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Abstract Background It is challenging to predict long-term outcomes of interventions without understanding how they work. Health economic models of public health interventions often do not incorporate the many determinants of individual and population behaviours that influence long term effectiveness. The aim of this paper is to draw on psychology, sociology, behavioural economics, complexity science and health economics to: (a) develop a toolbox of methods for incorporating the influences on behaviour into public health economic models (PHEM-B); and (b) set out a research agenda for health economic modellers and behavioural/ social scientists to further advance methods to better inform public health policy decisions. Methods A core multidisciplinary group developed a preliminary toolbox from a published review of the literature and tested this conceptually using a case study of a diabetes prevention simulation. The core group was augmented by a much wider group that covered a broader range of multidisciplinary expertise. We used a consensus method to gain agreement of the PHEM-B toolbox. This included a one-day workshop and subsequent reviews of the toolbox. Results The PHEM-B toolbox sets out 12 methods which can be used in different combinations to incorporate influences on behaviours into public health economic models: collaborations between modellers and behavioural scientists, literature reviewing, application of the Behaviour Change Intervention Ontology, systems mapping, agent-based modelling, differential equation modelling, social network analysis, geographical information systems, discrete event simulation, theory-informed statistical and econometric analyses, expert elicitation, and qualitative research/process tracing. For each method, we provide a description with key references, an expert consensus on the circumstances when they could be used, and the resources required. Conclusions This is the first attempt to rigorously and coherently propose methods to incorporate the influences on behaviour into health economic models of public health interventions. It may not always be feasible or necessary to model the influences on behaviour explicitly, but it is essential to develop an understanding of the key influences. Changing behaviour and maintaining that behaviour change could have different influences; thus, there could be benefits in modelling these separately. Future research is needed to develop, collaboratively with behavioural scientists, a suite of more robust health economic models of health-related behaviours, reported transparently, including coding, which would allow model reuse and adaptation.

Abstract Laser-lubricant interaction has been a critical reliability issue in a thermo-tribological system named heat-assisted magnetic recording, one of the next generation hard disk drive solutions to increasing data storage. The lubricant response under laser irradiation and the subsequent lubricant recovery are crucial to the system’s reliability and longevity, however, they cannot be diagnosed locally and timely so far. Here, we propose a thermal scheme to in-situ characterize the mechanical laser-lubricant interaction. The nanometer-thick lubricant has a thermal barrier effect on the near-field thermal transport in the system, according to which the lubricant thickness can be determined. As demonstrations, this paper reports the first quantitative in-situ measurements of the laser-induced lubricant depletion and the subsequent reflow dynamics. The proposed scheme shows a sub-angstrom resolution (~0.2 Å) and a fast response time within seconds, rendering in-situ real-time lubricant diagnosis feasible in the practical hard disk drive products.

Distributed leadership has become one of the most popular and important leadership models in the West, particularly in the field of education. However, both theoretical and empirical research into distributed leadership in the Chinese Higher Education context is rare. This dearth of literature on the subject has motivated the authors to carry out a research project focusing, from a Chinese perspective, on distributed leadership at the departmental level in one Chinese university. This article aims to determine the extent to which leadership is distributed at the departmental level, and the mechanism of leadership distribution in the Chinese context through the perceptions of Chinese Heads and other members of their departments. By conducting mixed methods research, which comprises questionnaires followed by semi-structured interviews, the findings of this study suggest that although the organizational structure is primarily hierarchical, leadership has been distributed to some extent within the departments. Leadership responsibilities are distributed mainly through formal distribution, and also through other top-down approaches, such as pragmatic and incremental distribution, implying the beginning of the practice of distributed leadership. The findings also suggest that leadership in this Chinese context is distributed through allocative practice, which is seen as more appropriate for centralized contexts.

Summary: In this protocol, we present a facile nanoscale thermal mapping technique for electronic devices by use of atomic force microscopy and a phase change material Ge2Sb2Te5. We describe steps for Ge2Sb2Te5 thin film coating, Ge2Sb2Te5 temperature calibration, thermal mapping by varying heater power, and thermal mapping by varying heating time. The protocol can be applied for resolving surface temperatures of various operational microelectronic devices with a nanoscale precision.For complete details on the use and execution of this protocol, please refer to Cheng et al.1 : Publisher’s note: Undertaking any experimental protocol requires adherence to local institutional guidelines for laboratory safety and ethics.

Abstract We continue the analysis of the geometry of generic Minkowski N $$ \mathcal{N} $$ = 1, D = 4 flux compactifications in M-theory using exceptional generalised geometry, including the calculation of the infinitesimal moduli spaces. The backgrounds can be classified into two classes: type-0 and type-3. For type-0, we review how the moduli arise from standard de Rham cohomology classes. We also argue that, under reasonable assumptions, there are no appropriate sources to support compact flux backgrounds for this class and so the only solutions are in fact G2 geometries. For type-3 backgrounds, given a suitable ∂ ′ ∂ ¯ ′ $$ {\partial}^{\prime }{\overline{\partial}}^{\prime } $$ -lemma, we show that the moduli can be calculated from a cohomology based on an involutive sub-bundle of the complexified tangent space. Using a simple spectral sequence we prove quite generally that the presence of flux can only reduce the number of moduli compared with the fluxless case. We then use the formalism to calculate the moduli of heterotic M-theory and show they match those of the dual Hull-Strominger system as expected.

Innovation has been identified as a critical indicator for an economy to succeed in the fourth industrial revolution. Historically, some members of the Association of Southeast Asian Nations have been better known for violation of intellectual rights rather than their protection. However, this is changing as their economies develop and they have been better integrated into the global economy. Integration has been facilitated by their membership of the World Trade Organization and bilateral Free Trade Agreements (FTAs) between individual states and their trading parties. ASEAN has entered into plurilateral FTAs with some of its trade partners. A key element of these plurilateral FTAs is that most dedicate a Chapter on the protection of intellectual property rights. These clauses have two essential elements. Firstly, they set out the obligations of the parties to protect intellectual property rights and their commitment to seek membership of intellectual property treaties. Secondly, the parties undertake to assist the lesser developed members with improving their processes and procedures so that they can accede to appropriate treaties. The research analysed the impact of these multilateral FTAs on the protection of patents and marks by the individual ASEAN members.

The widespread availability and diversity of open-source microcontrollers paired with off-the-shelf electronics and 3D printed technology has led to the creation of a wide range of low-cost scientific instruments, including microscopes, spectrometers, sensors, data loggers, and other tools that can be used for research, education, and experimentation. These devices can be used to explore a wide range of scientific topics, from biology and chemistry to physics and engineering. In this study, we designed and built a multifunction fluorescent open source in vivo/in vitro imaging system (openIVIS) system that integrates a Raspberry Pi with commercial cameras and LEDs with 3D printed structures combined with an acrylic housing. Our openIVIS provides three excitation wavelengths of 460 nm, 520 nm, and 630 nm integrated with Python control software to enable fluorescent measurements across the full visible light spectrum. To demonstrate the potential applications of our system, we tested its performance against a diverse set of experiments including laboratory assays (measuring fluorescent dyes, using optical nanosensors, and DNA gel electrophoresis) to potentially fieldable applications (plant and mineral imaging). We also tested the potential use for a high school biology environment by imaging small animals and tracking their development over the course of ten days. Our system demonstrated its ability to measure a wide dynamic range fluorescent response from millimolar to picomolar concentrations in the same sample while measuring responses across visible wavelengths. These results demonstrate the power and flexibility of open-source hardware and software and how it can be integrated with customizable manufacturing to create low-cost scientific instruments with a wide range of applications. Our study provides a promising model for the development of low-cost instruments that can be used in both research and education.

Purpose: There is a rising prevalence in undetected perinatal depression in many countries, more effort in screening and early identification of perinatal depression is needed. While the Whooley questionnaire is the recommended case-finding strategy for perinatal depression, there is no validated Chinese version. The aim was to evaluate the diagnostic accuracy and stability of the translated Chinese Whooley questionnaire against gold standard measurement during and early after pregnancy. Materials and Methods: This observational study recruited 131 pregnant women from an antenatal clinic in Hong Kong from September 2019 to May 2020. We translated the Whooley questionnaire in Chinese and evaluated self-reported responses against an interviewer-assessed diagnostic standard (DSM-IV criteria) in 107 women at 26–28 gestational weeks. We calculated sensitivity, specificity, positive predictive value, negative predictive value, positive likelihood ratio, negative likelihood ratio and diagnostic odds ratio, with DSM-IV diagnosis as the gold standard. Results: The Chinese Whooley questions had a sensitivity of 79% (95% CI 54.4–93.9), a specificity of 97% (95% CI 90.4–99.3), a positive likelihood ratio of 23.2 (95% CI 7.4–72.1) and a negative likelihood ratio of 0.2 (95% CI 0.1–0.5) in identifying perinatal depression. Conclusion: The translated Chinese Whooley questionnaire has an acceptable diagnostic accuracy in identifying perinatal depression. It can be implemented in health services among Cantonesespeaking Chinese population.

Abstract A main challenge in Heat-Assisted Magnetic Recording technology is the build-up of contaminants called smear on the near field transducer. In this paper, we investigate the role of optical forces originating from the electric field gradient in the formation of smear. First, based on suitable theoretical approximations, we compare this force with air drag and the thermophoretic force in the head-disk interface for two smear nanoparticle shapes. Then, we evaluate the force field’s sensitivity to the relevant parameter space. We find that the smear nanoparticle’s refractive index, shape, and volume significantly impact the optical force. Further, our simulations reveal that the interface conditions, such as spacing and the presence of other contaminants, also influence the magnitude of the force.

Introduction Severe aortic stenosis is a major cause of morbidity and mortality. The existing treatment pathway for transcatheter aortic valve implantation (TAVI) traditionally relies on tertiary Heart Valve Centre workup. However, this has been associated with delays to treatment, in breach of British Cardiovascular Intervention Society targets. A novel pathway with emphasis on comprehensive patient workup at a local centre, alongside close collaboration with a Heart Valve Centre, may help reduce the time to TAVI.Methods The centre performing local workup implemented a novel TAVI referral pathway. Data were collected retrospectively for all outpatients referred for consideration of TAVI to a Heart Valve Centre from November 2020 to November 2021. The main outcome of time to TAVI was calculated as the time from Heart Valve Centre referral to TAVI, or alternative intervention, expressed in days. For the centre performing local workup, referral was defined as the date of multidisciplinary team discussion. For this centre, a total pathway time from echocardiographic diagnosis to TAVI was also evaluated. A secondary outcome of the proportion of referrals proceeding to TAVI at the Heart Valve Centre was analysed.Results Mean±SD time from referral to TAVI was significantly lower at the centre performing local workup, when compared with centres with traditional referral pathways (32.4±64 to 126±257 days, p

Abstract Aims Secondary mitral regurgitation (SMR) is frequent in patients with heart failure with reduced ejection fraction (HFrEF) and portends detrimental prognosis. Despite interventions addressing the mitral valve (MV) have been proven effective to improve survival, an important knowledge gap exists regarding the role of medical therapy (MT) in this context. Thus, we aimed at investigating the role of MT optimization in patients with SMR and HFrEF. Methods and results A total of 435 patients with SMR and HFrEF were retrospectively evaluated. Of those, 158 with severe SMR were finally included, with 63 (40%) managed with MT alone and 96 (60%) with MV intervention plus MT. Echocardiography was performed after 30 days of MT optimization or MV intervention. Responders were patients with a final mitral regurgitation (MR) grade of ≤2+. Survival data were gathered through the National Database Index and patient chart review. MR severity improved in 131 patients (100% MV intervention; 57% MT) but stayed the same or worsened in 27 patients. Responders and non‐responders were similar for baseline characteristics. Overall, long‐term survival of responders was significantly higher than non‐responders [hazard ratio (HR) 0.55, 95% confidence interval (CI) (0.32–0.96), P = 0.032]. No difference in survival was observed when evaluated by intervention type in the overall population (MT alone, n = 63; MV intervention plus MT, n = 95) [HR 0.77, 95% CI (0.48–1.26), P = 0.3], nor within responder group (MT alone, n = 36; MV intervention plus MT, n = 95) [HR 1.03, 95% CI (0.56–1.89), P = 0.94]. Conclusions MT reduces SMR severity in 57% of the patients with severe SMR. A final SMR grade of ≤2+ is linked to improved survival, independently of the type of treatment they receive.

Abstract Background Transgenerational epigenetic risks associated with complex health outcomes, such as autism spectrum disorder (ASD), have attracted increasing attention. Transgenerational environmental risk exposures with potential for epigenetic effects can be effectively identified using space-time clustering. Specifically applied to ancestors of individuals with disease outcomes, space-time clustering characterized for vulnerable developmental stages of growth can provide a measure of relative risk for disease outcomes in descendants. Objectives (1) Identify space-time clusters of ancestors with a descendent with a clinical ASD diagnosis and matched controls. (2) Identify developmental windows of ancestors with the highest relative risk for ASD in descendants. (3) Identify how the relative risk may vary through the maternal or paternal line. Methods Family pedigrees linked to residential locations of ASD cases in Utah have been used to identify space-time clusters of ancestors. Control family pedigrees of none-cases based on age and sex have been matched to cases 2:1. The data have been categorized by maternal or paternal lineage at birth, childhood, and adolescence. A total of 3957 children, both parents, and maternal and paternal grandparents were identified. Bernoulli space-time binomial relative risk (RR) scan statistic was used to identify clusters. Monte Carlo simulation was used for statistical significance testing. Results Twenty statistically significant clusters were identified. Thirteen increased RR (> 1.0) space-time clusters were identified from the maternal and paternal lines at a p-value

The proliferation of harmful waterborne cyanobacterial algal blooms, some of which can produce potent toxins, poses severe risks to environmental and human health. Academic and governmental monitoring efforts may be constrained by budget, time, and staff, and thus miss otherwise significant pollution events. Here, we report on the implementation of a citizen science project to track harmful cyanobacterial blooms in lakes and waterways across Canada. Through both crowdsourcing and crowdfunding, the Adopt a Lake (Adopt a Lake 2022) campaign aimed to document the potential presence of cyanobacteria and toxins with the assistance of participants, thus improving public awareness of the issue of water quality preservation. Using social media, participants were encouraged to participate in the initiative by collecting samples during a bloom from a nearby pond or by making a financial contribution to support the initiative. Adopt a Lake benefitted from the analytical platform of Algal Blooms Treatment, Risk Assessment, Predictions, and Prevention (ATRAPP), a research project focused on the prediction and management of harmful cyanobacterial blooms. The presence of cyanotoxins, which can confirm whether a lake has a toxic bloom, was determined through high-resolution mass spectrometry analyses. This paper presents an overview of the implementation of the Adopt a Lake initiative, the campaign’s status, and the lessons learned, and it argues the importance of continual monitoring of cyanobacterial blooms.

The transradial approach (TRA) is an effective and safe alternative to transfemoral access for diagnostic neuroangiography and craniocervical interventions. While the technical aspects of supraclavicular intervention are well-described, there are little data on the TRA for thoracolumbar angiography and intervention. The authors describe the feasibility of the TRA for preoperative thoracic tumor embolization, emphasizing technique, device selection, navigation, and catheterization of thoracolumbar segmental arteries. This approach extends the benefits of TRA to spinal interventional neuroradiology.

Abstract Solid state materials possessing the ability for fast ionic diffusion of hydrogen have immense appeal for a wide range of energy-related applications. Ionic hydrogen transport research is dominated by proton conductors, but recently a few examples of hydride ion conductors have been observed as well. Barium hydride, BaH2, undergoes a structural phase transition around 775 K that leads to an order of magnitude increase in the ionic conductivity. This material provides a prototypical system to understand hydride ion diffusion and how the altered structure produced by the phase transition can have an enormous impact on the diffusion. We employ quasielastic and inelastic neutron scattering to probe the atomic scale diffusion mechanism and vibrational dynamics of hydride ions in both the low- and high-temperature phases. Jump lengths, residence times, diffusion coefficients, and activation energies are extracted and compared to the crystal structure to uncover the diffusion pathways. We find that the hydrogen jump distances, residence times, and energy barriers become reduced following the phase transition, allowing for the efficient conduction of hydride ions through a series of hydrogen jumps of length L = 3.1 Å.

The protozoan Cryptosporidium parvum is an important cause of gastroenteritis in humans and livestock, and cryptosporidiosis outbreaks are common. However, a multi-locus genotyping scheme is not widely adopted. We describe the further development and application of a seven-locus multi-locus variable number of tandem repeats analysis (MLVA) scheme. From 28th March to 31st July 2022, confirmed C. parvum stools (n = 213) from cryptosporidiosis patients (cases) in Wales (n = 95) and the north west of England (n = 118) were tested by MLVA. Typability (defined as alleles identified at all seven loci in a sample) was 81.2% and discriminatory power estimated by Hunter Gaston Discriminatory Index was 0.99. A MLVA profile was constructed from the alleles, expressed in chromosomal order. Profiles were defined as simple (single allele at each locus) or mixed (more than one allele at any locus). A total of 161 MLVA profiles were identified; 13 were mixed, an additional 38 simple profiles contained null records, and 110 were complete simple profiles. A minimum spanning tree was constructed of simple MLVA profiles and those identical at all seven loci defined genetic clusters of cases (here, null records were considered as an allele); 77 cases formed 25 clusters, ranging from two to nine (mode = two) cases. The largest cluster, following epidemiological investigation, signalled a newly-identified outbreak. Two other cases with mixed profiles that contained the outbreak alleles were included in the outbreak investigation. In another epidemiologically-identified outbreak of six initial cases, MLVA detected two additional cases. In a third, small outbreak of three cases, identical MLVA profiles strengthened the microbiological evidence. Review of the performance characteristics of the individual loci and of the seven-locus scheme suggested that two loci might be candidates for review, but a larger dataset over a wider geographical area and longer timeframe will help inform decision-making about the scheme by user laboratories and stakeholders (such as public health agencies). This MLVA scheme is straightforward in use, fast and cheap compared to sequence-based methods, identifies mixed infections, provides an important tool for C. parvum surveillance, and can enhance outbreak investigations and public health action.

BackgroundDiagnostic immunoassays for Lyme disease have several limitations including: 1) not all patients seroconvert; 2) seroconversion occurs later than symptom onset; and 3) serum antibody levels remain elevated long after resolution of the infection.IntroductionMENSA (Medium Enriched for Newly Synthesized Antibodies) is a novel diagnostic fluid that contains antibodies produced in vitro by circulating antibody-secreting cells (ASC). It enables measurement of the active humoral immune response.MethodsIn this observational, case-control study, we developed the MicroB-plex Anti-C6/Anti-pepC10 Immunoassay to measure antibodies specific for the Borrelia burgdorferi peptide antigens C6 and pepC10 and validated it using a CDC serum sample collection. Then we examined serum and MENSA samples from 36 uninfected Control subjects and 12 Newly Diagnosed Lyme Disease Patients.ResultsAmong the CDC samples, antibodies against C6 and/or pepC10 were detected in all seropositive Lyme patients (8/8), but not in sera from seronegative patients or healthy controls (0/24). Serum antibodies against C6 and pepC10 were detected in one of 36 uninfected control subjects (1/36); none were detected in the corresponding MENSA samples (0/36). In samples from newly diagnosed patients, serum antibodies identified 8/12 patients; MENSA antibodies also detected 8/12 patients. The two measures agreed on six positive individuals and differed on four others. In combination, the serum and MENSA tests identified 10/12 early Lyme patients. Typically, serum antibodies persisted 80 days or longer while MENSA antibodies declined to baseline within 40 days of successful treatment.DiscussionMENSA-based immunoassays present a promising complement to serum immunoassays for diagnosis and tracking therapeutic success in Lyme infections.

We describe an unusual presentation of transcatheter mitral valve edge-to-edge repair device embolization into the left common femoral vein in a patient with primary degenerative mitral regurgitation. We hypothesize a possible mechanism for this phenomenon, factors that may increase the risk of this complication, and outline the patient’s clinical course. (Level of Difficulty: Intermediate.)

Abstract As electric vehicles become more widely used, there is a higher demand for lithium‐ion batteries (LIBs) and hence a greater incentive to find better ways to recycle these at their end‐of‐life (EOL). This work focuses on the process of reclamation and re‐use of cathode material from LIBs. Black mass containing mixed LiMn2O4 and Ni0.8Co0.15Al0.05O2 from a Nissan Leaf pouch cell are recovered via two different recycling routes, shredding or disassembly. The waste material stream purity is compared for both processes, less aluminium and copper impurities are present in the disassembled waste stream. The reclaimed black mass is further treated to reclaim the transition metals in a salt solution, Ni, Mn, Co ratios are adjusted in order to synthesize an upcycled cathode, LiNi0.6Mn0.2Co0.2O2 via a co‐precipitation method. The two reclamation processes (disassembly and shredding) are evaluated based on the purity of the reclaimed material, the performance of the remanufactured cell, and the energy required for the complete process. The electrochemical performance of recycled material is comparable to that of as‐manufactured cathode material, indicating no detrimental effect of purified recycled transition metal content. This research represents an important step toward scalable approaches to the recycling of EOL cathode material in LIBs.

Epistasis plays an important role in the evolution of novel protein functions because it determines the mutational path a protein takes. Here, the authors combine functional, structural and biophysical analyses to characterize epistasis in a computationally redesigned ligand-inducible allosteric transcription factor and found that epistasis creates distinct biophysical and biological functional landscapes.

Abstract The prevalence of smokers is a major driver of lung cancer incidence in a population, though the “exposure–lag” effects are ill-defined. Here we present a multi-country ecological modelling study using a 30-year smoking prevalence history to quantify the exposure–lag response. To model the temporal dependency between smoking prevalence and lung cancer incidence, we used a distributed lag non-linear model (DLNM), controlling for gender, age group, country, outcome year, and population at risk, and presented the effects as the incidence rate ratio (IRR) and cumulative incidence rate ratio (IRRcum). The exposure–response varied by lag period, whilst the lag–response varied according to the magnitude and direction of changes in smoking prevalence in the population. For the cumulative lag–response, increments above and below the reference level was associated with an increased and decreased IRRcum respectively, with the magnitude of the effect varying across the lag period. Though caution should be exercised in interpretation of the IRR and IRRcum estimates reported herein, we hope our work constitutes a preliminary step towards providing policy makers with meaningful indicators to inform national screening programme developments. To that end, we have implemented our statistical model a shiny app and provide an example of its use.

Variants in the ACTA1 gene are a common cause of nemaline myopathy (NM); a muscle disease that typically presents at birth or early childhood with hypotonia and muscle weakness. Here, we generated an induced pluripotent stem cell line (iPSC) from lymphoblastoid cells of a 3-month-old female patient with intermediate NM caused by a dominant ACTA1 variant (c.515C > A (p.Ala172Glu)). iPSCs showed typical morphology, expressed pluripotency markers, demonstrated trilineage differentiation potential, and had a normal karyotype. This line complements our previously published ACTA1 iPSC lines derived from patients with typical and severe NM.

Nemaline myopathy (NM) is a congenital skeletal muscle disorder that typically results in muscle weakness and the presence of rod-like structures (nemaline bodies) in the sarcoplasma and/or in the nuclei of myofibres. Two induced pluripotent stem cell (iPSC) lines were generated from the lymphoblastoid cells of a 1-month-old male with severe NM caused by a homozygous recessive mutation in the ACTA1 gene (c.121C > T, p.Arg39Ter). The iPSC lines demonstrated typical morphology, expressed pluripotency markers, exhibited trilineage differentiation potential and displayed a normal karyotype. These isogenic lines represent a potential resource to investigate and model recessive ACTA1 disease in a human context.

Abstract Background As suggested by the World Health Organization, breastfeeding peer support is being introduced worldwide to support women’s breastfeeding needs. Evidence has shown that when such support is offered to women, the duration and exclusivity of breastfeeding is increased. We developed an innovative home-based intervention to sustain exclusive breastfeeding in Hong Kong. However, potential barriers must be addressed before a full randomised controlled trial (RCT) is conducted. The aim of this study was to determine the feasibility of a breastfeeding support programme with home-based visits from peer supporters over a six month period among postpartum Chinese women in Hong Kong. Methods We conducted a feasibility and pilot randomised controlled trial. Twenty primiparous women intending to breastfeed their healthy term singleton infant were recruited from a hospital in Kowloon, Hong Kong between February and March 2019. Participants were randomly allocated to the intervention or control group. Participants in the intervention group received five home-based visits with a peer supporter over a six month period, as well as standard care, whereas participants in the control group received standard care only. We assessed feasibility, compliance, and acceptability of the breastfeeding peer support programme. Other outcomes assessed were breastfeeding self-efficacy, duration, and exclusivity. Results It was feasible to recruit and train existing peer supporters, and peer supporters were able to deliver the intervention, which was acceptable to women, but rates of stopping the intervention and loss to follow-up were high. There was higher retention seen within the first month. Women interviewed at the end of the study reported that the intervention was positive. The cessation risk of any, and exclusive breastfeeding were not statistically different between the intervention and control groups. Conclusions This study provided valuable information on feasibility of the trial design and intervention. Modifications to the intervention, such as targeting women with lower breastfeeding self-efficacy, or combining home visits with technology and telephone follow-up may be more appropriate in a larger trial. Implementing the programme early during the antenatal phase and tailoring peer support to most appropriately sustain exclusive breastfeeding and other feeding modes should be incorporated in a future home-based peer support arm. Trial registration NCT03705494 on 15 Oct 2018.

Abstract Background The survival rates of advanced cancer patients remain low despite clinical therapy advancements. However, physical activity showed promising effects in improving cancer outcomes. This review aimed to systematically evaluate and synthesize the effects on overall mortality of post-diagnosis physical activity in advanced cancer patients. Methods A systematic search of six English databases (PubMed, EMBASE, CINAHL, PsycINFO, The Cochrane Central Register of Controlled Trials, and SPORTDiscus) was conducted from their inception up to 3 February 2021. The association of physical activity with survival was evaluated by combining study-specific hazard ratios with random-effects meta-analysis models. Results Eleven studies were identified. Compared with the reference group, higher-level physical activity was not significantly associated with a lower risk of earlier mortality in advanced cancer patients (InHR = − 0.18, 95% CI, − 0.36 to 0.01). When separated by study type, a higher level of physical activity in non-randomised trials was significantly associated with reduced mortality risk (InHR = − 0.25, 95% CI: − 0.44, − 0.06). However, in randomised trials, engaging in exercise was not significantly associated with a lower mortality risk compared with the control group (InHR = 0.08, 95%CI: − 0.17, 0.32). Conclusions Discrepancies were uncovered in the effect of physical activity on overall survival in randomised and non-randomised trials. In non-randomised trials, a higher level of physical activity was significantly associated with a lower risk of mortality, whereas no significant effect on survival was observed during exercise interventions compared to the control in randomised trials. Considering the wider benefits of physical activity, exercise can still be recommended to improve outcomes for advanced cancer patients. Nevertheless, it might be too late for advanced cancer patients to start exercising for survival improvements, based on findings from randomised controlled trials.

The ability to navigate the anterior lumbar disc space may improve clinical outcomes and implant longevity. However, no robotic navigation systems are presently authorized by the U.S. Food and Drug Administration to assist with anterior retroperitoneal lumbar interbody surgery. Furthermore, no studies to date have investigated such an application of this technology. This study examines the application of robotic navigation to anterior lumbar total disc replacement surgery to improve retroperitoneal exposure and orientation of the anterior lumbar spine, enhance coronal plane centralization of the implant, optimize surgical trajectory, and mitigate radiologic exposure. Postoperative outcomes of a small cohort of patients undergoing anterior lumbar total disc replacement surgery using robotic navigation were analyzed. The results of the study revealed that a modified use of the aforementioned robot-assisted surgical technology enhances coronal plane centralization and trajectory, all while mitigating radiologic exposure, resulting in more accurate placement of the implant within the intervertebral space at each level.

During the earliest stages of a pandemic, mathematical models are a tool that can be imple-mented quickly. However, such models are based on meagre data and limited biological understanding. We evaluate the accuracy of various models from recent pandemics (SARS, MERS and the 2009 H1N1 outbreak) as a guide to whether we can trust the early model predictions for COVID-19. We show that early models can have good predictive power for a disease's first wave, but they are less predictive of the possibility of a second wave or its strength. The models with the highest accuracy tended to include stochasticity, and models developed for a particular geographic region are often applicable in other regions. It follows that mathematical models developed early in a pandemic can be useful for long-term predictions, at least during the first wave, and they should include stochastic variations, to represent unknown characteristics inherent in the earliest stages of all pandemics.

Abstract Background Waterpipe smoking has gained global popularity in recent years, especially among young people. However, there is a lack of empirical investigation into waterpipe smoking in East Asia. This study aimed to investigate the demographical and psycho-social characteristics and patterns of waterpipe smoking (WPS) among university students in Hong Kong. Methods A cross-sectional survey was conducted via online questionnaires administered to 1288 Hong Kong university students (mean age: 22.4 [SD = 3.8]). Logistic regressions were used to compute adjusted odd ratios (aOR) for waterpipe ever-smoking in relation to respondents’ characteristics. Moreover, multinomial logistic regression yielded adjusted RR (aRR) for four different smoking status (i.e., never, waterpipe-only, cigarette-only, and dual smoking) regarding the characteristics. Results 23.8% of participants reported having ever smoked a waterpipe (vs. cigarette ever-smoking: 21.1%). Factors including being female (aOR:1.57; 95% CI: 1.22–2.02), older age (≥24 years: 4.17; 1.35–12.93), frequent alcohol consumption (>monthly: 26.02; 10.91–62.09), and higher sensation-seeking behaviours (high level: 2.98;1.46–6.08) were associated with waterpipe ever-smokers. The study also identified that demographical and psycho-social characteristics were variably associated with students’ smoking status. Particularly, more frequent alcohol consumption was most significantly associated with waterpipe-only smoking (aRR:45.73; 95% CI:11.44–182.73) (vs. cigarette-only smoking: 3.01; 1.76–5.14). Conclusions WPS is the most common form of tobacco smoking among university students in Hong Kong, and characteristics unique to the population were identified. There is no legislation of relevant policies on WPS despite its concerning significance in public health among young people, therefore immediate action to monitor and control WPS is needed in Hong Kong.

The law of mass action is used to govern interactions between susceptible and infected individuals in a variety of infectious disease models. However, the commonly used version is a simplification of the version originally used to describe chemical reactions. We reformulate a general disease model using the chemical-reaction definition of mass action incorporating both an altered transmission term and an altered recovery term in the form of positive exponents. We examine the long-term outcome as these exponents vary. For many scenarios, the reproduction number is either 0 or $\infty$, while it obtains finite values only for certain combinations. We found conditions under which endemic equilibria exist and are unique for a variety of possible exponents. We also determined circumstances under which backward bifurcations are possible or do not occur. The simplified form of mass action may be masking generalised behaviour that may result in practice if these exponents ``fluctuate'' around 1. This may lead to a loss of predictability in some models.

Ebola virus — one of the deadliest viral diseases, with a mortality rate around 90% — damages the immune system and organs, with symptoms including episodic fever, chills, malaise and myalgia. The Recombinant Vesicular Stomatitis Virus-based candidate vaccine (rVSV-ZEBOV) has demonstrated clinical efficacy against Ebola in ring-vaccination clinical trials. In order to evaluate the potential effect of this candidate vaccine, we developed risk equations for the daily risk of Ebola infection both currently and after vaccination. The risk equations account for the basic transmission probability of Ebola and the lowered risk due to various protection protocols: vaccination, hazmat suits, reduced contact with the infected living and dead bodies. Parameter space was sampled using Latin Hypercube Sampling, a statistical method for generating a near-random sample of parameter values. We found that at a high transmission rate of Ebola (i.e., if the transmission rate is greater than 90%), a large fraction of the population must be vaccinated (>80%) to achieve a 50% decrease in the daily risk of infection. If a vaccine is introduced, it must have at least 50% efficacy, and almost everyone in the affected areas must receive it to effectively control outbreaks of Ebola. These results indicate that a low-efficacy Ebola vaccine runs the risk of having vaccinated people be overconfident in a weak vaccine and hence the possibility that the vaccine could make the situation worse, unless the population can be sufficiently educated about the necessity for high vaccine uptake.

Summary: Background: To address the growing prevalence of hearing loss, WHO has identified a compendium of key evidence-based ear and hearing care interventions to be included within countries’ universal health coverage packages. To assess the cost-effectiveness of these interventions and their budgetary effect for countries, we aimed to analyse the investment required to scale up services from baseline to recommended levels, and the return to society for every US$1 invested in the compendium. Methods: We did a modelling study using the proposed set of WHO interventions (summarised under the acronym HEAR: hearing screening and intervention for newborn babies and infants, pre-school and school-age children, older adults, and adults at higher risk of hearing loss; ear disease prevention and management; access to technologies such as hearing aids, cochlear implants, or hearing assistive technologies; and rehabilitation service provision), which span the life course and include screening and management of hearing loss and related ear diseases, costs and benefits for the national population cohorts of 172 countries. The return on investment was analysed for the period between 2020 and 2030 using three scenarios: a business-as-usual scenario, a progress scenario with a scale-up to 50% of recommended coverage, and an ambitious scenario with scale-up to 90% of recommended coverage. Using data for hearing loss burden from the Global Burden of Disease Study 2019, a transition model with three states (general population, diagnosed, and those who have died) was developed to model the national populations in countries. For the return-on-investment analysis, the monetary value of disability-adjusted life-years (DALYs) averted in addition to productivity gains were compared against the investment required in each scenario. Findings: Scaling up ear and hearing care interventions to 90% requires an overall global investment of US$238·8 billion over 10 years. Over a 10-year period, this investment promises substantial health gains with more than 130 million DALYs averted. These gains translate to a monetary value of more than US$1·3 trillion. In addition, investment in hearing care will result in productivity benefits of more than US$2 trillion at the global level by 2030. Together, these benefits correspond to a return of nearly US$15 for every US$1 invested. Interpretation: This is the first-ever global investment case for integrating ear and hearing care interventions in countries’ universal health coverage services. The findings show the economic benefits of investing in this compendium and provide the basis for facilitating the increase of country's health budget for strengthening ear and hearing care services. Funding: None.

Background: In August 2020, an outbreak of Shiga toxin-producing Escherichia coli (STEC) O157:H7 occurred in the United Kingdom. Whole genome sequencing revealed that these cases formed a genetically distinct cluster. Methods: Hypotheses generated from case interviews were tested in analytical studies, and results informed environmental sampling and food chain analysis. A case–case study used non-outbreak ‘comparison’ STEC cases; a case–control study used a market research panel to recruit controls. Results: A total of 36 cases were identified; all cases reported symptom onset between August 3 and August 16, 2020. The majority of cases (83%) resided in the Midlands region of England and in Wales. A high proportion of cases reported eating out, with one fast-food restaurant chain mentioned by 64% (n = 23) of cases. Both the case–case study (adjusted odds ratio (aOR) 31.8, 95% confidence interval (CI) 1.6–624.9) and the case–control study (aOR 9.19, 95% CI 1.0–82.8) revealed statistically significant results, showing that the consumption of a specific fast-food product was independently associated with infection. Conclusions: Consumption of a specific fast-food product was a likely cause of this outbreak. The only ingredient specific to the product was cucumbers. The supply of cucumbers was immediately halted, and no further cases have been identified.

Purpose: To review the scientific literature seeking lessons for the COVID-19 era that could be learned from previous health services interruptions that affected the delivery of cancer screening services. Methods: A systematic search was conducted up to April 17, 2020, with no restrictions on language or dates and resulted in 385 articles. Two researchers independently assessed the list and discussed any disagreements. Once a consensus was achieved for each paper, those selected were included in the review. Results: Eleven articles were included. Three studies were based in Japan, two in the United States, one in South Korea, one in Denmark, and the remaining four offered a global perspective on interruptions in health services due to natural or human-caused disasters. No articles covered an interruption due to a pandemic. The main themes identified in the reviewed studies were coordination, communication, resource availability and patient follow-up. Conclusion: Lessons learned applied to the context of COVID-19 are that coordination involving partners across the health sector is essential to optimize resources and resume services, making them more resilient while preparing for future interruptions. Communication with the general population about how COVID-19 has affected cancer screening, measures taken to mitigate it and safely re-establish screening services is recommended. Use of mobile health systems to reach patients who are not accessing services and the application of resource-stratified guidelines are important considerations. More research is needed to explore best strategies for suspending, resuming and sustaining cancer screening programs, and preparedness for future disruptions, adapted to diverse health care systems.

Background:. Total knee replacement (TKR) designs continue to evolve with the aim of improving patient outcomes; however, there remains a significant patient dissatisfaction rate. We report the early functional outcomes of an evolutionary knee design in the context of a single-blinded, noninferiority, randomized controlled trial. Methods:. Patients were randomized to receive either the P.F.C. SIGMA or ATTUNE knee implant systems (DePuy Synthes). All implants were fixed-bearing, cruciate-retaining, and cemented constructs. Patients were assessed at baseline and 6 weeks, 3 months, and 1 year postoperatively using clinical and functional outcome measures, including range of motion, Oxford Knee Score (OKS), Oxford Knee Score-Activity and Participation Questionnaire (OKS-APQ), Patient Knee Implant Performance (PKIP) score, 5-Level EuroQol 5 Dimensions (EQ-5D-5L), and Short Form-36 outcome measures. Results:. There were 150 patients who underwent a surgical procedure (76 with the ATTUNE implant and 74 with the P.F.C. SIGMA implant), with 147 patients remaining at the final review. No differences were observed in any of the outcome measures between the groups at any time point. Tourniquet time was significantly shorter in the P.F.C. SIGMA arm (p = 0.001); however, this had no clinical impact on the OKS (analysis of covariance [ANCOVA] test) at the final review (p = 0.825). There was no difference in the numbers of patients achieving the minimal clinically important difference for the OKS between the groups (p = 0.817). Conclusions:. This trial did not show inferiority of the ATTUNE implant when compared with the P.F.C. SIGMA implant. The authors believe that implant innovation should continue and that modern implants should be introduced into the market following randomized controlled trials. Further work should assess the effect of non-implant-related factors on patient outcomes. Level of Evidence:. Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.

Background A majority of lung cancer patients are diagnosed at advanced stages. Although there is considerable evidence of the benefits of aerobic exercise and tai-chi for lung cancer patients, little is known about the comparative effectiveness of the 2 exercise modes in advanced lung cancer patients. Objectives To explore the feasibility and preliminary effects of aerobic exercise and tai-chi interventions on survival and well-being among advanced lung cancer patients. Methods In an assessor-blinded, exploratory randomized controlled trial, 30 advanced lung cancer patients were randomized to an aerobic exercise group, a tai-chi group (both attending 12-week, twice-weekly supervised sessions), or a self-management control group (receiving written exercise guidelines). The primary outcomes focused on feasibility including intervention completion, exercise adherence, and adverse events, while the secondary outcomes addressed preliminary effects and included 1-year survival, cancer symptoms (Pittsburgh Sleep Quality Index, Hospital Anxiety and Depression Score, Brief Fatigue Inventory), quality of life (EORTC QLQ-C30, QLQ-LC13), physical performance (6-minute walk test, up-and-go, sit-to-stand, 1-leg standing), activity levels (actigraph), and circadian rhythms (salivary cortisol). Results Intervention feasibility was established with a satisfactory completion rate at post-intervention for the aerobic exercise group (80%) and the tai-chi group (78%). The tai-chi group attained higher adherence than the exercise group in terms of attendance in supervised sessions (89% vs 75% of scheduled classes) and self-practice (225% vs 87% of the prescribed amount). Higher adherence to self-practice in the tai-chi group remained at the 6-month follow-up (81% vs 38% of the prescribed amount). No adverse event as a result of the intervention was reported. Effect-related outcomes did not show statistically significant changes in any group, except an improvement post-intervention in the up-and-go (−2.26, 95% CI: −4.04, −0.48) and sit-to-stand tests (4.52, 95% CI: 2.19, 6.85) in the aerobic exercise group. Conclusions The findings support the feasibility of aerobic exercise and tai-chi interventions in advanced lung cancer patients. A future study with a larger sample from multiple sites is recommended to confirm the comparative effects of the 2 exercise interventions relative to the self-management group and to enhance the generalizability of the findings.