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Background Around one in three pregnant women undergoes induction of labour in the United Kingdom, usually preceded by in-hospital cervical ripening to soften and open the cervix. Objectives This study set out to determine whether cervical ripening at home is within an acceptable safety margin of cervical ripening in hospital, is effective, acceptable and cost-effective from both National Health Service and service user perspectives. Design The CHOICE study comprised a prospective multicentre observational cohort study using routinely collected data (CHOICE cohort), a process evaluation comprising a survey and nested case studies (qCHOICE) and a cost-effectiveness analysis. The CHOICE cohort set out to compare outcomes of cervical ripening using dinoprostone (a prostaglandin) at home with in-hospital cervical ripening from 39 weeks of gestation. Electronic maternity record data were collected from 26 maternity units. Following pilot analysis, the primary comparison was changed to ensure feasibility and to reflect current practice, comparing home cervical ripening using a balloon catheter with in-hospital cervical ripening using any prostaglandin from 37 weeks of gestation. Analysis involved multiple logistic regression for the primary outcome and descriptive statistics for all other outcomes. The qCHOICE study reported descriptive statistics of quantitative survey data and thematic analysis of focus group and interview data. The economic analysis involved a decision-analytic model from a National Health Service and Personal Social Services perspective, populated with CHOICE cohort and published data. Secondary analysis explored the patient perspective utilising cost estimates from qCHOICE data. Setting Twenty-six United Kingdom maternity units. Participants Women with singleton pregnancies at or beyond 37 weeks of gestation having induction with details of cervical ripening method and location recorded. Main outcome measures CHOICE cohort Neonatal unit admission within 48 hours of birth for 48 hours or more. qCHOICE Maternal and staff experience of cervical ripening. Economic analysis Incremental cost per neonatal unit admission within 48 hours of birth avoided. Data sources Electronic maternity records from 26 maternity units; survey and interviews with service users/maternity staff; focus groups with maternity staff; published literature on economic aspects. Results CHOICE cohort: A total of 515 women underwent balloon cervical ripening at home and 4332 underwent in-hospital cervical ripening using prostaglandin in hospitals that did not offer home cervical ripening. Neonatal unit admission within 48 hours of birth for 48 hours or more following home cervical ripening with balloon was not increased compared with in-hospital cervical ripening with prostaglandin. However, there was substantial uncertainty with the adjusted analysis consistent with a 74% decrease in the risk through to an 81% increase. qCHOICE Important aspects of service users’ experience of home cervical ripening were quality of information provided, support and perception of genuine choice. Economic analysis Home cervical ripening with balloon led to cost savings of £993 (−£1198, −£783) per woman and can be considered the dominant strategy. Limitations Circumstances relating to the COVID-19 pandemic limited the number of participating maternity units and the duration for which units participated. Low numbers of women having at-home cervical ripening limited the power to detect differences in safety, effectiveness, cost and acceptability between study groups. Conclusions Home cervical ripening using balloon catheter may be as safe for babies as using prostaglandins in hospital in low and moderate-risk groups, but there is substantial uncertainty. Home cervical ripening with balloon is likely to be cost saving. Impacts on workload, service user and staff experiences were complex. Future work Future research should focus on optimising experience and logistics of home cervical ripening within busy maternity services. Study registration Current Controlled Trials ISRCTN32652461. Funding This award was funded by the National Institute for Health and Care Research (NIHR) Health Technology Assessment programme (NIHR award ref: NIHR127569) and is published in full in Health Technology Assessment; Vol. 28, No. 81. See the NIHR Funding and Awards website for further award information. Plain language summary Labour is often started artificially. This is called induction of labour. Induction of labour is usually planned when it is safer to end the pregnancy. The first stage of induction of labour – ‘cervical ripening’ – means using medication or a balloon to open the neck of the womb. Years ago, cervical ripening only happened in hospitals, but now many women are offered ‘home cervical ripening’. This means that induction of labour starts in hospital then women go home while the treatment starts working. This could mean that women spend less time in hospital. They may prefer to be at home. However, home cervical ripening may be less safe because problems may not be noticed as quickly. We looked at whether home cervical ripening is safe, acceptable to women and their partners, and good value for money. We used information about women and babies that is usually stored in electronic maternity notes. We studied women who had induction of labour in 26 United Kingdom maternity hospitals. Women were told about the study and could choose not to be included. Our main question was ‘does home cervical ripening increase the chance that a baby needs care in a neonatal unit, compared with cervical ripening in hospital?’ We surveyed women about their experience of induction of labour and any financial costs to them. We interviewed women, partners, doctors and midwives to hear what they thought about home cervical ripening. Fewer women than expected had home cervical ripening. We could not be certain that home cervical ripening with a balloon is as safe for babies as cervical ripening in hospital using medication. Home cervical ripening cost almost £1000 less per woman than in-hospital cervical ripening. Home cervical ripening was acceptable to women when they felt well looked after, when maternity staff communicated well with them, and when they felt they had a choice about going home. Scientific summary Background Around one in three pregnant women in the UK undergo induction of labour (IOL). The first step often involves cervical ripening (opening and shortening the cervix). Cervical ripening may be undertaken using either balloon catheters or administration of prostaglandin. Cervical ripening at home may reduce hospital stay during IOL and may be more acceptable to women than in-hospital cervical ripening. It is unclear whether it may increase risks to the unborn baby due to less monitoring of their well-being during the IOL process and whether it is acceptable to women and partners. It is also unclear whether home cervical ripening is cost-effective. Objective To assess whether it is safe, effective, cost-effective and acceptable to service users and providers to carry out home cervical ripening during IOL, the research questions asked were: Is home cervical ripening within an acceptable margin of in-hospital cervical ripening for safety, cost and acceptability outcomes? Is a strategy of home cervical ripening using a balloon as safe as in-hospital cervical ripening using prostaglandin for the primary outcome of neonatal unit (NINU) admission within 48 hours of birth for 48 hours or more? Is home cervical ripening as acceptable to service-users and health professionals as in-hospital cervical ripening? Are NHS and service user costs of home cervical ripening using a balloon comparable to costs of in-hospital cervical ripening using prostaglandin? Methods This project incorporated a prospective multicentre observational cohort study using real-world data from hospital electronic health records, a survey of service users and nested case studies involving interviews and focus groups, evaluating process and service user and provider experiences, and a health economic analysis. The original design was a comparison of home versus in-hospital cervical ripening using a non-inferiority design to determine whether home cervical ripening is within an acceptable margin (+ 4%) of in-hospital cervical ripening for the safety outcome of NNU admission, whether it is more acceptable to women and whether it is cost-effective. As insufficient home cervical ripening cases were identified at the pilot analysis stage, the statistical analysis was modified to a simple logistic regression on the primary outcome (NNU admission within 48 hours for 48 hours or more), unadjusted and adjusted by potential confounders. This was done because the limited sample size of the primary exposure variable (home vs. hospital) did not have enough power to answer the non-inferiority question as proposed. This had a knock-on effect on the other aspects of the project as well. Observational cohort A total of 26 maternity units in the UK contributed data to the observational cohort study, of whom 8 offered balloon home cervical ripening and 18 offered only in-hospital cervical ripening using prostaglandin. The sample included geographically and socially diverse populations. All units used the BadgerNet Maternity Notes (System C, Stratford-upon-Avon, UK) information system to record routine maternity care information. Deidentified data on all eligible women having IOL was extracted from the BadgerNet system using existing data fields. Data were securely transferred to the University of Edinburgh. Data were analysed using SAS software version 9.4 (SAS Institute Inc., Cary, NC, USA). We used mixed-effects logistic regression for the comparison of NNU admission within 48 hours to control for treatment indication bias, with hospital/trust as a random effect. Further outcomes were reported descriptively as medians and interquartile ranges, proportions and percentages. Process evaluation A process evaluation was undertaken to identify contextual influences on implementation of cervical ripening protocols and outcomes and assess the acceptability of home cervical ripening and the experiences of women and their birth partners, professionals and other key stakeholders. The process evaluation comprised an online postnatal survey, five case study sites and qualitative interviews and focus groups with service users and staff. Overall, 309 women returned completed surveys. In the case study sites, interviews were undertaken with women (n = 43), partners (n = 17) and health professionals (n = 48) and four focus groups were conducted with health professionals (n = 28). Because the COVID-19 pandemic occurred during the study period, which had wide-reaching effects on maternity care, an additional survey of healthcare professionals at all UK NHS trusts and boards was conducted to determine whether aspects of practice and policy around IOL had altered in response to the pandemic. In total, surveys were returned from 92 of the UK NHS trusts and boards offering maternity services across the UK. Survey data were reported using descriptive statistics and qualitative data were analysed using a thematic framework. The original design involved audio recording of a sample of consultations where IOL is discussed to assess women’s involvement in the decision-making processes (analysed using the OPTION scale); however, COVID-19-related restrictions precluded this element. Health economic analysis An economic analysis was undertaken from the perspective of the NHS and Personal Social Services using a decision tree model, populated with data from the CHOICE study. Resource use data were combined with unit costs to calculate the within study cost for each strategy and outcomes were reported in terms of incremental cost per NNU admission avoided. A secondary analysis considered the patient perspective, including costs incurred by women and their families relating to IOL, gathered from the qCHOICE survey responses. Data sources Electronic patient records from 26 study sites (extracted via the BadgerNet maternity records data system): observational cohort study; economic analysis. Qualitative interviews and focus groups: process evaluation. Postnatal survey: process evaluation; economic analysis. Published literature: economic analysis. Results Observational cohort study The unanticipated context of the CHOICE study was an NHS under pressure to manage high IOL rates (range 31–49%) and long delays throughout the IOL process during the COVID-19 pandemic. Home cervical ripening using balloon was performed in women for a wide array of indications (low to moderate risk groups) and from 37 weeks of gestation. The main analysis population consisted of 17,350 women with singleton pregnancies having IOL at 37 weeks or later, of whom 515 underwent home cervical ripening using balloon, 4332 underwent in-hospital cervical ripening with prostaglandin in hospitals that only offered in-hospital cervical ripening, and 7397 women underwent in-hospital cervical ripening with prostaglandin in a hospital that also offered home cervical ripening. Compared with in-hospital cervical ripening with prostaglandin, the rate of NNU admission within 48 hours of birth for 48 hours or more following home cervical ripening with balloon was not increased. The event rate for this primary outcome was expected to be 6% for the in-hospital group. The rate was much lower than expected in both arms (3.1% after home cervical ripening vs. 4.8% after in-hospital cervical ripening) and there was no statistically significant difference between groups before or after adjusting for potential confounding variables. However, the odds ratio of 0.75 has a wide 95% confidence interval (CI) of 0.35 to 1.64 (0.81; 95% CI 0.36 to 1.81 in the adjusted analysis) signalling substantial uncertainty in this finding. Process evaluation Eligibility criteria for those offered the option of home cervical ripening varied between sites. Care was often planned around capacity rather than in line with guidance/policy. Of 230 survey respondents who underwent to in-hospital cervical ripening, the mean stay prior to transfer to labour ward was 31.5 hours (range 0–260 hours). Women reported physically and emotionally unsafe situations caused by these delays. Impact of COVID-19 Of responding sites, 23% reported a change in the method used for cervical ripening and 28% reported a change in criteria for offering home cervical ripening. Only 7% and 6%, respectively, reported changes in the professionals undertaking cervical ripening or the approach for post-dates IOL. The majority of respondents stated that there was no change (61%) or that more women (28%) were discharged home after cervical ripening. There was little consistency in policy changes during the pandemic – one study site expanded home cervical ripening eligibility while another completely suspended it. Acceptability to service users While attitudes towards home cervical ripening were positive, the experiences of those who actually went home were mixed. The positive experiences were most often associated with being in the comfort of one’s own environment. Safety appeared to be the biggest concern for those who said they would not want to return home for cervical ripening. Crucially, women and birth partners wanted the choice to go home or stay in hospital and lack of choice was evident both in survey responses and in case study site interviews. Women who had home cervical ripening were more likely to choose that option again (64%) and recommend it to others (61%) than those who stayed in hospital (55%, 54%). Women who had a balloon catheter inserted reported more discomfort than those who had a prostaglandin pessary or osmotic dilator, although ability to cope with discomfort was similar across all cervical ripening methods. Attentive care and access to pain relief were important to women and birth partners. Acceptability to clinicians and health professionals Attitudes were generally positive, and many healthcare professionals perceived mechanical methods to be the safest for home cervical ripening. Home cervical ripening was often seen as a potential solution to workload and capacity issues, but several professionals highlighted that it was not necessarily straightforward and that there could be unintended consequences for workload, including the management of re-admissions. Information Half of survey respondents did not feel they had enough information about what to expect during IOL, and over half (57%) felt that they had either had no choice or no alternative when deciding to have IOL. Psychological correlates Forty-one survey respondents described their experience of IOL as difficult or traumatic. Some maternity professionals also reported moral distress in relation to the process. Factors mediating experience The principal factors mediating experience of IOL were support from healthcare professionals, the presence of birth partners, information provision and having choice, privacy and having their own space, and delays. In the survey, the most important factor in a positive experience was support from kind, caring staff and feeling safe. Barriers and enablers of adoption Staff shortages was one of the key barriers to adoption of home cervical ripening. Delays during IOL were linked to unit capacity, staffing and workload. Enablers included cross-boundary collaboration, cross-trust/board knowledge sharing, consistent training and professional confidence. Health economic analysis The economic model found that home cervical ripening with balloon led to cost savings of £993 (−£1198, −£783) per woman, with no difference in NNU admissions avoided (mean 0.005; 95% CI −0.05 to 0.013). At willingness-to-pay thresholds above £3000, there is an 82% probability that home cervical ripening with balloon is the optimal option and in economic terms would be considered the dominant strategy compared with in-hospital cervical ripening with prostaglandin. Probabilistic sensitivity analysis indicates little uncertainty regarding the cost savings, however there was uncertainty regarding the impact on NNU admission. Any potential increase in NNU admissions between arms would be negligible. The cost savings in the home cervical ripening group are driven primarily by reduced time in an antenatal ward for the home cervical ripening group, with an average of 476 minutes (7.9 hours) compared with 2243 minutes (37.4 hours) in the in-hospital group. The resource use and cost data also indicate some of the ‘hidden’ or displaced costs of the home cervical ripening option, with an increased number and duration of phone calls from women and their partners to the hospital compared with those in the in-hospital group. Economic analysis of ‘spill over’ costs found that the average transport cost was higher among the mothers who had hospital cervical ripening (£23.10) than mothers who had home cervical ripening (£18.74). The total patient perspective cost was higher in the hospital arm (£954) compared with the home arm (£665), which was predominantly driven by the opportunity cost of partners’/other caregivers’ time supporting the mother either at home or in hospital ‘away from other activities’. Conclusions The CHOICE study provided multiple perspectives on the difference between home cervical ripening with balloon and in-hospital cervical ripening with prostaglandin during IOL, within a context of high IOL rates and multiple delays in the process. Home cervical ripening with balloon appears both safe and cost-effective when compared with in-hospital cervical ripening with prostaglandin for a range of indications, although safety conclusions are uncertain. Acceptance of home cervical ripening depends upon high-quality informed decision-making and consistent support for women throughout the IOL process, a reality that was often lacking in the study participants’ experience. Future research should focus on: Further exploration and implementation of system features that lead to positive experiences of home cervical ripening. Measuring rare but important safety outcomes of home cervical ripening. Practice implications of the CHOICE findings are that units should consider the practicalities of offering genuine choice around setting for IOL and ensure adequate staffing and support for women throughout their IOL experience regardless of setting for cervical ripening. Unless women feel supported to choose between home and in-hospital settings, and they have sufficient information to allow realistic expectations of the IOL process, women will not have positive birth experiences. Study registration Current Controlled Trials ISRCTN32652461. Funding This award was funded by the National Institute for Health and Care Research (NIHR) Health Technology Assessment programme (NIHR award ref: NIHR127569) and is published in full in Health Technology Assessment; Vol. 28, No. 81. See the NIHR Funding and Awards website for further award information.

Abstract Introduction This article provides an overview of presentations and discussions from the inaugural Healthcare Delivery Science: Innovation and Partnerships for Health Equity Research (DESCIPHER) Symposium. Methods The symposium brought together esteemed experts from various disciplines to explore models for translating evidence‐based interventions into practice. Results The symposium highlighted the importance of disruptive innovation in healthcare, the need for multi‐stakeholder engagement, and the significance of family and community involvement in healthcare interventions. Conclusions The article concluded with a call to action for advancing healthcare delivery science to achieve health equity.

Abstract Background Endometriosis affects 190 million women and those assigned female at birth worldwide. For some, it is associated with debilitating chronic pelvic pain. Diagnosis of endometriosis is often achieved through diagnostic laparoscopy. However, when isolated superficial peritoneal endometriosis (SPE), the most common endometriosis subtype, is identified during laparoscopy, limited evidence exists to support the common decision to surgically remove it via excision or ablation. Improved understanding of the impact of surgical removal of isolated SPE for the management of chronic pelvic pain in women is required. Here, we describe our protocol for a multi-centre trial to determine the effectiveness of surgical removal of isolated SPE for the management of endometriosis-associated pain. Methods We plan to undertake a multi-centre participant-blind parallel-group randomised controlled clinical and cost-effectiveness trial with internal pilot. We plan to randomise 400 participants from up to 70 National Health Service Hospitals in the UK. Participants with chronic pelvic pain awaiting diagnostic laparoscopy for suspected endometriosis will be consented by the clinical research team. If isolated SPE is identified at laparoscopy, and deep or ovarian endometriosis is not seen, participants will be randomised intraoperatively (1:1) to surgical removal (by excision or ablation or both, according to surgeons’ preference) versus diagnostic laparoscopy alone. Randomisation with block-stratification will be used. Participants will be given a diagnosis but will not be informed of the procedure they received until 12 months post-randomisation, unless required. Post-operative medical treatment will be according to participants’ preference. Participants will be asked to complete validated pain and quality of life questionnaires at 3, 6 and 12 months after randomisation. Our primary outcome is the pain domain of the Endometriosis Health Profile-30 (EHP-30), via a between randomised group comparison of adjusted means at 12 months. Assuming a standard deviation of 22 points around the pain score, 90% power, 5% significance and 20% missing data, 400 participants are required to be randomised to detect an 8-point pain score difference. Discussion This trial aims to provide high quality evidence of the clinical and cost-effectiveness of surgical removal of isolated SPE. Trial registration ISRCTN registry ISRCTN27244948. Registered 6 April 2021.

Introduction People living with and dying from multimorbidity are increasing in number, and ensuring quality care for this population is one of the major challenges facing healthcare providers. People with multimorbidity often have a high burden of palliative and end-of-life care needs, though they do not always access specialist palliative care services. A key reason for this is that they are often not identified as being in the last stages of their life by current healthcare providers and systems.This scoping review aims to identify and present the available evidence on how people with multimorbidity are currently included in research, policy and clinical practice.Methods and analysis Scoping review methodology, based on Arksey and O’Malley’s framework, will be undertaken and presented using the Preferred Reporting Items for Systematic Review and Meta-Analyses extension for Scoping Reviews. Search terms have been generated using the key themes of ‘multimorbidity’, ‘end of life’ and ‘palliative care’. Peer-reviewed research will be obtained through systematic searching of Medline, EMBASE, CINAHL, Scopus and PsycINFO. Grey literature will be searched in a systematic manner. Literature containing a definition for adults with multimorbidity in a terminal phase of their illness experience will be included. After screening studies for eligibility, included studies will be described in terms of setting and characteristics as well as using inductive content analysis to highlight the commonalities in definitions.Ethics and dissemination Ethical approval is not required for this scoping review. The findings of the scoping review will be used internally as part of SPB’s PhD thesis at the University of St Andrews through the Multimorbidity Doctoral Training Programme for Health Professionals, which is supported by the Wellcome Trust (223499/Z/21/Z) and published in an open access, peer-reviewed journal for wider dissemination.

The production of eco-friendly hybrid sol–gel coatings for long term protection of metallic substrates from aggressive environments was one of the emerging areas, competing with conventional chromate and phosphate coatings. Herein, a nanocomposite has been synthesized from TiO2 and PVA through a novel sol-gel route and the structure and morphology of the same was characterized using X-ray diffraction, FTIR, UV–Vis spectroscopy, FESEM with EDAX, and AFM studies. The flower-like structured composite offers excellent corrosion protection properties in NaCl solution of sea water salinity. Impedance and polarization studies were carried out to monitor the anticorrosion performance of the materials coating. This coating on mild steel offers 98% inhibition efficiency in NaCl. The influence of loading PVA on TiO2 and its effect on corrosion efficiency have also been investigated. It is found that an optimum weight of 20 wt% PVA is required in the composite for beneficial corrosion resistance. 92% inhibition efficiency is registered by the coated MS in NaCl solution after 40 days of exposure and is quite encouraging compared to many of the recent reports. The Ti–O–Ti, and Fe-Ti-O linkage along with compactness and adherence of the material together contribute to better blocking of steel corrosion.

Abstract Introduction Learning health systems (LHSs) are usually created and maintained by single institutions or healthcare systems. The Indiana Learning Health System Initiative (ILHSI) is a new multi‐institutional, collaborative regional LHS initiative led by the Regenstrief Institute (RI) and developed in partnership with five additional organizations: two Indiana‐based health systems, two schools at Indiana University, and our state‐wide health information exchange. We report our experiences and lessons learned during the initial 2‐year phase of developing and implementing the ILHSI. Methods The initial goals of the ILHSI were to instantiate the concept, establish partnerships, and perform LHS pilot projects to inform expansion. We established shared governance and technical capabilities, conducted a literature review‐based and regional environmental scan, and convened key stakeholders to iteratively identify focus areas, and select and implement six initial joint projects. Results The ILHSI successfully collaborated with its partner organizations to establish a foundational governance structure, set goals and strategies, and prioritize projects and training activities. We developed and deployed strategies to effectively use health system and regional HIE infrastructure and minimize information silos, a frequent challenge for multi‐organizational LHSs. Successful projects were diverse and included deploying a Fast Healthcare Interoperability Standards (FHIR)‐based tool across emergency departments state‐wide, analyzing free‐text elements of cross‐hospital surveys, and developing models to provide clinical decision support based on clinical and social determinants of health. We also experienced organizational challenges, including changes in key leadership personnel and varying levels of engagement with health system partners, which impacted initial ILHSI efforts and structures. Reflecting on these early experiences, we identified lessons learned and next steps. Conclusions Multi‐organizational LHSs can be challenging to develop but present the opportunity to leverage learning across multiple organizations and systems to benefit the general population. Attention to governance decisions, shared goal setting and monitoring, and careful selection of projects are important for early success.

Objective Cancer screening should be equitably accessed by all populations. Uptake of colorectal cancer screening was examined using the Scottish Health and Ethnicity Linkage Study that links the Scottish Census 2001 to health data by individual-level self-reported ethnicity and religion.Setting Data on 1.7 million individuals in two rounds of the Scottish Bowel Cancer Screening Programme (2007–2013) were linked to the 2001 Census using the Scottish Community Health Index number.Main outcome measure Uptake of colorectal cancer screening, reported as age-adjusted risk ratios (RRs) by ethnic group and religion were calculated for men and women with 95% CI.Results In the first, incidence screening round, compared with white Scottish men, Other White British (RR 109.6, 95% CI 108.8 to 110.3) and Chinese (107.2, 95% CI 102.8 to 111.8) men had higher uptake. In contrast, men of all South Asian groups had lower uptake (Indian RR 80.5, 95% CI 76.1 to 85.1; Pakistani RR 65.9, 95% CI 62.7 to 69.3; Bangladeshi RR 76.6, 95% CI 63.9 to 91.9; Other South Asian RR 88.6, 95% CI 81.8 to 96.1). Comparable patterns were seen among women in all ethnic groups, for example, Pakistani (RR 55.5, 95% CI 52.5 to 58.8). Variation in uptake was also observed by religion, with lower rates among Hindu (RR (95%CI): 78.4 (71.8 to 85.6)), Muslim (69.5 (66.7 to 72.3)) and Sikh (73.4 (67.1 to 80.3)) men compared with the reference population (Church of Scotland), with similar variation among women: lower rates were also seen among those who reported being Jewish, Roman Catholic or with no religion.Conclusions There are important variations in uptake of bowel cancer screening by ethnic group and religion in Scotland, for both sexes, that require further research and targeted interventions.

Abstract Background Endometriosis affects 6–10% of women and is associated with debilitating pelvic pain. It costs the UK > £2.8 billion per year in loss of productivity. Endometriosis can be managed by surgical excision or medically by ovarian suppression. However, ~ 75% symptoms recur after surgery and available medical treatments have undesirable side effects and are contraceptive. Omega-3 purified fatty acids (PUFA) have been shown in animal models to reduce factors that are thought to lead to endometriosis-associated pain, have minimal side effects, and no effects on fertility. This paper presents a protocol for a two-arm, pilot parallel randomised controlled trial (RCT) which aims to inform the planning of a future multicentre trial to evaluate the efficacy of Omega-3 PUFA in the management of endometriosis-associated pain in women. Methods The study will recruit women with endometriosis over a 12-month period in the National Health Service (NHS) Lothian, UK, and randomise them to 8 weeks of treatment with Omega-3 PUFA or comparator (olive oil). The primary objective is to assess recruitment and retention rates. The secondary objectives are to determine the effectiveness/acceptability to participants of the proposed methods of recruitment/randomisation/treatments/questionnaires, to inform the sample size calculation and to refine the research methodology for a future large randomised controlled trial. Response to treatment will be monitored by pain scores and questionnaires assessing physical and emotional function compared at baseline and 8 weeks. Discussion We recognise that there may be potential difficulties in mounting a large randomised controlled trial for endometriosis to assess Omega-3 PUFA because they are a dietary supplement readily available over the counter and already used by women with endometriosis. We have therefore designed this pilot study to assess practical feasibility and following the ‘Initiative on Methods, Measurement, and Pain Assessment in Clinical Trials’ recommendations for the design of chronic pain trials. Trial registration ISRCTN44202346

Summary: Background: Ethnic minorities often experience barriers to health care. We studied six established quality indicators of health-system performance across ethnic groups in Scotland. Methods: In this population-based cohort study, we linked ethnicity from Scotland's Census 2001 (April 29, 2001) to hospital admissions and mortality records, with follow-up until April 30, 2013. Indicators of health-system performance included amenable deaths (ie, deaths avertable by effective treatment), preventable deaths (ie, deaths avertable by public health policy), avoidable deaths (combined amenable and preventable deaths), avoidable hospital admissions, unplanned readmissions, and length of stay. We calculated rate ratios and odds ratios (with 95% CIs) using Poisson and logistic regression, which we multiplied by 100, adjusting first for age-related covariates and then for socioeconomic-related and birthplace-related covariates. The white Scottish population was the reference (rate ratio [RR] 100). Findings: The results are based on 4·61 million people. During the 50·5 million person-years of study, 1·17 million avoidable hospital admissions, 587 740 unplanned readmissions, and 166 245 avoidable deaths occurred. South Asian groups had higher avoidable hospital admissions than the white Scottish group, with the highest reported RRs in Pakistani groups (RR 140·6 [95% CI 131·9–150·0] in men; RR 141·0 [129·0–154·1] in women). There was little variation between ethnic groups in length of stay or unplanned readmission. Preventable and amenable mortality were higher in the white Scottish group than several ethnic minorities including other white British, other white, Indian, and Chinese groups. Such differences were partly diminished by adjustment for socioeconomic status, whereas adjustment for country of birth had little additional effect. Interpretation: These data suggest concerns about the access to and quality of primary care to prevent avoidable hospital admissions, especially for south Asians. Relatively high preventable and amenable deaths in white Scottish people, compared with several ethnic minority populations, were unexpected. Future studies should both corroborate and examine explanations for these patterns. Studies using several indicators simultaneously are also required internationally. Funding: Chief Scientist's Office, Medical Research Council, NHS Research Scotland, Farr Institute.

The linked micromap graphical design uses color to link each geographic units name with its statistical graphic elements and map location across columns in a single row. Perceptual grouping of these rows into smaller chunks of data facilitates local focus and visual queries. Sorting the geographic units (the rows) in different ways can reveal patterns in the statistics, in the maps, and in the association between them. This design supports both exploration and communication in a multivariate geospatial context. This paper describes micromapST, an R package that implements the linked micromap graphical design specifically formatted for US state data, a common geographic unit used to display geographic patterns of health and other factors within the US. This package creates a graphic for the 51 geographic units (50 states plus DC) that fits on a single page, with states comprising the rows and state names, graphs and maps the columns. The graphical element for each state/column combination may represent a single statistical value, e.g., by a dot or horizontal bar, with or without an uncertainty measure. The distribution of values within each state, e.g., for counties, may be displayed by a boxplot. Two values per state may be represented by an arrow indicating the change in values, e.g., between two time points, or a scatter plot of the paired data. Categorical counts may be displayed as horizontal stacked bars, with optional standardization to percents or centering of the bars. Layout options include specification of the sort order for the rows, the graph/map linking colors, a vertical reference line and others. Output may be directed to the screen but is best displayed on a printer (or as a print image saved to any file format supported by R). The availability of a pre-defined linked micromap layout specifically for the 51 US states with graphical displays of single values, data distributions, change between two values, scatter plots of paired values, time series data and categorical data, facilitates quick exploration and communication of US state data for most common data types.

Neste texto, procura-se contar a história da exibição do sexo em filmes majoritariamente produzidos nos Estados Unidos no período de quase um século. Ao se perguntar quando, porque e como os Estados Unidos se transformaram de uma cultura que não exibia o sexo em uma que o exibe, a autora insiste no duplo significado do verbo screen (tanto como uma revelação quanto uma dissimulação). Exibir é revelar em uma tela. Mas um segundo e igualmente importante significado, como diz o dicionário é "proteger ou esconder atrás de uma tela". Os filmes tanto revelam como escondem. O artigo analisa a forma como mudanças sociais ocorridas nos Estados Unidos, como, por exemplo, a Revolução sexual dos anos 60 e novas visões a respeito da sexualidade, possibilitaram novas maneiras de representação do sexo no cinema, reorganizando a relação entre o público e o privado. O artigo se pergunta também sobre como nossos corpos e sentidos reagem ao encontro com o sexo na tela, introduzindo a ideia de "saber carnal" (carnal knowledge).In this paper, we try to tell the history of the exhibition of sex in movies mainly produced in the United States in almost a century. Asking when, why and how the United States became - from a culture that did not exhibit sex - into a culture that exhibits it, the author insists in the double sense of the verb to screen (as both a revelation and a dissimulation). To exhibit is to reveal in a screen. But another, and important, sense, as says the dictionary, is "to protect or hide behind a screen". Movies show as well as they reveal. The paper analyzes the way social change in the United States, for example the sexual revolution of the sixties and new views on sexuality allowed new ways of representing sex in the movies, creating a new relation between public and private. The paper also asks how our bodies and senses react to sex in the screen, introducing the idea of "carnal knowledge".

A growing body of research confirms the financial and academic benefits that accrue to students whose faculty adopt open educational resources, or OER. While there are no content licensing costs associated with using OER, there are several real costs that must be incurred by an institution that chooses to support its faculty in adopting OER. The Z-Degree initiative at Tidewater Community College utilizes only OER for the 21 courses, providing a pathway for students to earn an associate of science degree in business administration without ever buying a textbook. The authors introduce and illustrate the INTRO (INcreased Tuition Revenue through OER) model for sustaining the provision of OER adoption services. The adoption of OER as part of the Z-Degree decreases drop rates among Tidewater students, allowing the institution to retain tuition revenue it would otherwise have refunded. This retained revenue provides a renewable source of funds to sustainably support the adoption of OER.

GDNF signaling through the Ret receptor tyrosine kinase (RTK) is required for ureteric bud (UB) branching morphogenesis during kidney development in mice and humans. Furthermore, many other mutant genes that cause renal agenesis exert their effects via the GDNF/RET pathway. Therefore, RET signaling is believed to play a central role in renal organogenesis. Here, we re-examine the extent to which the functions of Gdnf and Ret are unique, by seeking conditions in which a kidney can develop in their absence. We find that in the absence of the negative regulator Spry1, Gdnf, and Ret are no longer required for extensive kidney development. Gdnf-/-;Spry1-/- or Ret-/-;Spry1-/- double mutants develop large kidneys with normal ureters, highly branched collecting ducts, extensive nephrogenesis, and normal histoarchitecture. However, despite extensive branching, the UB displays alterations in branch spacing, angle, and frequency. UB branching in the absence of Gdnf and Spry1 requires Fgf10 (which normally plays a minor role), as removal of even one copy of Fgf10 in Gdnf-/-;Spry1-/- mutants causes a complete failure of ureter and kidney development. In contrast to Gdnf or Ret mutations, renal agenesis caused by concomitant lack of the transcription factors ETV4 and ETV5 is not rescued by removing Spry1, consistent with their role downstream of both RET and FGFRs. This shows that, for many aspects of renal development, the balance between positive signaling by RTKs and negative regulation of this signaling by SPRY1 is more critical than the specific role of GDNF. Other signals, including FGF10, can perform many of the functions of GDNF, when SPRY1 is absent. But GDNF/RET signaling has an apparently unique function in determining normal branching pattern. In contrast to GDNF or FGF10, Etv4 and Etv5 represent a critical node in the RTK signaling network that cannot by bypassed by reducing the negative regulation of upstream signals.