Surviving to thrive in complexity: a mixed method evaluation of military rehabilitation post lower limb amputation

This cohort of combat casualties from Iraq and Afghanistan should not have survived; but they did. Their survival should now be defined by their disability; yet it is not. Using a mixed method research approach underpinned by complexity science and social theory, this study critically examines military rehabilitation post lower limb amputation and key components required to manage their complex needs. Structured around an adapted MRC evaluation framework for complex interventions, perspectives of clinicians, clinical managers and veterans have been captured and verified using the Nominal Group Technique, interviews, and veteran outcome data (ADVANCE). Clinicians and clinical managers cite the importance of a highly collaborative interdisciplinary team approach where a culture of innovation, creativity, trust, and interdependence is nurtured by leaders. Conversely, the multidisciplinary team structure led to feelings of distrust, inadequacy, isolation, and disempowerment to adapt their circumstance. Veterans highlight the prosthetic limb as a powerful symbol of autonomy and group membership; social bonds with peers, family and trusted clinicians, and the intensive goal centred, functionally based, rehabilitation process are also prized. These components support veterans to acquire the skills needed to feel connected with others and act autonomously – verified in the literature as extrinsic enablers of human thriving. The ADVANCE cohort presented with a high severity of injury, yet remarkably no psychological or social decline when compared to uninjured controls. However, psychosocial outcomes did not depend on prosthetic mobility as previous research has shown. Therefore, both qualitative and quantitative data, point to a social dynamic supporting clinicians and patients to achieve their intrinsic motivational needs – to feel connected, competent, autonomous, and thereby, to thrive. Rehabilitation programmes planned around the proposed model of human thriving should promote high levels of social, psychological, and physical recovery. Future research is suggested on factors impeding thriving, mental health, socket comfort and medication.Open Acces

The P2 Receptor Antagonist PPADS Supports Recovery from Experimental Stroke In Vivo

BACKGROUND: After ischemia of the CNS, extracellular adenosine 5'-triphosphate (ATP) can reach high concentrations due to cell damage and subsequent increase of membrane permeability. ATP may cause cellular degeneration and death, mediated by P2X and P2Y receptors. METHODOLOGY/PRINCIPAL FINDINGS: The effects of inhibition of P2 receptors by pyridoxalphosphate-6-azophenyl-2',4'-disulphonic acid (PPADS) on electrophysiological, functional and morphological alterations in an ischemia model with permanent middle cerebral artery occlusion (MCAO) were investigated up to day 28. Spontaneously hypertensive rats received PPADS or vehicle intracerebroventricularly 15 minutes prior MCAO for up to 7 days. The functional recovery monitored by qEEG was improved by PPADS indicated by an accelerated recovery of ischemia-induced qEEG changes in the delta and alpha frequency bands along with a faster and sustained recovery of motor impairments. Whereas the functional improvements by PPADS were persistent at day 28, the infarct volume measured by magnetic resonance imaging and the amount of TUNEL-positive cells were significantly reduced by PPADS only until day 7. Further, by immunohistochemistry and confocal laser scanning microscopy, we identified both neurons and astrocytes as TUNEL-positive after MCAO. CONCLUSION: The persistent beneficial effect of PPADS on the functional parameters without differences in the late (day 28) infarct size and apoptosis suggests that the early inhibition of P2 receptors might be favourable for the maintenance or early reconstruction of neuronal connectivity in the periinfarct area after ischemic incidents

Impact on and use of health services by international migrants: questionnaire survey of inner city London A&E attenders

BACKGROUND: Changing immigration trends pose new challenges for the UK's open access health service and there is considerable speculation that migrants from resource-poor countries place a disproportionate burden on services. Data are needed to inform provision of services to migrant groups and to ensure their access to appropriate health care. We compared sociodemographic characteristics and impact of migrant groups and UK-born patients presenting to a hospital A&E/Walk-In Centre and prior use of community-based General Practitioner (GP) services. METHODS: We administered an anonymous questionnaire survey of all presenting patients at an A&E/Walk-In Centre at an inner-city London hospital during a 1 month period. Questions related to nationality, immigration status, time in the UK, registration and use of GP services. We compared differences between groups using two-way tables by Chi-Square and Fisher's exact test. We used logistic regression modelling to quantify associations of explanatory variables and outcomes. RESULTS: 1611 of 3262 patients completed the survey (response rate 49.4%). 720 (44.7%) were overseas born, representing 87 nationalities, of whom 532 (73.9%) were new migrants to the UK (≤10 years). Overseas born were over-represented in comparison to local estimates (44.7% vs 33.6%; p < 0.001; proportional difference 0.111 [95% CI 0.087–0.136]). Dominant immigration status' were: work permit (24.4%), EU citizens (21.5%), with only 21 (1.3%) political asylum seekers/refugees. 178 (11%) reported nationalities from refugee-generating countries (RGCs), eg, Somalia, who were less likely to speak English. Compared with RGCs, and after adjusting for age and sex, the Australians, New Zealanders, and South Africans (ANS group; OR 0.28 [95% CI 0.11 to 0.71]; p = 0.008) and the Other Migrant (OM) group comprising mainly Europeans (0.13 [0.06 to 0.30]; p = 0.000) were less likely to have GP registration and to have made prior contact with GPs, yet this did not affect mode of access to hospital services across groups nor delay access to care. CONCLUSION: Recently arrived migrants are a diverse and substantial group, of whom migrants from refugee-generating countries and asylum seekers comprise only a minority group. Service reorganisation to ensure improved access to community-based GPs and delivery of more appropriate care may lessen their impact on acute services

Fish distribution database

This file contains the freshwater fish species presence/absence data used in our analysis. The first column lists each of the rivers for which we had community data, while the remaining columns indicate the presence/absence of individual species coded as 1 = present, 0 = absent

Data from: The Kimberley, north-western Australia, as a cradle of evolution and endemic biodiversity: an example using Grunters (Terapontidae)

Aim: To test two prominent, alternate hypotheses that provide explanations for the great accumulation of endemic species in the Kimberley bioregion in north-western Australia, using an extensively sampled, region wide phylogeny of northern Australia’s most speciose freshwater fish family, Terapontidae. Specifically, we test whether the Kimberley may act as (1) a “museum” accumulating taxa and endemic species over time or (2) a “cradle” of more recent diversification and neoendemism. Location: The Australian monsoonal tropics Taxon: Grunters (Terapontidae) Methods: We obtained a robust and well supported Bayesian phylogeny for the family using DNA sequences from mtDNA and nuclear gene regions. We performed molecular phylogenetic analyses using species tree methods including molecular dating analysis, ancestral range reconstruction, and diversification analysis. Results: Based on our phylogeny, the combined molecular clock estimates and likelihood-based historical biogeographic reconstructions suggest that terapontids recently transitioned into the Kimberley from the east during the late-Miocene. We found that 80% of Kimberley terapontids diversified within the Kimberley in the last 3 Ma. Further, diversification analyses identified a single significant shift in diversification rates ~1.4 Ma that corresponds with a change in global climate midway through the Pleistocene that was predominantly driven by speciation in the Kimberley. Main Conclusions: The weight of evidence suggests that the Kimberley has been a “cradle” of evolution for Terapontidae, rather than a “museum”. Our analysis provides strong evidence for a geologically recent transition of terapontids into the Kimberley from regions to the east during the late Miocene followed by a significant increase in speciation rates during the Pleistocene, driven by speciation in the Kimberley. The results provide important insight into the evolutionary and biogeographical processes that have shaped the regions unique biota, which will inform land managers working to protect and conserve both species and the processes responsible for generating and sustaining them

Terapontid_PosteriorTrees_10k

A posterior distribution of 10,000 trees sampled from the broader distribution used in the *BEAST analysi

Strengthening the primary care workforce to deliver high-quality care for non-communicable diseases in refugee settings: lessons learnt from a UNHCR partnership.

Non-communicable disease (NCD) prevention and care in humanitarian contexts has been a long-neglected issue. Healthcare systems in humanitarian settings have focused heavily on communicable diseases and immediate life-saving health needs. NCDs are a significant cause of morbidity and mortality in refugee settings, however, in many situations NCD care is not well integrated into primary healthcare services. Increased risk of poorer outcomes from COVID-19 for people living with NCDs has heightened the urgency of responding to NCDs and shone a spotlight on their relative neglect in these settings. Partnering with the United Nations Refugee Agency (UNHCR) since 2014, Primary Care International has provided clinical guidance and Training of Trainer (ToT) courses on NCDs to 649 health professionals working in primary care in refugee settings in 13 countries. Approximately 2300 healthcare workers (HCW) have been reached through cascade trainings over the last 6 years. Our experience has shown that, despite fragile health services, high staff turnover and competing clinical priorities, it is possible to improve NCD knowledge, skills and practice. ToT programmes are a feasible and practical format to deliver NCD training to mixed groups of HCW (doctors, nurses, technical officers, pharmacy technicians and community health workers). Clinical guidance must be adapted to local settings while co-creating an enabling environment for health workers is essential to deliver accessible, high-quality continuity of care for NCDs. On-going support for non-clinical systems change is equally critical for sustained impact. A shared responsibility for cascade training-and commitment from local health partners-is necessary to raise NCD awareness, influence local and national policy and to meet the UNHCR's objective of facilitating access to integrated prevention and control of NCDs

Data from: A revision of the bioregionalisation of freshwater fish communities in the Australian Monsoonal Tropics

The Australian freshwater fish fauna is very unique, but poorly understood. In the Australian Monsoonal Tropics (AMT) biome of northern Australia, the number of described and candidate species has nearly doubled since the last attempt to analyse freshwater fish species composition patterns and determine a bioregionalisation scheme. Here, we utilise the most complete database of catchment‐scale freshwater fish distributions from the AMT to date to: (a) reanalyze spatial patterns of species richness, endemism and turnover of freshwater fishes; (b) propose a biogeographic regionalisation based on species turnover; (c) assess the relationship between species turnover and patterns of environmental change and historic drainage connectivity; and (d) identify sampling gaps. Biogeographic provinces were identified using an agglomerative cluster analysis of a Simpson's beta (βsim) dissimilarity matrix. A generalised dissimilarity model incorporating eighteen environmental variables was used to investigate the environmental correlates of species turnover. Observed and estimated species richness and endemism were calculated and inventory completeness was estimated based on the ratio of observed to estimated species richness. Three major freshwater fish biogeographic provinces and 14 subprovinces are proposed. These differ substantially from the current bioregionalisation scheme. Species turnover was most strongly influenced by environmental variables that are interpreted to reflect changes in terrain (catchment relief and confinement), geology and climate (runoff perenniality, stream density), and biotic responses to climate (net primary productivity). Past connectivity between rivers during low sea‐level events is also influential highlighting the importance of historical processes in explaining contemporary patterns of biodiversity in the AMT. The inclusion of 49 newly discovered species and candidate species only reinforced known focal points of species richness and endemism in the AMT. However, a number of key sampling gaps remain that need to be filled to fully characterise the proposed bioregionalisation