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El objetivo del artículo se enfocó en analizar la percepción que tiene el personal docente costarricense con respecto al uso ético de la inteligencia artificial (IA) en su labor educativa. El documento se adentra en la inteligencia artificial en la educación, abordando su definición, características y cómo es percibida por el personal docente de niveles de primaria, secundaria y universitaria de Costa Rica. También examina las consideraciones éticas en su implementación en la enseñanza y la diversidad de herramientas de IA, su aplicación y la experiencia de las personas docentes en su uso. La investigación se llevó a cabo utilizando un enfoque mixto concurrente y se apoyó en técnicas de análisis descriptivos. Además, la recopilación de datos se realizó a través de un cuestionario, en el que participaron 134 personas docentes de todo el ámbito educativo costarricense. Para el análisis de datos, se emplearon estrategias cualitativas y cuantitativas. Los resultados indican que la familiaridad del personal docente con la inteligencia artificial en la educación es limitada. Asimismo, algunas personas desconocen las capacidades de la IA para adaptar el contenido al aprendizaje individualizado, aunque consideran que podría ayudar a apoyar al estudiantado. Se concluye que el personal docente revela una comprensión de la importancia en relación con el abordaje y las implicaciones éticas del uso de la IA en el aula. Finalmente, es necesaria una mayor formación sobre el uso óptimo de las herramientas de IA.

Background Irritable bowel syndrome, characterised by abdominal pain and a change in stool form or frequency, is most often managed in primary care. When first-line therapies are ineffective, National Institute for Health and Care Excellence guidelines suggest considering low-dose tricyclic antidepressants as second-line treatment, but their effectiveness in primary care is unknown and they are infrequently prescribed by general practitioners. Objective To evaluate the clinical and cost-effectiveness of low-dose titrated amitriptyline as a second-line treatment for irritable bowel syndrome in primary care. Design A pragmatic, randomised, multicentre, two-arm, double-blind, placebo-controlled trial. A nested, qualitative study explored participant and general practitioner experiences of treatments and trial participation, and implications for wider use of amitriptyline for irritable bowel syndrome in primary care. Participants, clinicians, investigators and analysts were masked to allocation. Setting Fifty-five general practices in three regions in England (Wessex, West of England, West Yorkshire). Participants Patients aged ≥ 18 years meeting Rome IV criteria for irritable bowel syndrome with ongoing symptoms after trying first-line treatments and no contraindications to TCAs. Intervention Amitriptyline 10 mg once-daily, self-titrated by participants to a maximum of 30 mg once-daily or matched placebo for 6 months. Participants randomised 1 : 1 with most having the option to continue blinded treatment for a further 6 months. Main outcome measures The primary participant-reported outcome was the effect of amitriptyline on global irritable bowel syndrome symptoms at 6 months, measured using the irritable bowel syndrome Severity Scoring System, with a 35-point between-group difference defined as the minimum clinically important difference. The key secondary outcome was the proportion of participants reporting subjective global assessment of relief at 6 months, defined as somewhat, considerable, or complete relief of symptoms. Other secondary outcomes included: effect on global symptoms, via the irritable bowel syndrome Severity Scoring System, and subjective global assessment of relief of irritable bowel syndrome symptoms at 3 and 12 months; effect on somatic symptom-reporting at 6 months; anxiety an–d depression scores; ability to work and participate in other activities at 3, 6 and 12 months; acceptability, tolerability and adherence to trial medication. Results Four hundred and sixty-three participants were randomised to amitriptyline (232) or placebo (231). An intention-to-treat analysis of the primary outcome showed a significant difference in favour of amitriptyline for irritable bowel syndrome Severity Scoring System score between arms at 6 months [−27.0, 95% confidence interval (CI) −46.9 to −7.10; p = 0.008]. For the key secondary outcome of subjective global assessment of relief of irritable bowel syndrome symptoms, amitriptyline was superior to placebo at 6 months (odds ratio 1.78, 95% CI 1.19 to 2.66; p = 0.005). Amitriptyline was superior to placebo across a range of other irritable bowel syndrome symptom measures but had no impact on somatoform symptom-reporting, anxiety, depression, or work and social adjustment scores. Adverse event trial withdrawals were more common with amitriptyline (12.9% vs. 8.7% for placebo) but most adverse events were mild. The qualitative study thematically analysed 77 semistructured interviews with 42 participants and 16 GPs. Most participants found the self-titration process acceptable and empowering. Conclusions General practitioners should offer low-dose amitriptyline to patients with irritable bowel syndrome whose symptoms do not improve with first-line therapies. Guidance and resources should support GP–patient communication to distinguish amitriptyline for irritable bowel syndrome from use as an antidepressant and to support patients managing their own dose titration. Study registration This trial is registered as ISRCTN48075063. Funding This award was funded by the National Institute for Health and Care Research (NIHR) Health Technology Assessment programme (NIHR award ref: 16/162/01) and is published in full in Health Technology Assessment Vol. 28, No. 66. See the NIHR Funding and Awards website for further award information. Plain language summary Background People with irritable bowel syndrome experience stomach (abdominal) pain and changes to their bowel movements. Irritable bowel syndrome can have a serious impact on people’s lives. Previous small trials suggest that a drug called amitriptyline used at a low dose may help irritable bowel syndrome. Amitriptyline is already used to treat other conditions. It is available for irritable bowel syndrome but is not used much by general practitioners. Methods We recruited adults aged ≥ 18 years with irritable bowel syndrome from UK general practices who did not have any issues preventing the use of amitriptyline. Patients received either low-dose amitriptyline or placebo (a dummy tablet) for 6 months. Patients could adjust the dose according to symptoms and side effects. Neither the researchers nor the patients knew which treatment they were getting. Participants recorded symptoms using a questionnaire containing an irritable bowel syndrome severity score. We looked at the difference in average irritable bowel syndrome severity score between patients receiving amitriptyline and placebo. We also looked at effects of amitriptyline on mood, ability to work, and non-gut symptoms related to irritable bowel syndrome, as well as safety and acceptability. Some patients and general practitioners were interviewed about their experiences. Results Four hundred and sixty-three patients took part. Participants receiving amitriptyline reported a bigger improvement in their irritable bowel syndrome severity scores at 6 months, compared with patients on placebo. Amitriptyline was better across a range of irritable bowel syndrome symptom measures but did not impact anxiety, depression or ability to work. Forty-six people (19.8%) stopped taking amitriptyline and 59 (25.5%) stopped the placebo before 6 months. Patients liked being able to adjust their dose and valued contact with the research team. Conclusion This study showed that amitriptyline is more effective than a placebo and is safe. General practitioners should offer low-dose amitriptyline to people with irritable bowel syndrome if symptoms do not improve with other standard treatments. Patients should be supported and helped to adjust their dose as needed. The dose adjustment sheet used in this trial will be made available. Scientific summary Background Irritable bowel syndrome (IBS) affects 5% of the population, accounting for > 3% of all consultations in primary care in England and Wales. Symptoms include abdominal pain in association with a change in stool form or frequency. The condition impacts on quality of life and ability to work and limits social activities. The medical management of IBS is unsatisfactory, with no therapy proven to alter the long-term natural history and, at best, modest symptom reduction. Previous meta-analyses of trials conducted in secondary and tertiary care suggest low-dose tricyclic antidepressants (TCAs) may be efficacious, probably because of their pain-modifying properties, as well as their influence on gut motility, rather than any effects on mood. Although National Institute for Health and Care Excellence guidelines for the management of IBS in primary care suggest considering low-dose TCAs as second-line treatment, their effectiveness in this setting is unknown and they are infrequently prescribed by general practitioners (GPs). Objectives Our objective was to determine the clinical and cost-effectiveness of low-dose titrated amitriptyline compared with placebo for 6 months as a second-line treatment in adults with IBS in primary care. Methods ATLANTIS was a pragmatic, randomised, multicentre, parallel-group, two-arm, double-blind, placebo-controlled trial. A nested, qualitative study explored participant and GP experiences of treatments and trial participation. A within-study cost-effectiveness analysis was planned but, due to the coronavirus disease discovered in 2019 (COVID-19) pandemic, health economic analyses were removed after obtaining additional funding to complete the trial to prioritise funds for participant recruitment. These will be subject to further funding. Participants, their GPs, investigators, the research team, and the analysis team were all masked to treatment allocation throughout the trial. Patients meeting Rome IV criteria for IBS who had tried first-line treatments and with ongoing IBS symptoms [score of ≥ 75 on the IBS Severity Scoring System (IBS-SSS)] were recruited via mail-out from 55 general practices in three regions in England. Participants were randomised 1 : 1 to receive either low-dose titrated amitriptyline or placebo. Both treatments were supplied for 6 months, with the dose commenced at 10 mg o.d. and titrated to a maximum of 30 mg o.d. or a minimum of 10 mg alternate days. Dose titration was participant-led according to IBS symptoms and side effects, with support from the trial team and a dose titration document developed with input via patient and public involvement. Participants recruited earlier to the trial had the option to continue blinded treatment for an additional 6 months. The primary outcome was the effect of amitriptyline on global IBS symptom scores at 6 months. The key secondary outcome was the proportion of participants with relief of IBS symptoms at 6 months. Other secondary outcomes included effect on global IBS symptoms and relief of IBS symptoms at 3 and 12 months, effect on IBS-associated somatic symptoms at 6 months, effect on quality of life, anxiety, and depression scores, and ability to work and participate in other activities at 3, 6 and 12 months, as well as acceptability and tolerability of, and adherence to, treatment. Patient-reported questionnaires at baseline and 3, 6 and 12 months post randomisation (unless otherwise indicated) were used to assess IBS symptom severity (measured via the IBS-SSS), relief of IBS symptoms [measured by subjective global assessment (SGA) of relief], adequate relief of IBS symptoms (measured by a weekly response to the question ‘Have you had adequate relief of your IBS symptoms?’), IBS-associated somatic symptoms [using the Patient Health Questionnaire-12 (PHQ-12)], mood [using the Hospital Anxiety and Depression Scale (HADS)], ability to work and participate in other activities [using the Work and Social Adjustment Scale (WSAS)], quality of life (using the EQ-5D-3L), healthcare use (using a bespoke health resource use questionnaire), and tolerability [using the Antidepressant Side-Effect Checklist (ASEC)]. Numbers of participants reporting serious adverse events (SAEs), including serious adverse reactions (SARs), were reported for each treatment group. An evaluable sample size of 414 participants would provide 90% power to detect a minimum clinically important difference of 35 points between amitriptyline and placebo at 6 months on the IBS-SSS. This sample size provided at least 85% power to detect a 15% absolute difference in the key secondary outcome of SGA of relief of IBS symptoms at 6 months. We planned to recruit 518 participants, allowing for 20% loss to follow-up. Effectiveness outcomes were analysed in the intention-to-treat population, defined as all participants randomised, regardless of adherence. All statistical testing used two-sided 5% significance levels. The primary outcome was analysed using a linear regression model, adjusted for minimisation variables and baseline IBS-SSS score. Missing data were imputed by treatment arm, via multiple imputation, and results were expressed as point estimates with 95% confidence intervals (CIs). Secondary binary outcomes were analysed in logistic or ordinal regression models, with results expressed as odds ratios (ORs) with 95% CIs. Continuous secondary outcomes, including PHQ-12, HADS and WSAS scores, were analysed as for the primary outcome, adjusted for the respective baseline score. All participants receiving at least one dose of trial medication, according to medication received, were included in the safety analysis. The nested, qualitative study aimed to identify factors that would facilitate or impede prescribing of, acceptability of, and adherence to, low-dose amitriptyline in IBS, to identify participants’ and GPs’ perspectives on the broader impact of the trial, and to explore psychosocial and contextual factors that might shape wider use of amitriptyline for IBS. Familiarity with amitriptyline may both hinder uptake, given its association with depression, and facilitate it, given that it is a known drug, taken in a low dose distinct from the antidepressant dose, already used for a range of other painful conditions and has comparatively mild, and in some cases potentially beneficial, side effects such as on sleep. Semi-structured audio-recorded telephone interviews were conducted with a diverse sub-sample of trial participants and GPs involved in the trial and transcribed verbatim. The final sample size was dependent on saturation, to achieve a rigorous, credible analysis in relation to the aims. Topic guides allowed flexible exploration of all required topics, while remaining open to participants’ individual experiences and perspectives. To enhance trustworthiness of the analysis, all qualitative study team members contributed to avoid producing idiosyncratic interpretations, a negative case analysis was undertaken, and an audit trail was produced to enhance transparency, including detailed coding manuals and interviewer field notes. Reflexive thematic analysis, incorporating techniques from grounded theory, was used to analyse the qualitative data. Data collection and initial analyses proceeded iteratively, and informed subsequent interviews. Analysis was primarily inductive, with researchers identifying themes in the data rather than imposing any pre-existing interpretive framework. Qualitative findings were related to the main trial findings by comparing themes across subgroups and against the quantitative data. Clinical results In total, 15,672 potentially eligible patients were invited to take part, of whom 1253 were interested and were screened. Of those screened, 463 (37.0%) were randomised {mean age 48.5 years [standard deviation (SD) 16.1 years], 315 (68.0%) female}, to amitriptyline (n = 232) or placebo (n = 231). Six-month follow-up was achieved for 401 (86.6%) participants, 204 (87.9%) in the amitriptyline arm, and 197 (85.3%) in the placebo arm. Participants were well balanced between treatment arms according to demographics and baseline characteristics, IBS symptom severity, PHQ-12 scores, HADS-depression and HADS-anxiety scores, and previous first-line treatments. Among participants, 80.4% had IBS-D or IBS-M, 84.2% had a normal HADS-depression score, and 84.7% had moderate to severe scores on the IBS-SSS, with a mean IBS-SSS score in all participants of 272.8 (SD 90.3). The median duration of IBS was 10 years. In total, 338 (73.0%) participants completed 6 months of treatment, 173 (74.6%) randomised to amitriptyline and 165 (71.4%) to placebo. Discontinuation of trial medication before 6 months occurred in 105 (22.7%) participants, 46 (19.8%) allocated to amitriptyline and 59 (25.5%) to placebo. The most common reason for discontinuing trial medication was adverse events (AEs) in 30 (12.9%) participants allocated to amitriptyline and 20 (8.7%) to placebo, followed by lack of benefit in 7 (3.0%) randomised to amitriptyline and 18 (7.8%) to placebo. There were a further 17 (3.7%) participants lost to follow-up and 3 (0.6%) who did not commence trial medication. By 3 months, similar proportions of participants randomised to amitriptyline had titrated their dose to 20 mg o.d. (35.2%) or 30 mg o.d. (37.8%), although by 6 months this had increased to 42.8% taking 30 mg o.d. However, in the placebo arm, 57.0% of participants titrated their dose to 30 mg o.d. within 3 months and this proportion was similar at 6 months. For the primary outcome, amitriptyline was superior to placebo at 6 months in the intention-to-treat analysis, with a significant difference in mean IBS-SSS score between arms (−27.0, 95% CI −46.9 to −7.1; p = 0.008). For the key secondary outcome, SGA of relief of IBS symptoms, amitriptyline was also superior to placebo (OR for relief of IBS symptoms = 1.78, 95% CI 1.19 to 2.66; p = 0.005). At 3 months, the difference in mean change in IBS-SSS score also favoured amitriptyline (−23.3, 95% CI −42.0 to −4.6; p = 0.014), as did the SGA of relief of IBS symptoms (OR = 1.70, 95% CI 1.15 to 2.53; p = 0.008). In a sensitivity analysis using an alternative definition of SGA of relief of IBS symptoms, where only those reporting considerable or complete relief of IBS symptoms at 3 or 6 months were classed as responders, the effect size in the amitriptyline arm increased at both 3 (OR = 1.81, 95% CI 1.17 to 2.79) and 6 months (OR = 1.88, 95% CI 1.20 to 2.95). Other sensitivity analyses on the per-protocol population for the primary outcome and on participants with complete data for the primary and key secondary outcomes gave consistent results, albeit with larger estimated treatment effects. In terms of adequate relief of IBS symptoms, amitriptyline was also superior to placebo with increased odds of adequate relief across all 25 weeks (OR = 1.56, 95% CI 1.20 to 2.03; p < 0.001), and a higher proportion of participants reporting adequate relief for ≥ 13 of 25 weeks [90/222 (40.5%) vs. 67/221 (30.3%)]. Significantly higher numbers of participants taking amitriptyline reported the drug to be acceptable and would have been willing to continue taking it at 6 months (OR = 1.60, 95% CI 1.08 to 2.35; p = 0.018). Adherence at 3 months was identical in the two treatment arms, but it was higher in the amitriptyline arm at 6 months [172/232 (74.1%) vs. 155/228 (68.0%)]. Amitriptyline had no significant effect on PHQ-12 scores at 6 months, or HADS-anxiety, HADS-depression or WSAS scores at either 3 or 6 months. In terms of treatment-emergent AEs, there was a statistically significant increase in the total ASEC score in those receiving amitriptyline compared with placebo at 3 months (1.39, 95% CI 0.29 to 2.50; p = 0.013) but not at 6 months (0.26, 95% CI −0.98 to 1.51; p = 0.681). The AEs reported in participants receiving amitriptyline in excess of those reported by the placebo arm mainly related to its known anticholinergic effects, including dry mouth, drowsiness, blurred vision and problems with urination. However, rates of treatment-emergent AEs fell between 3 and 6 months and few were severe. The commonest AEs leading to discontinuation in the amitriptyline arm were drowsiness and deterioration of mood. In total, there were five SARs, two in the amitriptyline arm and three in the placebo arm. There were five SAEs unrelated to trial medication, of which four occurred in the amitriptyline arm and one in the placebo arm. In the subset of participants recruited to 12 months’ follow-up and with the choice to continue treatment beyond 6 months, 44% of participants completed 12 months’ treatment. Despite the mixed sample, in the 12-month ITT population, weak evidence of a significant effect in favour of low-dose amitriptyline remained on the mean IBS-SSS (−22.6, 95% CI −49.35 to −4.16; p = 0.098) and the SGA of relief of global IBS symptoms (OR = 1.58, 95% CI 0.94 to 2.64; p = 0.083). In contrast to 6-month results, there was a statistically significant effect on the HADS-depression (−0.88, 95% CI −1.71 to 0.06; p = 0.036) and WSAS (−2.14, 95% CI −3.80 to −0.49; p = 0.011) scores in favour of low-dose amitriptyline. Qualitative results The qualitative study conducted and thematically analysed 77 semistructured interviews with 42 participants and 16 GPs. A multidisciplinary team including patient collaborators explored multiple aspects of participants’ and GPs’ experiences of treatments and participating in the ATLANTIS trial. The qualitative analysis of barriers and facilitators suggests that low-dose amitriptyline for IBS is acceptable to, and is often welcomed by, GPs and patients as an additional treatment option. Addressing concerns and promoting facilitators could facilitate wider use of low-dose amitriptyline for IBS which may be achieved through: Clear communication to clinicians, for example in clinical guidelines, that distinguishes low-dose amitriptyline for IBS from amitriptyline use for other conditions (especially depression). Resources to support GP–patient communication to distinguish low-dose amitriptyline for IBS from amitriptyline for other conditions (especially depression). This might include, for example, tips for GPs when discussing amitriptyline for IBS with patients, online materials to support or reinforce messages given during consultations, tailored packaging and patient inserts, and education for pharmacists. Clear guidance about low-dose amitriptyline for IBS and anticholinergic burden. This should highlight that low-dose amitriptyline has lower potential risk and that currently anticholinergic burden risk scores do not account for dose, so can overinterpret risk with low-dose amitriptyline. Guidance and resources for GPs and patients to support patients managing their own dose titration. The dose-titration document used in ATLANTIS was well received by GPs and patients. Conclusions In the largest trial of a TCA in IBS ever conducted, titrated low-dose amitriptyline was superior to placebo as a second-line treatment for IBS in primary care across multiple outcomes and was safe. The results of ATLANTIS strongly support use of titrated low-dose amitriptyline in this setting. GPs should offer low-dose amitriptyline to patients with IBS whose symptoms do not improve with first-line therapies, with appropriate support to guide patient-led dose titration, such as the self-titration document developed for this trial. Trial registration This trial is registered as ISRCTN48075063. Funding This award was funded by the National Institute for Health and Care Research (NIHR) Health Technology Assessment programme (NIHR award ref: 16/162/01) and is published in full in Health Technology Assessment; Vol. 28, No. 66. See the NIHR Funding and Awards website for further award information.

Introduction Traditionally, wards in acute care hospitals consist predominately of multioccupancy bays with some single rooms. There is an increasing global trend towards a higher proportion of single rooms in hospitals, with the UK National Health Service (NHS) advocating for single-room provision in all new hospital builds. There is limited evidence on the impact of a ward environment incorporating mostly single and some multioccupancy bays on patient care and organisational outcomes.Methods and analyses This study will assess the impact of a newly designed 28-bedded ward environment, with 20 single rooms and two four-bedded bays, on patient and staff experiences and outcomes in an acute NHS Trust in East England. The study is divided into two work packages (WP)—WP1 is a quantitative data extraction of routinely collected patient and staff data while WP2 is a mixed-methods process evaluation consisting of one-to-one, in-depth, semistructured interviews with staff, qualitative observations of work processes on the ward and a quantitative data evaluation of routinely collected process evaluation data from patients and staff.Ethics and dissemination Ethical approval was obtained from the UK Health Research Authority (IRAS ID: 334395). Study findings will be shared with key stakeholders, published in peer-reviewed high-impact journals and presented at relevant conferences.

The development of high-performance hydrogen peroxide (H2O2) sensors is critical for various applications, including environmental monitoring, industrial processes, and biomedical diagnostics. This study explores the development of efficient and selective H2O2 sensors based on bismuth oxide/bismuth oxyselenide (Bi2O3/Bi2O2Se) nanocomposites. The Bi2O3/Bi2O2Se nanocomposites were synthesized using a simple solution-processing method at room temperature, resulting in a unique heterostructure with remarkable electrochemical characteristics for H2O2 detection. Characterization techniques, including powder X-ray diffraction (XRD), X-ray photoelectron spectroscopy (XPS), and scanning electron microscopy (SEM), confirmed the successful formation of the nanocomposites and their structural integrity. The synthesis time was varied to obtain the composites with different Se contents. The end goal was to obtain phase pure Bi2O2Se. Electrochemical measurements revealed that the Bi2O3/Bi2O2Se composite formed under optimal synthesis conditions displayed high sensitivity (75.7 µA µM−1 cm−2) and excellent selectivity towards H2O2 detection, along with a wide linear detection range (0–15 µM). The superior performance is attributed to the synergistic effect between Bi2O3 and Bi2O2Se, enhancing electron transfer and creating more active sites for H2O2 oxidation. These findings suggest that Bi2O3/Bi2O2Se nanocomposites hold great potential as advanced H2O2 sensors for practical applications.

Abstract Genetic diversity underpins evolutionary potential that is essential for the long‐term viability of wildlife populations. Captive populations harbor genetic diversity potentially lost in the wild, which could be valuable for release programs and genetic rescue. The Critically Endangered Arabian leopard (Panthera pardus nimr) has disappeared from most of its former range across the Arabian Peninsula, with fewer than 120 individuals left in the wild, and an additional 64 leopards in captivity. We (i) examine genetic diversity in the wild and captive populations to identify global patterns of genetic diversity and structure; (ii) estimate the size of the remaining leopard population across the Dhofar mountains of Oman using spatially explicit capture–recapture models on DNA and camera trap data, and (iii) explore the impact of genetic rescue using three complementary computer modeling approaches. We estimated a population size of 51 (95% CI 32–79) in the Dhofar mountains and found that 8 out of 25 microsatellite alleles present in eight loci in captive leopards were undetected in the wild. This includes two alleles present only in captive founders known to have been wild‐sourced from Yemen, which suggests that this captive population represents an important source for genetic rescue. We then assessed the benefits of reintroducing novel genetic diversity into the wild population as well as the risks of elevating the genetic load through the release of captive‐bred individuals. Simulations indicate that genetic rescue can improve the long‐term viability of the wild population by reducing its genetic load and realized load. The model also suggests that the genetic load has been partly purged in the captive population, potentially making it a valuable source population for genetic rescue. However, the greater loss of its genetic diversity could exacerbate genomic erosion of the wild population during a rescue program, and these risks and benefits should be carefully evaluated. An important next step in the recovery of the Arabian leopard is to empirically validate these conclusions, implement and monitor a genomics‐informed management plan, and optimize a strategy for genetic rescue as a tool to recover Arabia's last big cat.

Cat-scratch disease (CSD) is an infectious disease caused by Bartonella henselae, presenting with fever and lymphadenopathy following contact with felines. The ocular manifestations include neuroretinitis, characterised by optic nerve swelling and a macular star. Case Presentation: We discuss a case of neuroretinitis that presented atypically, without a macular star. There was an initial suspicion of Bartonella, but the serology was negative. Our patient was eventually empirically treated for infective neuroretinitis based on a positive contact history (recently scratched by one of his three pet cats). There was progression to a macular star upon serial dilated fundus examination, and the repeated serology one week after symptom onset showed rising titres, supporting a diagnosis of CSD. Conclusions: A judicious review of systems, repeat assays, serial dilated fundus examination, and early ophthalmic evaluation are useful in cases of suspected neuroretinitis, remaining an important differential in the evaluation of sudden-onset painless vision loss and unilateral disc swelling.

The movement and biomass fluctuations of sargassum across the Tropical Atlantic have profound implications when influxes reach the Eastern Caribbean. These influxes have cross-cutting impacts across ecological, economic, and social systems. The objective of this work is to quantify sargassum biomass accumulation in the Eastern Caribbean, accounting for the spatial variability in sea surface temperature and morphotype diversity. A parallel implementation of a climatological drifter-based model was used to simulate advection of sargassum across the model domain. After determining the trajectory of virtual sargassum particles, Monte Carlo simulations using 1000 realizations were run to quantify biomass accumulations along these tracks. For simulations with a single morphotype, the biomass accumulation as predicted by the model effectively reproduced the seasonal distributions of sargassum for the simulated period (May 2017 to August 2017). The model closely approximated an observed increase during the period from May to July 2017, followed by a subsequent decline in sargassum abundance. A major factor that led to the discrepancy between the simulated and observed biomass accumulation is the occlusion of the optical satellite signal from cloud cover, which led to underestimates of sargassum abundance. The mean maximum growth rate required to reproduce the observed sargassum biomass was 0.05 day−1, which is consistent with other published experimental and computational studies that have reported similar growth rates for sargassum populations under comparable environmental conditions. An innovative aspect of this study was the investigation of the biomass dynamics of the three dominant morphotypes found in the study area. The results from these simulations show that the accumulation of the fastest growing morphotype, Sargassum fluitans var. fluitans, closely approximates the profiles of the overall prediction with a single morphotype.

Purpose – Online travel agencies (OTAs) have an important role to play in reactivating tourism activity following a health crisis by providing information about the health conditions of tourist destinations. Once developed, it is necessary to analyze the effectiveness of the information provided and ascertain whether the provision of such information effects the understanding of the value of using OTAs and, in turn, the intention to do so. Design/methodology/approach – This paper, based on an empirical case study conducted during the COVID-19 pandemic, examines whether following a health crisis, the quality of information provided by OTAs on the health conditions of tourist destinations and the perceived value of their offer generate a greater OTA services reuse intention, and signals, therefore, a return to travel. Findings – The results show the quality of the information positively influences the perceived value, but not the OTA services reuse intention. Rather, the perceived value positively influences the OTA services reuse intention. Practical implications – Overall, it can be suggested that providing quality health information for a destination is a necessary strategy because it contributes to increasing the perceived value of OTAs. To incentivize the intention for repeated use of OTA services, it is necessary to consider the perceived value that influences the intention to make repeat OTA reservations. Originality/value – This research offers a novel perspective about the OTAs’ contribution to the recovery of the activity of the tourism industry after a health crisis. This contributes to achieving a more resilient sector in the face of future health crises.

Introduction Effective communication can help optimise healthcare interactions and patient outcomes. However, few interventions have been tested clinically, subjected to cost-effectiveness analysis or are sufficiently brief and well-described for implementation in primary care. This paper presents the protocol for determining the effectiveness and cost-effectiveness of a rigorously developed brief eLearning tool, EMPathicO, among patients with and without musculoskeletal pain.Methods and analysis A cluster randomised controlled trial in general practitioner (GP) surgeries in England and Wales serving patients from diverse geographic, socioeconomic and ethnic backgrounds. GP surgeries are randomised (1:1) to receive EMPathicO e-learning immediately, or at trial end. Eligible practitioners (eg, GPs, physiotherapists and nurse practitioners) are involved in managing primary care patients with musculoskeletal pain. Patient recruitment is managed by practice staff and researchers. Target recruitment is 840 adults with and 840 without musculoskeletal pain consulting face-to-face, by telephone or video. Patients complete web-based questionnaires at preconsultation baseline, 1 week and 1, 3 and 6 months later. There are two patient-reported primary outcomes: pain intensity and patient enablement. Cost-effectiveness is considered from the National Health Service and societal perspectives. Secondary and process measures include practitioner patterns of use of EMPathicO, practitioner-reported self-efficacy and intentions, patient-reported symptom severity, quality of life, satisfaction, perceptions of practitioner empathy and optimism, treatment expectancies, anxiety, depression and continuity of care. Purposive subsamples of patients, practitioners and practice staff take part in up to two qualitative, semistructured interviews.Ethics approval and dissemination Approved by the South Central Hampshire B Research Ethics Committee on 1 July 2022 and the Health Research Authority and Health and Care Research Wales on 6 July 2022 (REC reference 22/SC/0145; IRAS project ID 312208). Results will be disseminated via peer-reviewed academic publications, conference presentations and patient and practitioner outlets. If successful, EMPathicO could quickly be made available at a low cost to primary care practices across the country.Trial registration number ISRCTN18010240.

Background: Irrational medicine use is a global problem that may potentiate antimicrobial resistance. Aim: This study aims to assess prescribing practices and the effect of a prescription audit and feedback coupled with small-group education intervention on prescribing indicators. Setting: The study was conducted in public-sector healthcare facilities in Eswatini. Methods: A cluster quasi-randomised controlled study was conducted from 2016 to 2019 using the World Health Organization/ International Network for Rational Use of Drugs (WHO/INRUD) prescribing indicators at baseline, post-intervention and post-follow-up. A 6-month unblinded intervention was tested in 32 healthcare facilities, randomly allocated to intervention (16) and control (16) arms. Prescribing practices were assessed post-intervention, and 6 months after the intervention, through an audit of 100 randomly selected prescriptions from each facility. Comparisons of WHO or INRUD prescribing indicators were conducted using the intention-to-treat analysis at the two times. Results: At baseline, in both arms, rational prescribing standards were met by the number of medicines per prescription and the use of injections. Antibiotic use was above 50% in both arms. After adjustment for baseline antibiotics use, region and level of care, there were no significant differences in all prescribing indicators between the two arms, post-intervention and at 6 months follow-up. Conclusion: In a lower middle-income setting with a high prevalence of irrational prescribing practices, a prescription audit, feedback and small-group education intervention had no benefits in improving rational prescribing. Contribution: Multifaceted strategies, strengthening of pharmacy and therapeutics committees, and holistic monitoring of medicine use are recommended to promote rational medicine use.

Abstract Background: A gap in the literature exists pertaining to a global research nurse/research midwife resources and communication skill set necessary to engage with participants of diverse populations and geographic regions in the community or home-based conduct of decentralized clinical trials. Aims: An embedded mixed methods study was conducted to examine research nurse/research midwife knowledge base, experiences, and communication skill sets pertaining to decentralized trials across global regions engaged in remote research: the USA, Republic of Ireland, United Kingdom, and Australia. Methods: An online survey was deployed across international research nurse/research midwife stakeholder groups, collecting demographics, decentralized trial experience, barriers and facilitators to optimal trial conduct, and the self-perceived communication competence (SPCC) and interpersonal communication competence (IPCC) instruments. Results: 86 research nurses and research midwives completed the survey across all countries: The SPCC and IPCC results indicated increased clinical research experience significantly correlated with increased SPCC score (p < 0.05). Qualitative content analysis revealed five themes: (1) Implications for Role, (2) Safety and Wellbeing, (3) Training and Education, (4) Implications for Participants, and (5) Barriers and Facilitators. Conclusions: Common trends and observations across the global sample can inform decentralized trial resource allocation and policy pertaining to the research nurse/research midwife workforce. This study demonstrates shared cultural norms of research nursing and midwifery across varied regional clinical trial ecosystems.

Engineered living materials (ELMs) incorporate living material to provide a gain of function over existing materials, such as self-repair. The use of bacteria in ELMs has been studied extensively in concrete, where repair can be facilitated by bacterial ureolytic calcium carbonate (CaCO3) precipitation; however, the study of bacteria in other construction materials is limited. We examined the ability of bacterial species to survive in common latex binder chemistries, a model paint formulation, and through the film-forming process. The longest survival was by bacterial spores of Bacillus simplex str. GGC-P6A, which survive in latex emulsions, a liquid coating composition, and in a dried film for >28 days. Surprisingly, our data show that non-spore-forming Escherichia coli survive at least 15 days in liquid composition, which appear to be influenced by the composition of the outer membrane, nutrient scavenging, and the ability to metabolize toxic acrylate. Spores of GGC-P6A were shown to grow in solid paint films from sites of damage, resulting in crack filling through carbonate precipitation, demonstrating the potential for self-repair through microbially mediated CaCO3 precipitation without directed pH modification. These data suggest that a range of bacterial species, in particular members of Bacilli, may facilitate new applications of bio-augmented, self-healing coating systems.

This paper is an exploration of play in tourism. It is situated in an approach to play and toys informed by phenomenological perspectives and theoretical insights drawn from existential anthropology. It argues that tourism and play are intimately linked and outlines the ways in which connections between the two have been made. This paper focuses on a particular practice of play in travel—one that involves the use of a toy. Using the notion of ‘toy tourism’, I examine the ways in which touristic practices associated with play are brought into being in the moment of doing. The research is located in the resorts of Palmanova and Magaluf on the Mediterranean island of Mallorca. I conducted the research using a doll from the Barbie Fashionista range, who I named Mordaith. I outline how and why Mordaith became my travel companion and the experience and events associated with my time with her in the resorts. This paper recounts the story of what happened when I brought about the play of toy tourism in Mallorca. It is an experimental approach that unfolds in the writing as much as in the gathering of information during fieldwork. I argue that what play is, and what a toy is, are neither fixed nor graspable objectivities. Rather, both toy and play, and, thus, toy tourism, emerge in my embodied imaginative understanding of what touristic and toy tourism practices are, as well as the actual embodied and emotional movements of employing a toy in practice.

Deletion of the nuclear hormone receptor small heterodimer partner (Shp) ameliorates the development of obesity and nonalcoholic steatohepatitis (NASH) in mice. Liver-specific SHP plays a significant role in this amelioration. The gut microbiota has been associated with these metabolic disorders, and the interplay between bile acids (BAs) and gut microbiota contributes to various metabolic disorders. Since hepatic SHP is recognized as a critical regulator in BA synthesis, we assessed the involvement of gut microbiota in the antiobesity and anti-NASH phenotype of Shp−/− mice. Shp deletion significantly altered the levels of a few conjugated BAs. Sequencing the 16S rRNA gene in fecal samples collected from separately housed mice revealed apparent dysbiosis in Shp−/− mice. Cohousing Shp−/− mice with WT mice during a Western diet regimen impaired their metabolic improvement and effectively disrupted their distinctive microbiome structure, which became indistinguishable from that of WT mice. While the Western diet challenge significantly increased lipopolysaccharide and phenylacetic acid (PAA) levels in the blood of WT mice, their levels were not increased in Shp−/− mice. PAA was strongly associated with hepatic peroxisome proliferator-activated receptor gamma isoform 2 (Pparg2) activation in mice, which may represent the basis of the molecular mechanism underlying the association of gut bacteria and hepatic steatosis. Shp deletion reshapes the gut microbiota possibly by altering BAs. While lipopolysaccharide and PAA are the major driving forces derived from gut microbiota for NASH development, Shp deletion decreases these signaling molecules via dysbiosis, thereby partially protecting mice from diet-induced metabolic disorders.

Summary: In light of growing interest in using emerging large language models (LLMs) for self-diagnosis, we systematically assessed the performance of ChatGPT-3.5, ChatGPT-4.0, and Google Bard in delivering proficient responses to 37 common inquiries regarding ocular symptoms. Responses were masked, randomly shuffled, and then graded by three consultant-level ophthalmologists for accuracy (poor, borderline, good) and comprehensiveness. Additionally, we evaluated the self-awareness capabilities (ability to self-check and self-correct) of the LLM-Chatbots. 89.2% of ChatGPT-4.0 responses were ‘good’-rated, outperforming ChatGPT-3.5 (59.5%) and Google Bard (40.5%) significantly (all p

Abstract The recent proliferation of pelagic Sargassum spp. in the Tropical Atlantic causes major ecological and socioeconomic impacts to the wider Caribbean when it washes ashore, with regional fisheries and tourism industries particularly affected. The Caribbean influxes have been tracked to a new bloom region known as the North Equatorial Recirculation Region (NERR) encompassing the area between the South Equatorial Current and the North Equatorial Counter Current and extending from Africa to South America. The vast biomass of Sargassum presents serious problems when it washes ashore but also represents significant commercial opportunities, especially with biofuel and fertilizer. The floating Sargassum mats are themselves diverse ecosystems that vary both in their biodiversity and biochemical attributes. Two major species (Sargassum fluitans and S. natans) have been identified as well as several distinguishable morphotypes of each. Oceanic mixing tends to blend the morphotypes together making it difficult to determine if there are regions of the NERR that favour bloom and growth of the distinct types. In this study, we quantify the species and morphotype composition of Sargassum strandings in Barbados and test if this is related to separate oceanic origins and routes travelled using a backtracking algorithm based on ocean drifter data. We found significant seasonal variation in the relative abundance of three morphotypes and this could be traced to two distinct easterly sub-origins and/or transport pathways; one area around 15° N that travels directly E–W across the Atlantic, and another area generally south of 10° N that takes a more meandering route coming close the coast of South America. These findings contribute towards our understanding of why the Tropical Atlantic bloom is presently occurring as well as towards addressing valorisation constraints surrounding variation in the supply of the three commonly occurring morphotypes.

Abstract Most cave formation requires mass separation from a host rock in a process that operates outward from permeable pathways to create the cave void. Given the poor solubility of Fe(III) phases, such processes are insufficient to account for the significant iron formation caves (IFCs) seen in Brazilian banded iron formations (BIF) and associated rock. In this study we demonstrate that microbially-mediated reductive Fe(III) dissolution is solubilizing the poorly soluble Fe(III) phases to soluble Fe(II) in the anoxic zone behind cave walls. The resultant Fe(III)-depleted material (termed sub muros) is unable to maintain the structural integrity of the walls and repeated rounds of wall collapse lead to formation of the cave void in an active, measurable process. This mechanism may move significant quantities of Fe(II) into ground water and may help to explain the mechanism of BIF dissolution and REE enrichment in the generation of canga. The role of Fe(III) reducing microorganism and mass separation behind the walls (outward-in, rather than inward-out) is not only a novel mechanism of speleogenesis, but it also may identify a previously overlooked source of continental Fe that may have contributed to Archaean BIF formation.

This study evaluated the acceptability and utilization of livelihood programs in Higher Education. The study's respondents were divided into two; for the quantitative data, the respondents were the 75 beneficiaries from the two partner communities of Camarines Sur Polytechnic Colleges (CSPC), while for the qualitative part, there were ten extensionists of CSPC. A semi-structured questionnaire was used to collect the data for the study. Frequency count, mean, and percentage weighted mean were used in the study. Likewise, the following statistical tools were used for the appropriate treatment of gathered data, in observance of the concurrent mixed method design, and to test the relationship, Pearson R was utilized to know the relationship between the two variables of acceptability and utilization of livelihood programs and to test the difference, Anova (two-way) was used. Results of the study showed that the level of acceptability of livelihood programs along the three skills training was interpreted as highly acceptable. Findings further revealed that the extent of utilization of extension programs for all five deliverable are interpreted as highly utilized. Results further showed that the rating of beneficiaries, along with training, community outreach, and technical assistance, have a significant relationship with the level of acceptability and utilization of livelihood programs. In contrast, communication information and technology transfer and utilization have no significant relationship. Likewise, results showed no significant differences in the ratings of beneficiaries on the level of acceptability and utilization along the five deliverable. The extensionists encountered different challenges in implementing the various extension programs. Thus, an action plan was proposed as an intervention strategy based on the study results.

Abstract Objectives To outline the planning, development and optimisation of a psycho-educational behavioural intervention for patients on active surveillance for prostate cancer. The intervention aimed to support men manage active surveillance-related psychological distress. Methods The person-based approach (PBA) was used as the overarching guiding methodological framework for intervention development. Evidence-based methods were incorporated to improve robustness. The process commenced with data gathering activities comprising the following four components: • A systematic review and meta-analysis of depression and anxiety in prostate cancer • A cross-sectional survey on depression and anxiety in active surveillance • A review of existing interventions in the field • A qualitative study with the target audience The purpose of this paper is to bring these components together and describe how they facilitated the establishment of key guiding principles and a logic model, which underpinned the first draft of the intervention. Results The prototype intervention, named PROACTIVE, consists of six Internet-based sessions run concurrently with three group support sessions. The sessions cover the following topics: lifestyle (diet and exercise), relaxation and resilience techniques, talking to friends and family, thoughts and feelings, daily life (money and work) and information about prostate cancer and active surveillance. The resulting intervention has been trialled in a feasibility study, the results of which are published elsewhere. Conclusions The planning and development process is key to successful delivery of an appropriate, accessible and acceptable intervention. The PBA strengthened the intervention by drawing on target-user experiences to maximise acceptability and user engagement. This meticulous description in a clinical setting using this rigorous but flexible method is a useful demonstration for others developing similar interventions. Trial registration and Ethical Approval ISRCTN registered: ISRCTN38893965 . NRES Committee South Central – Oxford A. REC reference: 11/SC/0355

This study deviates from the standard view of template-based training courses that have dominated the experience of in-service English teachers in Ecuador. Its purpose is to underscore the contextualization of training modules as a strategic method for duplicating and scaling up multi-level teacher training to sustain their knowledge and skills. The impact is assessed through a three-level survey administered to 394 teachers from three provinces. The results suggest that the influence of class size and the adaptability and replicability of training are factors that influence the effectiveness and sustainability of an English as a foreign language program. The study highlights the crucial role of collaboration that facilitates collective efforts to contextualize training to achieve profound insight related to classroom practices.

Este documento proporciona una visión general de la construcción de un molino de martillos de tamaño compacto de bajo costo para uso en laboratorio. Reducir el tamaño de partícula de diversos materiales para estudiar sus propiedades fisicoquímicas mediante la construcción de un molino de martillos. El molino de martillos fue construido con materiales que se pueden obtener en almacenes de equipos industriales y residuos vehiculares. La metodología de construcción se basó en la mecánica de precisión y la metalurgia. Desarrollos Tecnológicos Teck S. A. y el Laboratorio de Biomasa de la Facultad de Química de la Universidad de Costa Rica, San José, Costa Rica, en 2020. Los materiales lignocelulósicos residuales se molieron del racimo vacío de palma aceitera de fruta (Elaeis guineensis), la cáscara de nuez de la palma de fruta Coyol (Acrocomia spp.), rocas, cáscara de coco, madera, lodo y escoria de aluminio. La construcción del molino de martillos es de forma compacta y versátil porque permite moler una amplia variedad de materiales para procesos de investigación que requieren la reducción de materiales orgánicos e inorgánicos. Debido a su modesto tamaño, se puede colocar en un laboratorio y dado que su fuente de alimentación es de 110 voltios, no son necesarios requisitos especiales.

Abstract Western chimpanzees (Pan troglodytes verus) are Critically Endangered and Guinea is a key stronghold for this subspecies. However, Guinea is also rich in minerals with some of the highest‐grade iron‐ore deposits in the world. Specifically, the Nimba Mountains, home to western chimpanzees, is one of the sites under consideration for mining activities. To assess the impact of mining activities in the area, we used non‐invasive genetic sampling to estimate chimpanzee population size, sex ratio, community composition, and range boundaries on the western flank of the massif. The level of genetic diversity and affinity between communities was estimated and recommendations for future genetic censusing provided. Between 2003 and 2018, we collected 999 fecal samples of which 663 were analyzed using a panel of 26 microsatellites. We identified a minimum of 136 chimpanzees in four communities, with evidence of migratory events, a high level of shared ancestry and genetic diversity. We assessed sampling intensities and capture rates for each community. Saturation was reached in two communities with sampling between 3.2 and 4.3 times the estimated number of chimpanzees. Our findings highlight the utility of genetic censusing for temporal monitoring of ape abundance, as well as capturing migratory events and gauging genetic diversity and population viability over time. We recommend genetic sampling, combined with camera trapping, for use in future Environmental and Social Impact Assessments, as these methods can yield robust baselines for implementing the mitigation hierarchy, future biomonitoring and conservation management.

Mass accumulations of pelagic sargassum (Sargassum natans and S. fluitans) in the Tropical Atlantic, across the Caribbean and off the coast of West Africa, are causing extensive ecological and socioeconomic harm. The extraordinary volumes of sargassum influxes could also provide a business opportunity if innovative ways are developed to utilise the raw material. In-water harvesting provides the best opportunity to collect substantial amounts of ‘fresh’ sargassum that can be used in a variety of applications. However, sargassum rafts are living and diverse ecosystems with a range of associated fauna including fish that are targeted by fishers. The consequences of in-water harvesting of sargassum on the biodiversity, including associated fishes, remain poorly understood. Characterisation of this biodiversity within nearshore and offshore environments is needed to help guide best harvest practices and assess possible impacts on fishing opportunities. We assessed the free-swimming fauna associated with sargassum rafts at various distances from shore with the use of underwater video recordings. Over a three-month period, a total of 35 underwater surveys were conducted off the eastern and southern coastline of Barbados. Thirteen species (12 fishes and one comb jelly) from 8 families were identified, with the family Carangidae representing the greatest number of species (n=6). Application of the MaxN metric (maximum number of individuals of a species seen during deployment) revealed significant correlations with raft characteristics notably raft volume, raft distance from shore and water depth. The three environmental variables accounted for 9% of the variation (adjusted R2) in the free-swimming community composition with raft volume being the major driver of species richness. This aligns with ecological theory and supports our hypothesis that larger rafts would host greater species richness. The results demonstrate a strong affiliation between pelagic sargassum rafts and species biodiversity and abundance that will need to be considered by managers when seeking a best compromise between protecting beaches from inundation by sargassum and protecting biodiversity and fishing opportunities.

Objectives: The COVID-19 pandemic accelerated the replacement of many face-to-face healthcare consultations with telephone consultations. Little is known about the extent to which empathy can be expressed in telephone consultations. Our objective is to review evidence related to empathy in telephone consultations including clinical outcomes, and patient/practitioner experiences. Methods: Searches of Medline/Ovid and PsycINFO/Ovid were undertaken. Titles and abstract screening, data extraction, and risk of bias were undertaken by two reviewers. Discrepancies were resolved in discussion with additional reviewers. Included studies were specific to tele-communications with empirical data on empathy related to patient outcomes/views, published (in English), 2010–2021. Studies that did not mention empathy explicitly were excluded. Results: Our search yielded 740 individual records and 8 studies (527 patients, 20 practitioners) met inclusion criteria: Some barriers to expression of empathy were noted, but no major obstacles were reported. However, data was sparse and most studies had a high risk of bias. Conclusion: Empathy in telephone consultations is possible, (though the loss of non-verbal cues and touch can present barriers) however the research does not yet identify how. Innovation: It is possible to establish and display empathy in telephone consultations, but future research needs to identify how this can be optimized. Funding: This work was supported by a National Institute for Health Research (NIHR) School for Primary Care Research grant (project number 389). The University of Southampton's Primary Care Department is a member of the NIHR School for Primary Care Research and supported by NIHR Research funds. The views expressed are those of the authors and not necessarily those of the NIHR or the Department of Health and Social Care.Protocol registration.PROSPERO (CRD42021238087).

We investigate the contrasting realities of the pandemic on psychosocial experiences and ways of coping among American Voices Project respondent surveys (N = 720) and interviews (N = 172). Despite similar levels of distress early in the pandemic, by late 2020 clear differences across education, race and ethnicity, and gender emerged, both quantitatively and qualitatively. Those with structural advantages reported greater gains from the pandemic, including self-improvement opportunities like therapy and time outdoors. In contrast, respondents without college degrees, Black and Hispanic individuals, and women reported experiencing greater psychosocial shocks into the later months of 2020 and feeling disproportionately undervalued, socially disconnected, and stressed, respectively. The former two groups also systematically differed in their coping strategies, which included hard work, emotion suppression, and faith.

The United States is experiencing a teacher shortage crisis that is even more pronounced in rural communities. Teachers may be driven away from the profession if they feel inadequately trained or under-supported to address students' mental health needs. As such, an important teacher retention strategy is to ensure schools have enough mental health professionals. The goal of this study was to explore three different yet complementary strategies to recruit and retain a robust rural school mental health workforce: a rural immersion program for graduate students enrolled in counseling and school psychology programs, a virtual professional development series for existing rural school mental health professionals, and a workforce hiring strategy. Each strategy showed promise: six out of seven students stated they were more inclined to work in a rural setting as a result of the immersion, self-efficacy and job satisfaction significantly increased for rural school mental health professionals participating in the virtual professional development, and important recruitment strategies were identified by rural school leaders. While there is reason for optimism when it comes to creating a robust rural school mental health workforce, funds are urgently needed to make these strategies available to rural communities across the country.

Background: Practitioner expressions of optimism and empathy may improve treatment engagement, adherence, and patient satisfaction but are not delivered consistently amid the challenges of everyday clinical practice. Aim: To explore primary care practitioner (PCP) views about optimistic and empathic communication in consultations; and to identify behavioural, attitudinal, and/or contextual issues likely to encourage or deter PCPs from practising such communication. Design & setting: Qualitative interview study with 20 PCPs (GPs, practice nurses, and primary care physiotherapists). Method: Semi-structured telephone interviews with 20 PCPs. Data were analysed thematically. Results: A conceptual mismatch between optimism and patient expectations became apparent; when asked how PCPs communicate about the likely effects of a treatment, answers were focussed around managing patient expectations. When prompted, it became clear PCPs were open to communicating optimistically with patients, but emphasised the need for realism. Concerns arose that patients may not be receptive to optimistic messages, especially when holding negative expectations. PCPs felt that expressing empathy is fundamental to all clinical consultations, noting that it can be challenging. Some PCPs worried that increasing expressions of empathy might increase their risk of clinician burnout and felt guilty about (appropriately) communicating empathy while maintaining some emotional distance. Conclusion: PCPs agreed expressing realistic optimism during consultations could aid communication and would constitute a novel change to practice. PCPs strive for clinical empathy but can struggle to manage emotional self-protection. Specific training to help PCPs express realistic optimism and empathy, and better utilise efficient non-verbal skills could help these issues.

Moral injury has emerged as a topic of significant research and clinical interest over the last decade. However, much work remains to be done to comprehensively define the moral injury construct, with implications for understanding the etiology and maintenance of moral injury, its symptoms, associations with and distinctions from traumatic illness, and treatment approaches. We provide a brief overview of the existing moral injury literature and introduce a novel dual process model (DPM) of moral injury and traumatic illness. The DPM posits an event exposure which may satisfy DSM-5 posttraumatic stress disorder (PTSD) criterion A, potential morally injurious event (PMIE) criteria, or both, followed by individual role appraisal as a perpetrator through action or inaction, a witness, a victim, or a combination of the these. Role appraisal influences symptoms and processes across biological, psychological, behavioral, social, spiritual/religious, as well as values, character, and identity domains to support a label of traumatic illness, moral injury, or both. The DPM provides a flexible analytical framework for evaluating symptoms associated with moral injury and traumatic stress and has important implications for treatment. The most thoroughly reviewed evidence-based interventions for traumatic stress hinge on exposure and habituation mechanisms to manage dysregulation of fear and memory systems, but these mechanisms often do not address core domains of moral injury identified in the DPM, including spiritual, religious, values, character, and identity domains as these exist largely outside of the putative fear network. We provide brief vignettes to illustrate the practical application of the DPM and argue that adjunct and stand-alone approaches which address values and character domains, leveraging principles of Stoicism, non-judgment of experience, acceptance, and values-oriented action, are more likely than traditional trauma treatment approaches to positively affect moral injury symptoms.

Proliferation of sargassum across the tropical Atlantic since 2011 has motivated a range of forecasting methods. Statistical methods based on basin-scale satellite data are used to address seasonal timescales. Other methods involve explicit Lagrangian calculations of trajectories for particles that are representative of drifting sargassum over days-months. This computed sargassum drift is attributed to the combined action of surface currents, winds and waves, individually or in various combinations. Such calculations are undertaken with both observed surface drift and simulated currents, each involving strengths and weaknesses. Observed drift implicitly includes the action on sargassum of winds and waves, assumed equivalent between drifters and sargassum mats. Simulated currents provide large gridded datasets that facilitate computation of ensembles, enabling some quantification of the uncertainty inherent in an eddy-rich ocean, further subject to interannual variability. A more limited number of forecasts account for in situ growth or loss of sargassum biomass, subject to considerable uncertainty. Forecasts provide either non-dimensional indices or quantities of sargassum, accumulated in specified areas or counted across specified transects over a given time interval. Proliferation of different forecast methodologies may reduce uncertainty, if predictions for given seasons are consistent in broad terms, but there is scope to coordinate different approaches with common geographical foci and predicted variables, to facilitate direct inter-comparisons. In an example of forecasting westward sargassum flux into the Caribbean during the first half of 2022, challenges and opportunities are highlighted. In conclusion, prospects for closer alignment of complementary forecasting methods, and implications for sargassum management, are identified.

Abstract Objectives To characterize the bacterial community of Wind Cave’s Madison aquifer through whole-genome sequencing, and to better understand the bacterial ecology by identifying genes involved in acyl-homoserine lactone (AHL) based quorum-sensing (QS) systems. Results Genome-based taxonomic classification revealed the microbial richness present in the pristine Madison aquifer. The strains were found to span eleven genera and fourteen species, of which eight had uncertain taxonomic classifications. The genomes of strains SD129 and SD340 were found to contain the archetypical AHL QS system composed of two genes, luxI and luxR. Surprisingly, the genomes of strains SD115, SD129, SD274 and SD316 were found to contain one to three luxR orphans (solos). Strain SD129, besides possessing an archetypical AHL QS luxI-luxR pair, also contained two luxR solos, while strain SD316 contained three LuxR solos and no luxI-luxR pairs. The ligand-binding domain of two LuxR solos, one each from strains SD129 and SD316, were found to contain novel substitutions not previously reported, thus may represent two LuxR orphans that detection and response to unknown self-produced signal(s), or to signal(s) produced by other organisms.

CD46, or membrane cofactor protein, is a type-one transmembrane protein from the complement regulatory protein family. Alongside its role in complement activation, CD46 is involved in many other processes, from T-cell activation to reproduction. It is also referred to as a pathogen magnet, because it is used as a receptor by multiple bacteria and viruses. Bovine CD46 (bovCD46) in particular is involved in bovine viral diarrhoea virus entry, an economically important disease in cattle industries. This study presents the X-ray crystallographic structure of the extracellular region of bovCD46, revealing a four-short-consensus-repeat (SCR) structure similar to that in human CD46. SCR1-3 are arranged linearly, while SCR 4 has a reduced interface angle, resulting in a hockey stick-like appearance. The structure also reveals the bovine viral diarrhoea virus interaction site in SCR1, which is likely to confer pestivirus specificity for their target host, CD46. Insights gained from the structural information on pestivirus receptors, such as CD46, could offer valuable guidance for future control strategies.