Helping the Community from the Bottom Up: Distributing Diapers to the Williamsburg Community

There is a great need for a sustainable supply of clean diapers for low-income residents of Williamsburg since this region is without a diaper bank. Being unable to afford diapers can have a myriad of negative consequences from being unable to send children to child care to increased health risks involved in leaving a baby in a soiled diaper. Our model of a diaper bank differs from most because we mail diapers directly to families, eliminating transportation needs. We hope to partner with community agencies and The College of William & Mary to expand our services and create a more sustainable model in order to serve families in the Greater Williamsburg area. We believe that providing diapers will help break many unhealthy cycles and create a brighter future for our community

Exercise-induced bronchoconstriction in athletes – A qualitative assessment of symptom perception

© 2016Background A poor relationship between perceived respiratory symptoms and objective evidence of exercise-induced bronchoconstriction (EIB) in athletes is often reported; however, the reasons for this disconnect remain unclear. The primary aim of this study was to utilise a qualitative-analytical approach to compare respiratory symptoms in athletes with and without objectively confirmed EIB. Methods Endurance athletes who had previously undergone bronchoprovocation test screening for EIB were divided into sub-groups, based on the presence or absence of EIB ± heightened self-report of dyspnoea: (i) EIB-Dys- (ii) EIB + Dys+ (iii) EIB + Dys- (iv) EIB-Dys+. All athletes underwent a detailed semi-structured interview. Results Twenty athletes completed the study with an equal distribution in each sub-group (n = 5). Thematic analysis of individual narratives resulted in four over-arching themes: 1) Factors aggravating dyspnoea, 2) Exercise limitation, 3) Strategies to control dyspnoea, 4) Diagnostic accuracy. The anatomical location of symptoms varied between EIB + Dys + athletes and EIB-Dys + athletes. All EIB-Dys + reported significantly longer recovery times following high-intensity exercise in comparison to all other sub-groups. Finally, EIB + Dys + reported symptom improvement following beta-2 agonist therapy, whereas EIB-Dys + deemed treatment ineffective. Conclusion A detailed qualitative approach to the assessment of breathlessness reveals few features that distinguish between EIB and non-EIB causes of exertional dyspnoea in athletes. Important differences that may provide value in clinical work-up include (i) location of symptoms, (ii) recovery time following exercise and (iii) response to beta-2 agonist therapy. Overall these findings may inform clinical evaluation and development of future questionnaires to aid clinic-based assessment of athletes with dyspnoea

Strategic Considerations for Locational Regulation of Shellfish Aquaculture in Scotland

Aquaculture is an increasingly important industry for Scotland, helping to sustain economic growth in the rural and coastal communities, and producing Scotland’s most valuable food export. In 2014, the Scottish shellfish farming industry produced almost 8,000 tonnes of shellfish for consumption, estimated to be worth approximately £10.5million. The Scottish shellfish aquaculture industry is aiming to double production volumes by 2020, compared to 2012, and the Scottish Government supports the achievement of these growth targets, with due regard to the marine environment, and refers to the targets in Scotland’s National Marine Plan (NMP) and Strategic Framework for Scottish Aquaculture. Sustainable development demands that such expansion respects environmental limits so that the capacity of the marine environment to accommodate economic development activity is not exceeded. This requires consistent and effective regulation of shellfish aquaculture development to set limits which protect the marine environment but which don’t unnecessarily constrain expansion. The Scottish Aquaculture Research Forum (SARF) commissioned this study to undertake a systematic review of the shellfish aquaculture planning decision-making process after concerns regarding the degree of consistency with which planning applications are treated in different parts of Scotland were raised by the Ministerial Group on Sustainable Aquaculture (MGSA), particularly in relation to the issue of biological carrying capacity. The study objectives were met through undertaking a review of the shellfish planning applications and determinations made in Scotland between 2009 and 2014 and through consultation with key stakeholders in the process including local planning authorities (LPAs), regulators, other statutory consultees in the planning process, industry representatives and individual shellfish businesses/farmers. The initial findings were also discussed with key stakeholders at a project workshop held in October 2015. The results of the planning review showed that of the 148 planning applications made between 2009 and 2014 (118 for mussels, 26 for oyster and 4 for integrated multi-trophic aquaculture (IMTA) developments), 131 were granted (89%), 9 were withdrawn (6%) and 8 were refused (5%). These results do not indicate that the planning determination system has unduly constrained the development of the industry over this time period through overly conservative determinations. Overall, the study found that there was consistency in the approach to planning considerations and determinations across Scotland. The one exception to this was the finding that the current model used to assess the risk of exceedance of biological carrying capacity for proposed shellfish developments produced different results when used by the two end users (the LPA and the statutory consultee) who assess this issue for applications in the Shetland Islands. The reason for this relates to the LPA making allowance for the carrying capacity for the indigenous wild shellfish populations within the model (i.e. using a safety margin for wild shellfish stocks), while the statutory consultee does not as they consider the model to be sufficiently precautionary. Consultation with stakeholders did highlight a number of more minor but nevertheless important issues, where there is opportunity to improve both the planning and wider consenting process and help support sustainable expansion of the industry. Within the determination process, landscape and visual impacts (particularly cumulative impacts) and impacts on commercial fisheries are relatively difficult considerations for LPAs to assess. Aspects of the planning process which concerned industry stakeholders included the cost of the process (including the proportionality of the planning fees for the shellfish industry), competition for space with other marine sectors and unutilised capacity (consented sites not producing fish or shellfish). Stakeholders also felt that the wider consenting regime for the aquaculture industry was complex and that there was an element of duplication between the different consents required. The study also briefly considered future influences on the planning process and the shellfish aquaculture industry. Indicative future projections of shellfish production suggested that the 2020 production targets (13,000 tonnes) may not be met at the current industry growth rate. Expansion of the industry requires expansion at existing and new sites to be available with suitable natural resources and minimal constraints relating to other marine users. The incoming regional marine plans, where based on good data, should be a useful source of information for developers and support industry development where it is appropriate

A Risk Benefit Analysis of Mariculture as a means to Reduce the Impacts of Terrestrial Production of Food and Energy

The Scottish Aquaculture Research Forum (SARF) and WWF-UK commissioned this study to investigate whether the pressure on land and freshwater for future food and energy resources, and impacts on the climate, related to greenhouse gas (GHG) emissions, may be reduced through expansion of global mariculture. The study has undertaken a high level assessment of the ‘environmental footprint’ of global mariculture and terrestrial-based food and energy production systems through the collation and assessment of available Life Cycle Assessments (LCA) for key food products (beef, pork, chicken, freshwater finfish, marine finfish, shellfish and crustacean species) and biomass (terrestrial and algal) for energy production. The outputs of the footprint comparison were then used to assess the risks and benefits of increasing global mariculture, through the development of projected future scenarios in which mariculture contributes differing proportions of projected future food requirements. The analysis also qualitatively considered the socio-economic and wider environmental risks and benefits (e.g. in relation to ecosystem services) of global mariculture expansion, where expansion may occur geographically and whether future technological developments may help mitigate against identified impacts. The study identifies the key uncertainties and limitations of the risk/benefit analysis and makes prioritised recommendations on how these limitations can be addressed and the analysis developed for more regional or site-specific assessments

Usability-Focused Development and Usage of NeoTree-Beta, an App for Newborn Care in a Low-Resource Neonatal Unit, Malawi

Background: Neonatal mortality is high in low-resource settings. NeoTree is a digital intervention for neonatal healthcare professionals (HCPs) aiming to achieve data-driven quality improvement and improved neonatal survival in low-resource hospitals. Optimising usability with end-users could help digital health interventions succeed beyond pilot stages in low-resource settings. Usability is the quality of a user's experience when interacting with an intervention, encompassing their effectiveness, efficiency, and overall satisfaction. Objective: To evaluate the usability and usage of NeoTree beta-app and conduct Agile usability-focused intervention development. Method: A real-world pilot of NeoTree beta-app was conducted over 6 months at Kamuzu Central Hospital neonatal unit, Malawi. Prior to deployment, think-aloud interviews were conducted to guide nurses through the app whilst voicing their thoughts aloud (n = 6). System Usability Scale (SUS) scores were collected before the implementation of NeoTree into usual clinical care and 6 months after implementation (n = 8 and 8). During the pilot, real-world user-feedback and user-data were gathered. Feedback notes were subjected to thematic analysis within an Agile “product backlog.” For usage, number of users, user-cadre, proportion of admissions/outcomes recorded digitally, and median app-completion times were calculated. Results: Twelve overarching usability themes generated 57 app adjustments, 39 (68%) from think aloud analysis and 18 (32%) from the real-world testing. A total of 21 usability themes/issues with corresponding app features were produced and added to the app. Six themes relating to data collection included exhaustiveness of data schema, prevention of errors, ease of progression, efficiency of data entry using shortcuts, navigation of user interface (UI), and relevancy of content. Six themes relating to the clinical care included cohesion with ward process, embedded education, locally coherent language, adaptability of user-interface to available resources, and printout design to facilitate handover. SUS scores were above average (88.1 and 89.4 at 1 and 6 months, respectively). Ninety-three different HCPs of 5 cadres, recorded 1,323 admissions and 1,197 outcomes over 6 months. NeoTree achieved 100% digital coverage of sick neonates admitted. Median completion times were 16 and 8 min for admissions and outcomes, respectively. Conclusions: This study demonstrates optimisation of a digital health app in a low-resource setting and could inform other similar usability studies apps in similar settings

Decreased expression of the mitochondrial bcat protein correlates with improved patient survival in idh-wt gliomas

Background and research question: Gliomas represent 43% of all solid intracranial tumours, of which glioblastomas have the poorest prognosis. Recently, the human cytosolic branched-chain aminotransferase protein (hBCATc), which metabolises the branched-chain amino acids (BCAA), was identified as a biomarker and therapeutic target for glioblastomas carrying wild-type isocitrate dehydrogenase (IDH-WT) genes. However, the clinical utility of the mitochondrial isoform, hBCATm, which also metabolises BCAAs, was not determined nor its potential role in predicting patient survival.Methods: Glioblastomas, of grades II-IV, from 53 patients were graded by a neuropathologist, where the IDH and MGMT status were assessed. Tumours positive for hBCATm, hBCATc and BCKDC were characterised using immunohistochemistry and Western blot analysis using antibodies specific to these proteins.Results: Here, we report that in IDH-WT tumours, the expression of hBCATm is significantly increased (p=0.034) relative to IDH mutation gliomas, and significantly correlates with patient survival, on Kaplan-Meier analysis, where low hBCATm expression is a positive prognostic factor (p=0.003). Moreover, increased hBCATm expression in these glioblastomas correlated with tumour grade indicating their role as a predictive biomarker of glioma progression. Multiple banding was observed for the branched-chain α-keto acid dehydrogenase complex, which catalyses the committed step in BCAA metabolism, but a significant change in expression was absent (p=0.690). Conclusion: Until now, IDH-WT glioblastomas have a uniformly poor prognosis, however we demonstrate for the first time that relatively low hBCATm may select for a better performing subset within this group and may represent a therapeutic target in these hard to treat patients

Clinical effectiveness and cost-effectiveness of a multifaceted podiatry intervention for falls prevention in older people : a multicentre cohort randomised controlled trial (the REducing Falls with ORthoses and a Multifaceted podiatry intervention trial)

BACKGROUND: Falls are a serious cause of morbidity and cost to individuals and society. Evidence suggests that foot problems and inappropriate footwear may increase the risk of falling. Podiatric interventions could help reduce falls; however, there is limited evidence regarding their clinical effectiveness and cost-effectiveness. OBJECTIVES: To determine the clinical effectiveness and cost-effectiveness of a multifaceted podiatry intervention for preventing falls in community-dwelling older people at risk of falling, relative to usual care. DESIGN: A pragmatic, multicentred, cohort randomised controlled trial with an economic evaluation and qualitative study. SETTING: Nine NHS trusts in the UK and one site in Ireland. PARTICIPANTS: In total, 1010 participants aged ≥ 65 years were randomised (intervention, n = 493; usual care, n = 517) via a secure, remote service. Blinding was not possible. INTERVENTIONS: All participants received a falls prevention leaflet and routine care from their podiatrist and general practitioner. The intervention also consisted of footwear advice, footwear provision if required, foot orthoses and foot- and ankle-strengthening exercises. MAIN OUTCOME MEASURES: The primary outcome was the incidence rate of falls per participant in the 12 months following randomisation. The secondary outcomes included the proportion of fallers and multiple fallers, time to first fall, fear of falling, fracture rate, health-related quality of life (HRQoL) and cost-effectiveness. RESULTS: The primary analysis consisted of 484 (98.2%) intervention and 507 (98.1%) usual-care participants. There was a non-statistically significant reduction in the incidence rate of falls in the intervention group [adjusted incidence rate ratio 0.88, 95% confidence interval (CI) 0.73 to 1.05; p = 0.16]. The proportion of participants experiencing a fall was lower (50% vs. 55%, adjusted odds ratio 0.78, 95% CI 0.60 to 1.00; p = 0.05). No differences were observed in key secondary outcomes. No serious, unexpected and related adverse events were reported. The intervention costs £252.17 more per participant (95% CI -£69.48 to £589.38) than usual care, was marginally more beneficial in terms of HRQoL measured via the EuroQoL-5 Dimensions [mean quality-adjusted life-year (QALY) difference 0.0129, 95% CI -0.0050 to 0.0314 QALYs] and had a 65% probability of being cost-effective at the National Institute for Health and Care Excellence threshold of £30,000 per QALY gained. The intervention was generally acceptable to podiatrists and trial participants. LIMITATIONS: Owing to the difficulty in calculating a sample size for a count outcome, the sample size was based on detecting a difference in the proportion of participants experiencing at least one fall, and not the primary outcome. We are therefore unable to confirm if the trial was sufficiently powered for the primary outcome. The findings are not generalisable to patients who are not receiving podiatry care. CONCLUSIONS: The intervention was safe and potentially effective. Although the primary outcome measure did not reach significance, a lower fall rate was observed in the intervention group. The reduction in the proportion of older adults who experienced a fall was of borderline statistical significance. The economic evaluation suggests that the intervention could be cost-effective. FUTURE WORK: Further research could examine whether or not the intervention could be delivered in group sessions, by physiotherapists, or in high-risk patients. TRIAL REGISTRATION: Current Controlled Trials ISRCTN68240461. FUNDING: This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 21, No. 24. See the NIHR Journals Library website for further project information

Under the influence of nature: the contribution of natural capital to tourism spend

Tourism and outdoor leisure is an important economic sector for many countries, and has a substantial reliance on natural capital. Natural capital may be the primary purpose for tourism, or it may be a secondary factor, where the choice of location for a leisure activity is influenced by natural capital. Typically, when valuing tourism and outdoor leisure, all expenditure associated with the activity is assigned to the ecosystem it occurs in. However, this value illustrates the dependency on natural capital, rather than the contribution of natural capital. In natural capital accounting, a major challenge is to separately identify the contribution of natural capital from that of other forms of capital. In this study we develop a transparent and repeatable method that is able to attribute the contribution of natural capital (here defined as ecosystems) to the output of multiple tourism and outdoor leisure activities. Using national statistics from Great Britain, we calculate the natural capital contribution to tourism spend by activity at a national and regional scale, and for a case study map and value the contributing ecosystems. We estimated that, out of a total £36 billion spent on tourism and leisure activities in 2017, £22.5 billion was attributable to natural capital. This equates to 0.9% of the UK GDP. The Gross Value Added component of this attributable was £10.5 billion, equivalent to 0.4% of the UK GDP. Regions with the highest natural capital contribution in Great Britain were Scotland and Wales, with the lowest being Greater London and the West Midlands in England. For the case study, the ecosystems with the greatest contribution to terrestrial activities were marine and enclosed farmland. These methods can be applied worldwide for anywhere with aggregate economic statistics on expenditure associated with tourism and outdoor leisure, with the aid of open source GIS datasets

Development and Implementation of Digital Diagnostic Algorithms for Neonatal Units in Zimbabwe and Malawi: Development and Usability Study

BACKGROUND: Despite an increase in hospital-based deliveries, neonatal mortality remains high in low-resource settings. Due to limited laboratory diagnostics, there is significant reliance on clinical findings to inform diagnoses. Accurate, evidence-based identification and management of neonatal conditions could improve outcomes by standardizing care. This could be achieved through digital clinical decision support (CDS) tools. Neotree is a digital, quality improvement platform that incorporates CDS, aiming to improve neonatal care in low-resource health care facilities. Before this study, first-phase CDS development included developing and implementing neonatal resuscitation algorithms, creating initial versions of CDS to address a range of neonatal conditions, and a Delphi study to review key algorithms. OBJECTIVE: This second-phase study aims to codevelop and implement neonatal digital CDS algorithms in Malawi and Zimbabwe. METHODS: Overall, 11 diagnosis-specific web-based workshops with Zimbabwean, Malawian, and UK neonatal experts were conducted (August 2021 to April 2022) encompassing the following: (1) review of available evidence, (2) review of country-specific guidelines (Essential Medicines List and Standard Treatment Guidelinesfor Zimbabwe and Care of the Infant and Newborn, Malawi), and (3) identification of uncertainties within the literature for future studies. After agreement of clinical content, the algorithms were programmed into a test script, tested with the respective hospital's health care professionals (HCPs), and refined according to their feedback. Once finalized, the algorithms were programmed into the Neotree software and implemented at the tertiary-level implementation sites: Sally Mugabe Central Hospital in Zimbabwe and Kamuzu Central Hospital in Malawi, in December 2021 and May 2022, respectively. In Zimbabwe, usability was evaluated through 2 usability workshops and usability questionnaires: Post-Study System Usability Questionnaire (PSSUQ) and System Usability Scale (SUS). RESULTS: Overall, 11 evidence-based diagnostic and management algorithms were tailored to local resource availability. These refined algorithms were then integrated into Neotree. Where national management guidelines differed, country-specific guidelines were created. In total, 9 HCPs attended the usability workshops and completed the SUS, among whom 8 (89%) completed the PSSUQ. Both usability scores (SUS mean score 75.8 out of 100 [higher score is better]; PSSUQ overall score 2.28 out of 7 [lower score is better]) demonstrated high usability of the CDS function but highlighted issues around technical complexity, which continue to be addressed iteratively. CONCLUSIONS: This study describes the successful development and implementation of the only known neonatal CDS system, incorporated within a bedside data capture system with the ability to deliver up-to-date management guidelines, tailored to local resource availability. This study highlighted the importance of collaborative participatory design. Further implementation evaluation is planned to guide and inform the development of health system and program strategies to support newborn HCPs, with the ultimate goal of reducing preventable neonatal morbidity and mortality in low-resource settings