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Abstract Aim Relatives of patients who have experienced an out of hospital cardiac arrest (OHCA) experience confusion and distress during resuscitation. Clear information from ambulance clinicians and the opportunity to witness the resuscitation helps them navigate the chaotic scene. However, UK-based evidence concerning relatives’ experiences of unsuccessful resuscitation attempts and interactions with ambulance clinicians is lacking. This qualitative study explores those experiences to inform ambulance clinician practice. Methods Two ambulance services in the UK identified OHCA events attended by their clinicians within the previous two weeks. After a minimum of three months relatives of non-survivors of these events were invited to participate in either a remote or face-to-face interview. Interviews focussed on their experiences of the resuscitation attempt and interactions with ambulance clinicians, their feelings at the time, and their reflections on the event afterwards. Data were analysed using reflexive thematic analysis. Results Semi-structured interviews were conducted with 14 relatives of OHCA non-survivors. Thematic analysis identified four themes. Cardiac arrest is a traumatic event for relatives, with chaotic noisy scenes increasing their distress. Many described feelings symptomatic of Post-Traumatic Stress Disorder since the event. During resuscitation, participants needed information from clinicians about what was happening, and provided information about their relatives’ wishes. Participants needed reassurance from clinicians that everything possible was done to save their relative and were reassured when they could witness some of the resuscitation. Participants were surprised how long resuscitation seemed to last; some were distressed that it lasted so long. Conclusion Relatives’ experiences highlight two key challenges for ambulance clinicians: (1) being aware of the tension relatives feel between needing reassurance that the crew is doing everything to save the patient and wanting to avoid prolonged and ultimately futile resuscitation attempts; and (2) having ongoing conversations with those present to inform clinical decision-making whilst managing the resuscitation attempt.

Background Guidelines for sepsis recommend treating those at highest risk within 1 hour. The emergency care system can only achieve this if sepsis is recognised and prioritised. Ambulance services can use prehospital early warning scores alongside paramedic diagnostic impression to prioritise patients for treatment or early assessment in the emergency department. Objectives To determine the accuracy, impact and cost-effectiveness of using early warning scores alongside paramedic diagnostic impression to identify sepsis requiring urgent treatment. Design Retrospective diagnostic cohort study and decision-analytic modelling of operational consequences and cost-effectiveness. Setting Two ambulance services and four acute hospitals in England. Participants Adults transported to hospital by emergency ambulance, excluding episodes with injury, mental health problems, cardiac arrest, direct transfer to specialist services, or no vital signs recorded. Interventions Twenty-one early warning scores used alongside paramedic diagnostic impression, categorised as sepsis, infection, non-specific presentation, or other specific presentation. Main outcome measures Proportion of cases prioritised at the four hospitals; diagnostic accuracy for the sepsis-3 definition of sepsis and receiving urgent treatment (primary reference standard); daily number of cases with and without sepsis prioritised at a large and a small hospital; the minimum treatment effect associated with prioritisation at which each strategy would be cost-effective, compared to no prioritisation, assuming willingness to pay £20,000 per quality-adjusted life-year gained. Results Data from 95,022 episodes involving 71,204 patients across four hospitals showed that most early warning scores operating at their pre-specified thresholds would prioritise more than 10% of cases when applied to non-specific attendances or all attendances. Data from 12,870 episodes at one hospital identified 348 (2.7%) with the primary reference standard. The National Early Warning Score, version 2 (NEWS2), had the highest area under the receiver operating characteristic curve when applied only to patients with a paramedic diagnostic impression of sepsis or infection (0.756, 95% confidence interval 0.729 to 0.783) or sepsis alone (0.655, 95% confidence interval 0.63 to 0.68). None of the strategies provided high sensitivity (> 0.8) with acceptable positive predictive value (> 0.15). NEWS2 provided combinations of sensitivity and specificity that were similar or superior to all other early warning scores. Applying NEWS2 to paramedic diagnostic impression of sepsis or infection with thresholds of > 4, > 6 and > 8 respectively provided sensitivities and positive predictive values (95% confidence interval) of 0.522 (0.469 to 0.574) and 0.216 (0.189 to 0.245), 0.447 (0.395 to 0.499) and 0.274 (0.239 to 0.313), and 0.314 (0.268 to 0.365) and 0.333 (confidence interval 0.284 to 0.386). The mortality relative risk reduction from prioritisation at which each strategy would be cost-effective exceeded 0.975 for all strategies analysed. Limitations We estimated accuracy using a sample of older patients at one hospital. Reliable evidence was not available to estimate the effectiveness of prioritisation in the decision-analytic modelling. Conclusions No strategy is ideal but using NEWS2, in patients with a paramedic diagnostic impression of infection or sepsis could identify one-third to half of sepsis cases without prioritising unmanageable numbers. No other score provided clearly superior accuracy to NEWS2. Research is needed to develop better definition, diagnosis and treatments for sepsis. Study registration This study is registered as Research Registry (reference: researchregistry5268). Funding This award was funded by the National Institute for Health and Care Research (NIHR) Health Technology Assessment programme (NIHR award ref: 17/136/10) and is published in full in Health Technology Assessment; Vol. 28, No. 16. See the NIHR Funding and Awards website for further award information. Plain language summary Sepsis is a life-threatening condition in which an abnormal response to infection causes heart, lung or kidney failure. People with sepsis need urgent treatment. They need to be prioritised at the emergency department rather than waiting in the queue. Paramedics attempt to identify people with possible sepsis using an early warning score (based on simple measurements, such as blood pressure and heart rate) alongside their impression of the patient’s diagnosis. They can then alert the hospital to assess the patient quickly. However, an inaccurate early warning score might miss cases of sepsis or unnecessarily prioritise people without sepsis. We aimed to measure how accurately early warning scores identified people with sepsis when used alongside paramedic diagnostic impression. We collected data from 71,204 people that two ambulance services transported to four different hospitals in 2019. We recorded paramedic diagnostic impressions and calculated early warning scores for each patient. At one hospital, we linked ambulance records to hospital records and identified who had sepsis. We then calculated the accuracy of using the scores alongside diagnostic impression to diagnose sepsis. Finally, we used modelling to predict how many patients (with and without sepsis) paramedics would prioritise using different strategies based on early warning scores and diagnostic impression. We found that none of the currently available early warning scores were ideal. When they were applied to all patients, they prioritised too many people. When they were only applied to patients whom the paramedics thought had infection, they missed many cases of sepsis. The NEWS2, score, which ambulance services already use, was as good as or better than all the other scores we studied. We found that using the NEWS2, score in people with a paramedic impression of infection could achieve a reasonable balance between prioritising too many patients and avoiding missing patients with sepsis. Scientific summary Background Sepsis is a life-threatening reaction to an infection in which the immune system overreacts to infection and causes organ damage. Early recognition and treatment of sepsis has the potential to reduce mortality. Guidelines for sepsis highlight the importance of early recognition and treatment, with treatment recommended within 1 hour of presentation for those at highest risk. The emergency care system can only achieve this if sepsis is recognised and prioritised. Ambulance services can use prehospital early warning scores to identify people with a high risk of sepsis and then pre-alert the emergency department (ED) or provide the patient with prehospital treatment. However, they need to determine which score to use, the threshold of positivity for the score, and whether to apply the early warning score to all medical cases or just those where the paramedic diagnostic impression suggests sepsis, infection or a non-specific presentation. This requires estimates of the diagnostic accuracy of early warning scores and consideration of the balance between sensitivity (avoiding missing sepsis) and specificity (prioritising too many patients who do not have sepsis). Objectives We aimed to determine the accuracy, impact and cost-effectiveness of prehospital early warning scores for adults with suspected sepsis. Our specific objectives were: to estimate the accuracy of prehospital early warning scores for identifying sepsis requiring time-critical treatment in adults with possible sepsis who are attended by emergency ambulance to estimate the impact of using prehospital early warning scores to guide key prehospital decisions, in terms of the operational consequences, and the cost-effectiveness of alternative strategies. Methods We undertook (1) a retrospective cohort study to estimate the accuracy of prehospital early warning scores alongside paramedic diagnostic impression and (2) decision-analytic modelling of the operational consequences and cost-effectiveness of using prioritisation strategies based on early warning score and diagnostic impression. Retrospective cohort study We used a literature review and expert opinion to identify 21 early warning scores for evaluation. We used routine ambulance service data to identify all episodes in 2019 in which two ambulance services (Yorkshire and West Midlands) transported patients with medical presentations to four acute hospitals (Sheffield Northern General Hospital, Doncaster Royal Infirmary, Rotherham General Hospital, University Hospitals Coventry and Warwickshire). We excluded episodes with injury, mental health problems, cardiac arrest or direct transfer to specialist services, and cases with no vital signs recorded. We calculated early warning scores from the first recorded vital signs on the ambulance service electronic patient-report form and categorised the paramedic diagnostic impression as sepsis, infection, non-specific presentation or other specific presentation. We then determined the number of cases that ambulance services would prioritise at each hospital using each early warning score alongside the categorised paramedic diagnostic impression. We planned to use the National Health Service (NHS) Digital Data Access Request Service to link ambulance service to hospital data but NHS Digital were unable to provide this service. We therefore instituted a rescue plan to link ambulance service to hospital data at one participating hospital (Sheffield) to determine whether patients had a reference standard diagnosis of sepsis, adjudicated by two independent clinicians following hospital record review. The primary reference standard consisted of meeting the sepsis-3 definition [evidence of infection with a change of two or more points in the Sequential (sepsis-related) Organ Failure Assessment (SOFA) score] and receiving treatment for sepsis. The secondary reference standard consisted of meeting the sepsis-3 definition alone. We analysed the ambulance service data descriptively to report the mean daily number of cases that the ambulance service would pre-alert to each hospital for each combination of early warning score and diagnostic impression. For the accuracy analysis, we constructed receiver operating characteristic (ROC) curves to evaluate sensitivity and specificity over the range of each score. We calculated the area under the ROC curve, sensitivities, specificities, and positive and negative predictive values at key cut-points, each with a 95% confidence interval (CI). Reporting of the results highlights sensitivity and positive predictive value as these best indicate under-triage (sensitivity, the proportion of sepsis cases prioritised) and overtriage (positive predictive value, the proportion of prioritised cases with sepsis). To select strategies for the decision-analytic modelling, we calculated the proportion of mean daily ambulance arrivals that would be prioritised at each hospital and excluded strategies that would prioritise a potentially unmanageable proportion (> 10%). We then compared the accuracy of strategies and excluded those with sensitivity and specificity both inferior to another strategy. We also excluded strategies that were not clearly superior to a comparable strategy involving the National Early Warning Score, version 2 (NEWS2) on the basis that NEWS2 is already widely used by NHS ambulance services, whereas other strategies would require additional training and support to implement. Decision-analytic modelling We developed a decision-analytic model to evaluate the consequences to healthcare providers and the cost-effectives for the health services of using 23 different strategies to prioritise patients transported to hospital with possible sepsis. Due to the paucity of data associated with the benefit of early treatment for sepsis and conflicting results from studies where data existed, threshold analyses were independently undertaken to estimate the reduction in mortality, the reduction in general ward length of stay (LoS) and the reduction in intensive care unit LoS that would be required by each strategy in order to be cost-effective compared with a strategy of no prioritisation of patients. We additionally present the number of prehospital alerts associated with each strategy, the number of patients with sepsis who have been correctly prioritised and the number of patients with sepsis who are not prioritised. Results Retrospective cohort study We collected data from 95,022 ambulance episodes involving 71,204 patients with median age 66 years, and included 37,588 (53.0%) women, and 40,045 (94.9%) with white ethnicity. The mean (standard deviation) number of daily attendances meeting the study inclusion criteria was 93.5 (14.7) at Sheffield Northern General Hospital, 59.5 (10.8) at Doncaster Royal Infirmary, 51.3 (8.9) at Rotherham General Hospital and 74 (11) at University Hospitals Coventry and Warwickshire. Most early warning scores operating at their pre-specified thresholds would prioritise fewer than 10% of attendances when applied only to those with a diagnostic impression of sepsis or infection, but would prioritise more than 10% when applied to non-specific attendances or all attendances. The exceptions were qSOFA (threshold > 1), the Screening to Enhance PrehoSpital Identification of Sepsis (SEPSIS) score, the Critical Illness Score (CIS; threshold > 4), the Paramedic Initiated Treatment of Sepsis Targeting Out-of-hospital Patients clinical trial rule, the PRESS score and the sepsis alert criteria. Yorkshire Ambulance Service recorded only one diagnostic impression, whereas West Midlands Ambulance Service recorded multiple unranked impressions, so strategies prioritised a greater proportion of patients transported to University Hospitals Coventry and Warwickshire. Consequently, in the West Midlands most strategies prioritised more than 10% of cases when applied to those with a diagnostic impression of infection or sepsis. We linked 12,870 out of 24,955 (51.6%) cases to the Sheffield Northern General Hospital records at Sheffield and identified 348 (2.7%) with the primary reference standard. The sensitivity and positive predictive value of paramedic diagnostic impression were 0.328 (95% CI 0.28 to 0.379) and 0.285 (95% CI 0.243 to 0.331) for sepsis, 0.572 (95% CI 0.519 to 0.623) and 0.156 (95% CI 0.137 to 0.176) for infection or sepsis, and 0.897 (95% CI 0.86 to 0.924) and 0.053 (95% CI 0.048 to 0.059) for non-specific presentation, infection or sepsis. The early warning scores had a greater area under the ROC curve when applied to all cases rather than alongside diagnostic impression, but the low prevalence of the reference standard meant that thresholds with sensitivity above 0.7 generally had positive predictive value below 0.15, which would prioritise an unmanageable number of cases. When higher thresholds were used to provide acceptable positive predictive value and a manageable number of cases, strategies that applied the early warning score only to those with a diagnostic impression of sepsis or infection tended to have better overall accuracy. NEWS2 had the highest area under the ROC curve when applied only to those with a paramedic diagnostic impression of sepsis or infection (0.756, 95% CI 0.729 to 0.783) or sepsis alone (0.655, 95% CI 0.63 to 0.68). Only the SEPSIS score had a higher area under the ROC curve than NEWS2 when applied to non-specific presentation, infection or sepsis (0.862 vs. 0.858) and all cases (0.882 vs. 0.877). None of the strategies provided high sensitivity (e.g. > 0.8) with acceptable positive predictive value (e.g. > 0.15). NEWS2, using varying thresholds and combinations with diagnostic impression, provided combinations of sensitivity and specificity that were similar or superior to all other early warning scores. We identified strategies reflecting published recommendations for prioritisation that could offer options with varying trade-offs between sensitivity and positive predictive value. Applying NEWS2 only to those with a paramedic diagnostic impression of sepsis or infection respectively provided sensitivities and positive predictive values of 0.522 (95% CI 0.469 to 0.574) and 0.216 (95% CI 0.189 to 0.245) with a threshold > 4, 0.447 (95% CI 0.395 to 0.499) and 0.274 (95% CI 0.239 to 0.313) with a threshold > 6, and 0.314 (95% CI 0.268 to 0.365) and 0.333 (95% CI 0.284 to 0.386) with a threshold > 8. Applying qSOFA > 1 only to those with a paramedic diagnostic impression of sepsis or infection provided sensitivity of 0.305 (95% CI 0.259 to 0.355) and positive predictive value of 0.356 (95% CI 0.304 to 0.412). Decision-analytic modelling The modelling provided estimates for a range of strategies with varying sensitivity and specificity of the number of cases (overall and with sepsis) that would be prioritised in a large and a small hospital. At a large hospital receiving 93.5 eligible cases per day, applying NEWS2 > 4 only to those with a diagnostic impression of infection or sepsis would prioritise 6.10 cases per day, including 1.32 with sepsis, while failing to prioritise 1.21 with sepsis. The corresponding numbers using NEWS2 > 6 were 4.11, 1.13 and 1.40, using NEWS2 > 8 were 2.38, 0.79 and 1.73, and using qSOFA > 1 were 2.17, 0.77 and 1.76. At a small hospital receiving 53.1 eligible cases per day, applying NEWS2 > 4 only to those with a diagnostic impression of infection or sepsis would prioritise 3.35 cases per day, including 0.72 with sepsis, while failing to prioritise 0.66 with sepsis. The corresponding numbers using NEWS2 > 6 were 2.26, 0.62 and 0.77, using NEWS2 > 8 were 1.31, 0.44 and 0.95, and using qSOFA > 1 were 1.19, 0.42 and 0.96. The threshold analysis showed that the relative risk of mortality associated with prioritisation at which each strategy would be cost-effective compared to no prioritisation [assuming willingness to pay £20,000 per quality-adjusted life-year (QALY) gained] ranged from 0.977 applying NEWS2 > 0 only to those with a diagnostic impression of infection or sepsis, to 0.996 applying NEWS2 > 11 only to those with a diagnostic impression of sepsis. The comparable ranges for other measures of effectiveness for these two strategies were: increase in QALYs 0.00056–0.00002; reduction in length of ward stay 3.8–0.7 days; reduction in intensive care LoS 1.2–0.2 days. Conclusions We were unable to identify a strategy that would prioritise a substantial majority of patients with sepsis without prioritising a potentially unmanageable number of patients for the ED. Most early warning scores, used at a recommended threshold, are likely to prioritise an unmanageable number of cases unless they are only used to prioritise cases with a paramedic diagnostic impression of infection or sepsis. However, paramedic diagnostic impression of infection or sepsis only identified 57% of cases with a reference standard diagnosis of sepsis requiring urgent treatment. The NEWS2 provides sensitivity and specificity for identifying sepsis that is generally similar or superior to other scores operating at a comparable threshold. We therefore found no evidence to justify the support and training required to implement an alternative strategy to NEWS2, which is already widely used in NHS ambulance services. National Early Warning Score, version 2, could be used at thresholds of > 4 or > 6 in presentations with a diagnostic impression of infection or sepsis, reflecting the Academy of Medical Royal Colleges clinical decision support framework, or > 8 to provide similar sensitivity and specificity to the use of qSOFA > 1 recommended in the sepsis-3 guidelines. These strategies provide a range of options that ambulance services and hospitals could use, depending upon capacity to manage prioritised cases and what prioritisation involves. Health economic modelling suggests that sensitive strategies for identifying patients with possible sepsis for prioritisation could be cost-effective, if we are convinced that reducing treatment delay reduces mortality and the emergency care system has the capacity to deliver meaningful prioritisation to substantial numbers of cases. Limitations Inability of NHS Digital to link ambulance service to hospital data meant that we were only able to estimate the accuracy of early warning scores at one hospital using data from 51.6% of the eligible population for whom the ambulance service had NHS numbers. The included patients were markedly older than the excluded patients. We were unable to identify reliable evidence to estimate the effectiveness of early treatment for sepsis, so were unable to identify the most cost-effective strategy. Future research Research into prehospital early warning scores for sepsis is limited by our current inability to clinically measure the dysregulated host response that characterises sepsis and uncertain estimates of the benefits of early treatment. We therefore need to prioritise research to develop better ways of defining and diagnosing sepsis, and to develop and evaluate effective early treatment for sepsis. Future research involving routine ambulance service and hospital data requires a system for NHS data management that supports health data science. Study registration This study is registered as Research Registry (reference: researchregistry5268). Funding This award was funded by the National Institute for Health and Care Research (NIHR) Health Technology Assessment programme (NIHR award ref: 17/136/10) and is published in full in Health Technology Assessment; Vol. 28, No. 16. See the NIHR Funding and Awards website for further award information.

Abstract Background The ‘Prehospital Assessment of the Role of Adrenaline: Measuring the Effectiveness of Drug Administration In Cardiac Arrest’ (PARAMEDIC2) trial showed that adrenaline improves overall survival, but not neurological outcomes. We sought to determine the within-trial and lifetime health and social care costs and benefits associated with adrenaline, including secondary benefits from organ donation. Methods We estimated the costs, benefits (quality-adjusted life years (QALYs)) and incremental cost-effectiveness ratios (ICERs) associated with adrenaline during the 6-month trial follow-up. Model-based analyses explored how results altered when the time horizon was extended beyond 6 months and the scope extended to include recipients of donated organs. Results The within-trial (6 months) and lifetime horizon economic evaluations focussed on the trial population produced ICERs of £1,693,003 (€1,946,953) and £81,070 (€93,231) per QALY gained in 2017 prices, respectively, reflecting significantly higher mean costs and only marginally higher mean QALYs in the adrenaline group. The probability that adrenaline is cost-effective was less than 1% across a range of cost-effectiveness thresholds. Combined direct economic effects over the lifetimes of survivors and indirect economic effects in organ recipients produced an ICER of £16,086 (€18,499) per QALY gained for adrenaline with the probability that adrenaline is cost-effective increasing to 90% at a £30,000 (€34,500) per QALY cost-effectiveness threshold. Conclusions Adrenaline was not cost-effective when only directly related costs and consequences are considered. However, incorporating the indirect economic effects associated with transplanted organs substantially alters cost-effectiveness, suggesting decision-makers should consider the complexity of direct and indirect economic impacts of adrenaline. Trial registration ISRCTN73485024 . Registered on 13 March 2014.

Abstract Background X-linked hypophosphataemia (XLH) is a rare, hereditary, progressive and lifelong phosphate wasting disorder characterised by pathological elevations in fibroblast growth factor (FGF) 23 concentration and activity; XLH has an incidence of approximately 1 in 20–25,000 individuals. Excess FGF23 activity leads to increased phosphate excretion in the kidneys – mediated by downregulation of renal tubular phosphate transporters – and reduced phosphate absorption in the intestines – due to impaired vitamin D activation. This results in impaired bone growth and mineralisation, short and disproportionate stature, leg bowing, musculoskeletal pain, spontaneous dental abscesses, rickets, and osteomalacia. The spectrum of manifestations differs between paediatric and adult patients. Those involved in the treatment of this condition face many challenges, including a lack of robust natural history and demographic data. This multicentre, international, rare-disease patient registry (XLH Registry) was established to address the paucity of data in XLH and to help inform future clinical practice. Results The XLH Registry collects standard diagnostic and monitoring practice data, including (where applicable) diagnosis and disease progression history, treatment regimens and family history; the protocol does not mandate any interventions or clinical assessments. The XLH Registry aims to recruit 1200 paediatric and adult patients with XLH over 10 years, and several data analyses and peer-reviewed publications are expected to be generated throughout this period. A post-authorisation safety study for Bburosumab, for which the registry Sponsor is the marketing authorisation holder, will be nested as a sub-study within the XLH Registry via a subsequent protocol amendment. Conclusion The data collected within this rare-disease patient registry will be utilised to synthesise real-world evidence to inform the management of XLH, to improve the quality of life and standard of care of patients living with this rare debilitating disease.

How can digitised assets of Galleries, Libraries, Archives and Museums be reused to unlock new value? What are the implications of viewing large-scale cultural heritage data as an economic resource, to build new products and services upon? Drawing upon valuation studies, we reflect on both the theory and practicalities of using mass-digitised heritage content as an economic driver, stressing the need to consider the complexity of commercial-based outcomes within the context of cultural and creative industries. However, we also problematise the act of considering such heritage content as a resource to be exploited for economic growth, in order to inform how we consider, develop, deliver and value mass-digitisation. Our research will be of interest to those wishing to understand a rapidly changing research and innovation landscape, those considering how to engage memory institutions in data-driven activities and those critically evaluating years of mass-digitisation across the heritage sector.

Objective: To assess the effect the Pre-clerkship Residency Exploration Program (PREP) had on student career interest and improving understanding of physical medicine and rehabilitation (PMR). Design: During a 2-week program, students were exposed to a PMR elective, workshop, career presentation, and panel discussion with PMR residents. Interest and understanding were assessed using pre- and postprogram questionnaires. Setting: PREP was held at a Canadian medical school during the summer between the second and third years of undergraduate medical training. Participants: Second-year medical student participants (N=40) (26 women and 14 men, aged 20 to >30 y) were randomly selected from 74 applicants at a Canadian medical school. Interventions: Of the 40 program participants, 20 participated in a PMR elective and specialty-specific workshop. The full cohort of 40 participants participated in the PMR career presentation and PMR resident panel discussion. Main Outcome Measure: Primary outcome measure was an increase in understanding of the PMR specialty. Results: Understanding of the roles and responsibilities of physiatrists increased significantly, with larger trends in those with greater exposure time. After PREP, comfort level in common PMR procedures also significantly increased. Higher exposure time was correlated with an increased top 3 career selection. Student interest in PMR did not significantly change after the program. Conclusion: Although no statistically significant effects were found from the 2-week PREP in this population in terms of career choice, benefits were found in the participants comfort with PMR procedures and understanding the roles and responsibilities of physiatrists. A brief exposure as part of a 2-week summer elective is beneficial for career decision planning and may be feasible to implement in medical curricula. Keywords: Career choice, Education, Physical and Rehabilitation Medicine, Rehabilitation

With the vision of ubiquitous computing becoming increasingly realized through smart city solutions, the proliferation of smartphones and smartwatches, and the rise of the quantified-self movement, a new technological layer is being added to the urban environment. This technological layer offers the possibility to capture, track, measure, visualize, and augment our experience of the urban environment. But to that end, there is a growing need to better understand the triangular relationship between person, place, and technology. Urban HCI studies are increasingly focusing on emotion and affect to create a better understanding of people’s experience of the city, and to investigate how technology could potentially play a role in augmenting this urban lived experience. Artist Christian Nold for example, used wearable technology to measure people's arousal levels as they walked freely through the urban environment, identifying locations in the city that evoked an emotional response from people. After these walks, people’s arousal levels were superimposed on a map of the city and participants were asked to interpret their own data, resulting in aggregated, fully annotated, and beautifully visualized emotion maps of the city. Based on a systematic review of emotions maps in existing literature, and our own work which seeks to understand how people’s experiences of places in the urban environment that are meaningful to them on a personal level, for example the place where they have met their partner, could potentially inform the design of future technological devices and services, this journal paper discusses the strengths, limitations and potential of capturing, representing, exploring and sharing this personal, geo-located emotion data with other people using emotion maps. Although our analysis seems to indicate that emotion maps in their current form are only of limited efficacy in accurately capturing, representing and communicating the profound, complex emotional bond that people have with personally meaningful places in the city, there appears to be potential for the use of emotion maps as a provocation in a speculative design approach.

The choice of a future career specialty has always been a stressful decision for medical students. To mitigate this stress and assist students in making more informed career decisions we developed the Pre-clerkship Residency Exploration Program (PREP), a two-week summer elective program that provides students with the opportunity to gain exposure to specialities that traditionally do not receive a lot of attention in medical school. To initiate this student led program we faced many obstacles, suffered many failures, learned a tremendous amount and eventually found success. In this article, we offer 12 tips on how to create a medical education program that is sustainable, effective and receives strong buy-in from faculty and administration. Our tips come from the perspective of students starting their own program but are translatable to anyone interested in taking an innovative idea and seeing it through to fruition.

Biological therapies are increasingly used to treat ulcerative colitis (UC).To compare the efficacy of biologics in adults with moderately-to-severely active UC, stratified by prior exposure to anti-tumour necrosis factor (anti-TNF) therapy.A systematic literature review was undertaken to identify studies of biologics approved for UC. Network meta-analysis was conducted for endpoints at induction and maintenance.Seven studies were included in the meta-analysis of induction treatment for anti-TNF therapy-naïve patients. All biologics were more effective than placebo in inducing clinical response, clinical remission, and mucosal healing. Infliximab demonstrated a statistically significant improvement over adalimumab in clinical response (odds ratio [OR] [95% credible interval (CrI)]: 2.19 [1.35-3.55]), clinical remission (OR [95% CrI]: 2.81 [1.49-5.49]), and mucosal healing (OR [95% CrI]: 2.23 [1.21-4.14]); there were no other significant differences between biologics for induction efficacy. Five studies were included in the meta-analysis of maintenance treatment, two studies rerandomised responder patients at end of induction, and three followed the same patients 'straight through'. To account for design differences, the number of responders at end of induction was assumed to be equivalent to the number rerandomised. Vedolizumab showed significantly different durable clinical response from comparators (OR [95% CrI] infliximab 3.18 [1.14-9.20], golimumab 2.33 [1.04-5.41], and adalimumab 3.96 [1.67-9.84]). In anti-TNF therapy-experienced patients, only vedolizumab and adalimumab could be compared. At induction, no significant differences in efficacy were seen. During maintenance, vedolizumab showed significantly improved rates of mucosal healing versus adalimumab (OR [95% CrI]: 6.72 [1.36-41.0]).This study expands the understanding of comparative efficacies of biologic treatments for UC, encompassing outcomes and populations not previously studied. All biologic treatments were effective for UC during induction. Vedolizumab demonstrated possible clinical benefits in the maintenance setting versus all comparators, irrespective of prior anti-TNF exposure and after adjusting for differences in study design.

Abstract Using smartphone-based ecological momentary assessment, this study investigated an association between natural diversity on mental wellbeing. A sample of 1,998 participants completed 41,448 assessments between April 2018 and September 2023. Environments which included a larger range of natural features, such as trees, plants and birdlife (high natural diversity) were associated with greater mental wellbeing than environments including a smaller range of natural features (low natural diversity). There was evidence of a mediating effect of natural diversity on the association between natural environments and mental wellbeing. These results highlight the importance of policies and practices that support richness of biodiversity for public mental health.