rest, before, and after aerobic exercise training in patients with COPD and healthy control subjects. This study demonstrated that while exercise training improved aerobic fitness, it had little effect on CBF regulation in patients with COPD or control subjects.

Background Ankle fractures are one of the most common fractures in adults aged 20–65 years. The British Orthopaedic Association (BOA) and British Orthopaedic Foot and Ankle Society (BOFAS) jointly produced Standards for Trauma (BOAST) BOAST 12, with the aim of reducing morbidity by standardising care of these injuries. The primary aim of the AUGMENT study was to determine the extent and clinical effect of variation from BOAST 12. Methods AUGMENT was a multi-centre prospective trainee led audit of consecutive patients presenting with an ankle fracture within a four-week period. Data were collected on patient demographics, comorbidities, management and 12-week outcome. The BOAST 12 standards were divided into four subgroups; documentation, imaging, management and follow-up. Percentage compliance with each subgroup was analysed. A multivariate logistic regression analysis was used to determine impact of overall compliance on likelihood of discharge in follow-up period. Findings 971 patients were included across 52 sites. The overall rate of BOAST 12 compliance was 41.7%. Variations in practice were observed in clinical documentation, especially of neurovascular status, (40.7%) and VTE assessment (61.5%). Patient management compliance with all 16 of the BOAST 12 standards was associated with a higher rate of discharge during the 12-week follow-up period (p = 0.005). Conclusion AUGMENT has demonstrated that the management of ankle fractures is variable across the UK. Over half of patients had aspects of their care that were not BOAST 12 compliant. When compliance was observed, it was associated with earlier discharge from orthopaedic care.

Draft abstract: Background: The closure of schools has been a recommended non-pharmaceutical intervention in response to pandemics because of its potential for reducing the transmission of infection between children, school staff and those that they contact. However, given the many roles that schools play in society, school closure for any extended period is likely to have additional impacts. Literature reviews of research exploring school closure to date appear to have focused upon epidemiological effects and there is an unmet need for research that considers the multiplicity of potential impacts of school closures. Methods: We used systematic searching, coding and synthesis techniques to develop a systems-based logic model. We included literature related to school closure planned in response to epidemics large and small, spanning the 1918-19 ‘flu pandemic through to the emerging literature on the 2019 novel coronavirus. We used over 170 research studies and a number of policy documents to arrive at our model. Results: The model organises the concepts used by authors in this literature into seven higher level domains: children’s health and wellbeing, children’s education, impacts on teachers and other school staff, the school organisation, considerations for parents and families, public health considerations, and broader economic impacts. The model also collates ideas about potential moderating factors and ethical considerations. While clearly dependent upon the nature of epidemics experienced to date, we aim for the model to provide a starting point for theorising about school closures in general, and as part of a wider system that is influenced by many contextual and population factors. Conclusions: The model highlights that the impacts of school closures are much broader than those related solely to health, and demonstrates that there is a need for further concerted work in this area. The publication of this logic model should help the framing of future research in this area as well as aid decision-makers when considering future school closure policy and possible mitigation strategies., These are supplementary files to complement the journal article published in F1000 Research

Background Bezlotoxumab reduced rates of recurrent Clostridioides difficile infection (rCDI) vs placebo in Monoclonal Antibodies for C. difficile Therapy (MODIFY) I/II trial participants receiving antibacterial drug treatment for CDI. A secondary objective of MODIFY I/II was to assess bezlotoxumab’s efficacy against C. difficile strains associated with increased rates of morbidity and mortality. Methods In this post-hoc analysis of pooled MODIFY I/II data, efficacy endpoints were assessed in participants infected with restriction endonuclease analysis BI and non-BI strains of C. difficile at study entry. Treatment outcomes were compared between participants receiving bezlotoxumab (alone or with actoxumab [B, B+A]) and those receiving no bezlotoxumab (placebo or actoxumab [P, A]). Results From 2559 randomized participants, C. difficile was isolated from 1588 (67.2%) baseline stool samples. Participants with BI strains (n = 328) were older and had more risk factors for rCDI than non-BI strain participants (n = 1260). There were no differences in initial clinical cure rate between BI and non-BI strains in either group. The rCDI rate for BI strains treated with bezlotoxumab was lower than for the no bezlotoxumab group (B, B+A vs P, A: 23.6% vs 43.9%) and was also lower for the non-BI strains (B, B+A vs P, A: 21.4% vs 36.1%). Rates of 30-day CDI-associated rehospitalization were greater with BI vs non-BI strains in both groups. Conclusions Infection with BI strains of C. difficile predicted poor outcomes in the MODIFY I/II trials. Bezlotoxumab (alone or with actoxumab) treatment was effective both in BI and non-BI subpopulations.

This paper critically explores how survey and routinely collected data could aid in assessing the generalisability of public health evidence. We propose developing approaches that could be employed in understanding the relevance of public health evidence, and investigate ways of producing meta-analytic estimates tailored to reflect local circumstances, based on analyses of secondary data. Currently, public health decision makers face challenges in interpreting global review evidence to assess its meaning in local contexts. A lack of clarity on the definition and scope of generalisability, and the absence of consensus on its measurement, has stunted methodological progress. The consequence of failing to tackle generalisability means that systematic review evidence often fails to fulfil its potential contribution in public health decision making. Three approaches to address these problems are considered and emerging challenges discussed: (1) purposeful exploration after a review has been conducted, and we present a framework of potential avenues of enquiry and a worked example; (2) recalibration of the results to weight studies differentially based on their similarity to conditions in an inference population, and we provide a worked example using UK Census data to understand potential differences in the effectiveness of community engagement interventions among sites in England and Wales; (3) purposeful exploration before starting a review to ensure that the findings are relevant to an inference population. The paper aims to demonstrate how a more nuanced treatment of context in reviews of public health interventions could be achieved through greater engagement with existing large sources of secondary data.

Purpose: The purpose of this study was to explore whether methods adapted from oncology pharmacological trials have utility in reporting adherence (tolerability) of exercise treatment in cancer. Methods: Using a retrospective analysis of a randomized trial, 25 prostate cancer patients received an aerobic training regimen of 72 supervised treadmill walking sessions delivered thrice weekly between 55% and 100% of exercise capacity for 24 consecutive weeks. Treatment adherence (tolerability) was assessed using conventional (lost to follow-up and attendance) and exploratory (e.g., permanent discontinuation, dose modification, and relative dose intensity) outcomes. Results: The mean total cumulative ‘‘planned’’ and ‘‘completed’’ dose was 200.7 T 47.6 and 153.8 T 68.8 METIh, respectively, equating to a mean relative dose intensity of 77% T 24%. Two patients (8%) were lost to follow-up, and mean attendance was 79%. A total of 6 (24%) of 25 patients permanently discontinued aerobic training before week 24. Aerobic training was interrupted (missing Q3 consecutive sessions) or dose reduced in a total of 11 (44%) and 24 (96%) patients, respectively; a total 185 (10%) of 1800 training sessions required dose reduction owing to both health-related (all nonserious) and non–health-related adverse events. Eighteen (72%) patients required at least one session to be terminated early; a total of 59 (3%) sessions required early termination. Conclusions: Novel methods for the conduct and reporting of exercise treatment adherence and tolerability may provide important information beyond conventional metrics in patients with cancer.

This cross-sectional study included postmenopausal women, aged 45-75 years, with the aim to assess the presence of vulvovaginal atrophy (VVA) confirmed by a clinical assessment in the Italian population attending menopausal/gynecological centers. Apart from baseline variables, women scored vaginal, vulvar and urinary VVA symptoms. Impact of VVA on sexual function and quality of life (QoL) was assessed thorough EuroQoL questionnaire (EQ5D3L), Day-to-Day Impact of Vaginal Aging (DIVA), Female Sexual Function Index (FSFI) and Female Sexual Distress Scale-revised (FSDS-R). A physical examination was carried out in accordance with routine gynecological practice. VVA was confirmed in 90% of the 1226 evaluable patients (aged 59.0 ± 7.3 years). The prevalence of postmenopausal women with VVA confirmed by gynecological clinical assessment was 75.3%. The patients with VVA confirmed (n = 926) had more severe symptoms (p