'I thought it would be a very clearly defined role and actually it wasn't': a qualitative study of transition training for pharmacists moving into general practice settings in Wales

Objective Pharmacists are increasingly contributing to the skill mix of general practice surgeries to help alleviate pressures faced by UK doctors working in primary care. However, they need support in overcoming barriers to their integration. The purpose of this work was to evaluate a programme designed to support pharmacists’ transition to working in general practice settings. We explored the learning needs of pharmacists’, the barriers and enablers to their integration and provide recommendations based on our results. Intervention A qualitative evaluation of a 1-year transition programme in Wales starting in September 2018 to support pharmacists’ transition to working in general practice settings. Design and setting We employed an interpretative phenomenological approach involving 10 pharmacists across Wales enrolled on the transition to general practice training programme, and their tutors. Data were collected across two sequential phases: in phase 1 telephone interviews were held with pharmacists midway through their training; in phase 2, focus groups were conducted with both pharmacists and tutors towards the end of the programme. Results Pharmacists enter general practice settings with a variety of prior experience. The programme provided a framework that pharmacists found helpful to map their experience to but the programme needed to be flexible to individual learning needs. The tutor role was typically regarded as the most valuable component, but interaction with the wider general practice team was critical to ease the transition. Pharmacists encountered a lack of clarity about their role which impeded their integration into the workplace team. Conclusions A formal programme with a designated tutor can support pharmacists’ transition into general practice settings. The programme’s competency framework facilitated reciprocal understanding of the pharmacist’s role in the team, helped to manage expectations and enhanced collaborative practice. Recommendations to facilitate pharmacist integration into general practice settings are provided

Durrington Walls to West Amesbury by way of Stonehenge: a major transformation of the Holocene landscape

A new sequence of Holocene landscape change has been discovered through an investigation of sediment sequences, palaeosols, pollen and molluscan data discovered during the Stonehenge Riverside Project. The early post-glacial vegetational succession in the Avon valley at Durrington Walls was apparently slow and partial, with intermittent woodland modification and the opening-up of this landscape in the later Mesolithic and earlier Neolithic, though a strong element of pine lingered into the third millennium BC. There appears to have been a major hiatus around 2900 cal BC, coincident with the beginnings of demonstrable human activities at Durrington Walls, but slightly after activity started at Stonehenge. This was reflected in episodic increases in channel sedimentation and tree and shrub clearance, leading to a more open downland, with greater indications of anthropogenic activity, and an increasingly wet floodplain with sedges and alder along the river’s edge. Nonetheless, a localized woodland cover remained in the vicinity of DurringtonWalls throughout the third and second millennia BC, perhaps on the higher parts of the downs, while stable grassland, with rendzina soils, predominated on the downland slopes, and alder–hazel carr woodland and sedges continued to fringe the wet floodplain. This evidence is strongly indicative of a stable and managed landscape in Neolithic and Bronze Age times. It is not until c 800–500 cal BC that this landscape was completely cleared, except for the marshy-sedge fringe of the floodplain, and that colluvial sedimentation began in earnest associated with increased arable agriculture, a situation that continued through Roman and historic times

Analysis of Dentists’ Participation in Continuing Professional Development Courses from 2001-2006

Currently in Western Australia (WA) there is no requirement for dentists to participate in continuing professional development (CPD). The aim of this study was to determine the participation pattern of dentists in WA in CPD activities. Data was collated regarding registrants for courses conducted by the University Continuing Dental Education Committee. Information concerned number of courses attended by each dentist, location of work and year of graduation from university. Details of subject, length and type of courses conducted were also gathered. Most courses were half to one day in duration with many subjects covered. Between 10.1-24.4% of dentists registered in WA attended at least one course each year. Low numbers of recently graduated and older dentists attended courses. Similar percentages of metropolitan and rural dentists attended courses. Participation in CPD activities of dentists in WA was low. Half day or evening courses appear to be favoured by dentists

The Dorsiflexion Range of Motion Screen: A Validation Study

# Background Limited ankle dorsiflexion (DF) is associated with ankle sprains and other lower extremity injuries. Current ankle measurements can be laborious to perform in an athletic environment. # Purpose The purpose of this study was to determine the reliability and discriminant validity of a novel closed-chain ankle DF ROM test, the standing ankle dorsiflexion screen (SADS). # Study Design Reliability and validity study # Methods Thirty-seven healthy subjects participated in the study. Two raters measured closed-chain ankle DF range of motion (ROM) using a modified lunge position with an electronic inclinometer. Four raters measured ankle DF using the SADS. Reliability was calculated using intraclass correlation coefficients (ICC) and kappa coefficients for the raters using an electronic inclinometer and the SADS scale, respectively. An independent t-test compared the SADS categories of “behind” and “beyond” to the modified lunge test ROM (*p*<0.05). # Results Excellent ICC values (0.95 $$95$$) and high kappa values were observed (0.61-0.81), with high percent agreement (86-94%). There was a significant difference in ankle DF ROM between the nominally scored “behind” and “beyond” categories, regardless of rater or trial analyzed (behind: 41.3° ± 4.7°; beyond: 51.8°± SD 6.1°, *p* <0.001). # Conclusions The SADS was observed to have excellent interrater reliability and high discriminant validity. Furthermore, there was a distinct closed chain ankle DF ROM difference between the “behind” and “beyond” SADS nominal scores. # Clinical Relevance The SADS can be used as a quick and efficient closed chain ankle DF ROM screen. # Level of Evidence 2

A pragmatic cluster randomised trial evaluating three implementation interventions

Background Implementation research is concerned with bridging the gap between evidence and practice through the study of methods to promote the uptake of research into routine practice. Good quality evidence has been summarised into guideline recommendations to show that peri-operative fasting times could be considerably shorter than patients currently experience. The objective of this trial was to evaluate the effectiveness of three strategies for the implementation of recommendations about peri-operative fasting. Methods A pragmatic cluster randomised trial underpinned by the PARIHS framework was conducted during 2006 to 2009 with a national sample of UK hospitals using time series with mixed methods process evaluation and cost analysis. Hospitals were randomised to one of three interventions: standard dissemination (SD) of a guideline package, SD plus a web-based resource championed by an opinion leader, and SD plus plan-do-study-act (PDSA). The primary outcome was duration of fluid fast prior to induction of anaesthesia. Secondary outcomes included duration of food fast, patients' experiences, and stakeholders' experiences of implementation, including influences. ANOVA was used to test differences over time and interventions. Results Nineteen acute NHS hospitals participated. Across timepoints, 3,505 duration of fasting observations were recorded. No significant effect of the interventions was observed for either fluid or food fasting times. The effect size was 0.33 for the web-based intervention compared to SD alone for the change in fluid fasting and was 0.12 for PDSA compared to SD alone. The process evaluation showed different types of impact, including changes to practices, policies, and attitudes. A rich picture of the implementation challenges emerged, including inter-professional tensions and a lack of clarity for decision-making authority and responsibility. Conclusions This was a large, complex study and one of the first national randomised controlled trials conducted within acute care in implementation research. The evidence base for fasting practice was accepted by those participating in this study and the messages from it simple; however, implementation and practical challenges influenced the interventions' impact. A set of conditions for implementation emerges from the findings of this study, which are presented as theoretically transferable propositions that have international relevance. Trial registration ISRCTN18046709 - Peri-operative Implementation Study Evaluation (POISE

Mutations in Known Monogenic High Bone Mass Loci Only Explain a Small Proportion of High Bone Mass Cases.

High bone mass (HBM) can be an incidental clinical finding; however, monogenic HBM disorders (eg, LRP5 or SOST mutations) are rare. We aimed to determine to what extent HBM is explained by mutations in known HBM genes. A total of 258 unrelated HBM cases were identified from a review of 335,115 DXA scans from 13 UK centers. Cases were assessed clinically and underwent sequencing of known anabolic HBM loci: LRP5 (exons 2, 3, 4), LRP4 (exons 25, 26), SOST (exons 1, 2, and the van Buchem's disease [VBD] 52-kb intronic deletion 3'). Family members were assessed for HBM segregation with identified variants. Three-dimensional protein models were constructed for identified variants. Two novel missense LRP5 HBM mutations ([c.518C>T; p.Thr173Met], [c.796C>T; p.Arg266Cys]) were identified, plus three previously reported missense LRP5 mutations ([c.593A>G; p.Asn198Ser], [c.724G>A; p.Ala242Thr], [c.266A>G; p.Gln89Arg]), associated with HBM in 11 adults from seven families. Individuals with LRP5 HBM (∼prevalence 5/100,000) displayed a variable phenotype of skeletal dysplasia with increased trabecular BMD and cortical thickness on HRpQCT, and gynoid fat mass accumulation on DXA, compared with both non-LRP5 HBM and controls. One mostly asymptomatic woman carried a novel heterozygous nonsense SOST mutation (c.530C>A; p.Ser177X) predicted to prematurely truncate sclerostin. Protein modeling suggests the severity of the LRP5-HBM phenotype corresponds to the degree of protein disruption and the consequent effect on SOST-LRP5 binding. We predict p.Asn198Ser and p.Ala242Thr directly disrupt SOST binding; both correspond to severe HBM phenotypes (BMD Z-scores +3.1 to +12.2, inability to float). Less disruptive structural alterations predicted from p.Arg266Cys, p.Thr173Met, and p.Gln89Arg were associated with less severe phenotypes (Z-scores +2.4 to +6.2, ability to float). In conclusion, although mutations in known HBM loci may be asymptomatic, they only account for a very small proportion (∼3%) of HBM individuals, suggesting the great majority are explained by either unknown monogenic causes or polygenic inheritance.This study was supported by The Wellcome Trust and NIHR CRN (portfolio number 5163). CLG was funded by a Wellcome Trust Clinical Research Training Fellowship (080280/Z/06/Z), the EU 7th Framework Programme under grant agreement number 247642 (GEoCoDE), a British Geriatric Society travel grant, and is now funded by Arthritis Research UK (grant ref 20000). SH acknowledges Arthritis Research UK support (grant ref 19580). KESP acknowledges the support of Cambridge NIHR Biomedical Research Centre. KAW is supported by the core programme of the MRC Nutrition and Bone Health group at MRC Human Nutrition Research, funded by the UK Medical Research Council (Grant code U10590371). EM acknowledges support of the Sheffield Teaching Hospitals Foundation Trust Clinical Research Facility. The SGC is a registered charity (no. 1097737) that receives funds from AbbVie, Bayer, Boehringer Ingelheim, Genome Canada (Ontario Genomics Institute OGI- 055), GlaxoSmithKline, Janssen, Lilly Canada, Novartis Research Foundation, Ontario Ministry of Economic Development & Innovation, Pfizer, Takeda, and Wellcome Trust (092809/Z/10/Z).This is the final version of the article. It first appeared from Wiley via http://dx.doi.org/10.1002/jbmr.270

Brexit and the Cultural Sector

A collaborative ebook on the effects of the Brexit vote on the UK's cultural sector and its agents: "It's not just the economy, stupid! Brexit and the Cultural Sector", edited by Gesa Stedman and Sandra van Lente. Our contributors come from a broad range of cultural and artistic practice and many of them worry about two aspects which have come to the fore in the context of Brexit: the stark social rift which separates the Leave and Remain camps, and the nasty rise of xenophobia and insularity in all its different shapes and forms. Although our authors do not intend to be read or viewed as all-encompassing, and although they differ in respect to the focus they chose for their essays, poems, or statements, one aspect unifies their utterances: passion. Passion for the multi-faceted characteristics of culture, language, exchange, dialogue, border-crossings, passion for an outward-looking approach to both Britain, its different nations, and its neighbours close and far. A passionate fear of what Britain might lose in the process of departing from the EU. And the fear of loss does not concentrate on the loss of revenue or even on the probable obstacles to travel and artistic exchange once Brexit is in place. But the loss of ambivalence and ambiguity, the loss of conflicting opinions, texts, stances, diversity, in short: everything that culture, which is free to find its own forms of expression, is valued for

BIOSAFETY. Safeguarding gene drive experiments in the laboratory.

Multiple stringent confinement strategies should be used whenever possibleThis is the author accepted manuscript. The final version is available from AAAS via http://dx.doi.org/10.1126/science.aac793

Understanding the circumgalactic medium is critical for understanding galaxy evolution

Galaxies evolve under the influence of gas flows between their interstellar medium and their surrounding gaseous halos known as the circumgalactic medium (CGM). The CGM is a major reservoir of galactic baryons and metals, and plays a key role in the long cycles of accretion, feedback, and recycling of gas that drive star formation. In order to fully understand the physical processes at work within galaxies, it is therefore essential to have a firm understanding of the composition, structure, kinematics, thermodynamics, and evolution of the CGM. In this white paper we outline connections between the CGM and galactic star formation histories, internal kinematics, chemical evolution, quenching, satellite evolution, dark matter halo occupation, and the reionization of the larger-scale intergalactic medium in light of the advances that will be made on these topics in the 2020s. We argue that, in the next decade, fundamental progress on all of these major issues depends critically on improved empirical characterization and theoretical understanding of the CGM. In particular, we discuss how future advances in spatially-resolved CGM observations at high spectral resolution, broader characterization of the CGM across galaxy mass and redshift, and expected breakthroughs in cosmological hydrodynamic simulations will help resolve these major problems in galaxy evolution.Comment: Astro2020 Decadal Science White Pape