Pregnant women’s experiences and views on an “opt-out” referral pathway to specialist smoking cessation support: a qualitative evaluation

Introduction: Smoking in pregnancy remains an important and costly public health concern with policy makers worldwide researching methods to aid cessation. UK government guidelines recommend implementation of an “opt-out” (ie, whether requested or not) referral pathway for pregnant smokers to specialist smoking cessation support using carbon monoxide (CO) screening. This study explores the views of pregnant smokers who experienced this new pathway in one UK hospital trust. Methods: Eighteen semi-structured telephone interviews with women who experienced the opt-out pathway were undertaken. Data were analyzed thematically. Results: Three themes were identified relating to expectations, acceptability and impact of the pathway. Women were generally very accepting of the CO testing especially when it met their prior expectations and was perceived as being a routine component of antenatal care. They considered the visual feedback from the CO monitoring improved their motivation to quit. Views on the automatic referral for cessation support were divided with questions raised as to the removal of choice, with many women also expressing dissatisfaction about perceived lack of contact by Stop Smoking Services (SSS) following referral. Conclusion: The opt-out pathway is potentially an acceptable addition to current practice. The women considered CO monitoring to be the most valuable element of the pathway. Women keen to engage with SSS desired a more efficient system of contact. Implications: This study presents a unique insight into pregnant women’s views on the implementation of opt-out referrals for smoking cessation. Introducing CO testing and opt-out referrals at the time of antenatal ultrasound examination can potentially increase motivation to stop smoking in pregnancy. The findings demonstrate that facilitating access to SSS was not always achieved, and further refinement is needed to ensure more effective contact procedures. Ensuring all women are fully informed prior to the CO testing may further improve both the impact of the opt-out referral pathway and the chance of successfully engaging with SSS

A rapid review examining purchasing changes resulting from fiscal measures targeted at high sugar food and non-alcoholic drinks

To aim of the review was to examine the most recent (2010 onwards) research evidence on the health and behavioural impacts, in adults and children, of fiscal strategies that target high sugar foods and sugar-sweetened drinks (SSDs). A pragmatic rapid review was undertaken using a systematic search strategy. The review was part of a programme of work to support policy development in relation to high sugar food and SSDs. A total of 11 primary research publications were included, describing evidence from France (n = 1), the Netherlands (n = 3), and the United States of America (n = 7), assessed through a variety of study designs, with the majority in adult populations (n = 10). The evidence reviewed focused on consumer behaviour outcomes and suggested that fiscal strategies can influence purchases of high sugar products. Although the majority of studies (n = 10), including three field studies, demonstrated that an increase in the price of high sugar foods and SSDs resulted in a decrease in purchases, eight studies were conducted in a laboratory or virtual setting which may not reflect real-life situations. Findings from this review support evidence from the broader literature that suggests that fiscal measures can be effective in influencing the purchasing of high sugar foods and SSDs

‘Opt-out’ referrals after identifying pregnant smokers using exhaled air carbon monoxide: impact on engagement with smoking cessation support

Background. In the UK, free smoking cessation support is available to pregnant women; only a minority access this. ‘Opt-out’ referrals to stop smoking services (SSS) are recommended by UK guidelines. These involve identifying pregnant smokers using exhaled carbon monoxide (CO) and referring them for support unless they object. Methods. To assess impact of ‘opt-out’ referrals for pregnant smokers on SSS uptake and effectiveness, we conducted a ‘before-after’ service development evaluation. In a six-month ‘before’ period there was a routine ‘opt-in’ referral system for self-reported smokers at antenatal ‘booking’ appointments. In a six-month ‘after’ period, additional ‘opt-out’ referrals were introduced at 12 weeks ultrasound appointments; women with CO≥4ppm were referred to, and outcome data were collected from, local SSS. Results. Approximately 2300 women attended antenatal care in each period. Before the implementation 536 (23.4%) women reported smoking at ‘booking’ and 290 (12.7%) were referred to SSS. After the implementation 524 (22.9%) women reported smoking at ‘booking’, an additional 156 smokers (6.8%) were identified via the ‘opt-out’ referrals and, in total, 421 (18.4%) were referred to SSS. Over twice as many women set a quit date with the SSS after ‘opt-out’ referrals were implemented (121 (5.3%, 95%CI: 4.4%-6.3%) compared to 57 (2.5%, 95%CI: 1.9%-3.2%) before implementation) and reported being abstinent four weeks later (93 (4.1%, 95%CI: 3.3%-4.9%) compared to 46 (2.0%, 1.5%-2.7%) before implementation). Conclusions. In a hospital with an ‘opt-in’ referral system, adding CO screening with ‘opt-out’ referrals as women attended ultrasound examinations doubled numbers of pregnant smokers setting quit dates and reporting smoking cessation

Rehabilitation versus surgical reconstruction for non-acute anterior cruciate ligament injury (ACL SNNAP): a pragmatic randomised controlled trial

BackgroundAnterior cruciate ligament (ACL) rupture is a common debilitating injury that can cause instability of the knee. We aimed to investigate the best management strategy between reconstructive surgery and non-surgical treatment for patients with a non-acute ACL injury and persistent symptoms of instability.MethodsWe did a pragmatic, multicentre, superiority, randomised controlled trial in 29 secondary care National Health Service orthopaedic units in the UK. Patients with symptomatic knee problems (instability) consistent with an ACL injury were eligible. We excluded patients with meniscal pathology with characteristics that indicate immediate surgery. Patients were randomly assigned (1:1) by computer to either surgery (reconstruction) or rehabilitation (physiotherapy but with subsequent reconstruction permitted if instability persisted after treatment), stratified by site and baseline Knee Injury and Osteoarthritis Outcome Score—4 domain version (KOOS4). This management design represented normal practice. The primary outcome was KOOS4 at 18 months after randomisation. The principal analyses were intention-to-treat based, with KOOS4 results analysed using linear regression. This trial is registered with ISRCTN, ISRCTN10110685, and ClinicalTrials.gov, NCT02980367.FindingsBetween Feb 1, 2017, and April 12, 2020, we recruited 316 patients. 156 (49%) participants were randomly assigned to the surgical reconstruction group and 160 (51%) to the rehabilitation group. Mean KOOS4 at 18 months was 73·0 (SD 18·3) in the surgical group and 64·6 (21·6) in the rehabilitation group. The adjusted mean difference was 7·9 (95% CI 2·5–13·2; p=0·0053) in favour of surgical management. 65 (41%) of 160 patients allocated to rehabilitation underwent subsequent surgery according to protocol within 18 months. 43 (28%) of 156 patients allocated to surgery did not receive their allocated treatment. We found no differences between groups in the proportion of intervention-related complications.InterpretationSurgical reconstruction as a management strategy for patients with non-acute ACL injury with persistent symptoms of instability was clinically superior and more cost-effective in comparison with rehabilitation management

Testing a global standard for quantifying species recovery and assessing conservation impact.

Recognizing the imperative to evaluate species recovery and conservation impact, in 2012 the International Union for Conservation of Nature (IUCN) called for development of a "Green List of Species" (now the IUCN Green Status of Species). A draft Green Status framework for assessing species' progress toward recovery, published in 2018, proposed 2 separate but interlinked components: a standardized method (i.e., measurement against benchmarks of species' viability, functionality, and preimpact distribution) to determine current species recovery status (herein species recovery score) and application of that method to estimate past and potential future impacts of conservation based on 4 metrics (conservation legacy, conservation dependence, conservation gain, and recovery potential). We tested the framework with 181 species representing diverse taxa, life histories, biomes, and IUCN Red List categories (extinction risk). Based on the observed distribution of species' recovery scores, we propose the following species recovery categories: fully recovered, slightly depleted, moderately depleted, largely depleted, critically depleted, extinct in the wild, and indeterminate. Fifty-nine percent of tested species were considered largely or critically depleted. Although there was a negative relationship between extinction risk and species recovery score, variation was considerable. Some species in lower risk categories were assessed as farther from recovery than those at higher risk. This emphasizes that species recovery is conceptually different from extinction risk and reinforces the utility of the IUCN Green Status of Species to more fully understand species conservation status. Although extinction risk did not predict conservation legacy, conservation dependence, or conservation gain, it was positively correlated with recovery potential. Only 1.7% of tested species were categorized as zero across all 4 of these conservation impact metrics, indicating that conservation has, or will, play a role in improving or maintaining species status for the vast majority of these species. Based on our results, we devised an updated assessment framework that introduces the option of using a dynamic baseline to assess future impacts of conservation over the short term to avoid misleading results which were generated in a small number of cases, and redefines short term as 10 years to better align with conservation planning. These changes are reflected in the IUCN Green Status of Species Standard

Panarchy, ontological and epistemological phenomena, and the Plague

Building resilience to major economic, social, and ecological crises such as armed conflict and natural disasters is seen as critical to maintaining system integrity. Although studies of system survival can be used to gauge whether or not social systems are resilient, this can only be conducted in retrospect. Contemporary measures of resilience rely on proxy measures that one can argue build capacity for resilience, but are not direct proxies for resilience itself, except in highly subscribed conditions. This leads us to our key research questions: Can the resilience of a system be measured contemporaneously by those within a social system? What can we learn from past efforts to understand the resilience of social systems by those living through their transformations? To answer these we examine Europe in the second half of the 14th century, during the outbreak and spread of the Plague through the continent. Through an examination of academic research relying on contemporary accounts during this period, we examine the indicators Europeans used at the time to understand changes in their social-ecological systems. We find a time lag between quantitative indicators of system resilience and the systemic shocks introduced by the Plague. However, narratives from the time suggest that those who experienced the epidemic were trying to develop personal understandings of the social changes around them and collective understandings of how to respond to these crises, both in advance of collecting easily comparable data that could be used for broader administrative purposes. The progression from individual narratives, to common understandings, and finally to comparable data is likely a common process that occurs as those within a social-ecological system make sense of a shift of the system from one arrangement to another

Moral Entrepreneurship: Thinking and Acting at the Landscape Level to Foster Sustainability Transitions

This research contributes to an important yet overlooked theme in sustainability transitions scholarship: the role of normative deliberation in large-scale systemic change. We adopt the term “moral entrepreneur” to describe the deliberate efforts to change institutionalized moral norms, and thus foster sustainability transitions. We adopt an interdisciplinary approach and, by drawing on the institutional lens, synthesize the multi-level perspective from sustainability transitions studies with the scholarship on discursive action from organization and management studies to explore the mechanisms by which moral entrepreneurs contribute to transformative change. Based on an analysis of the creation of the American national parks in the early 20th century and specifically John Muir’s role therein, we argue that moral entrepreneurs trigger landscape level changes by gradually disassociating rules and practices from their moral foundations through engaging in a macro-systemic discourse

How game changers catalyzed, disrupted, and incentivized social innovation: three historical cases of nature conservation, assimilation, and women's rights

We explore the impact of "game changers" on the dynamics of innovation over time in three problem domains, that of wilderness protection, women's rights, and assimilation of indigenous children in Canada. Taking a specifically historical and cross-scale approach, we look at one social innovation in each problem domain. We explore the origins and history of the development of the National Parks in the USA, the legalization of contraception in the USA and Canada, and the residential school system in Canada. Based on a comparison of these cases, we identify three kinds of game changers, those that catalyze social innovation, which we define as "seminal," those that disrupt the continuity of social innovation, which we label exogenous shocks, and those that provide opportunities for novel combinations and recombinations, which we label as endogamous game changers

How Game Changers Catalyzed, Disrupted, and Incentivized Social Innovation: Three Historical Cases of Nature Conservation, Assimilation, and Women’s Rights

We explore the impact of “game changers” on the dynamics of innovation over time in three problem domains, that of wilderness protection, women’s rights, and assimilation of indigenous children in Canada. Taking a specifically historical and cross-scale approach, we look at one social innovation in each problem domain. We explore the origins and history of the development of the National Parks in the USA, the legalization of contraception in the USA and Canada, and the residential school system in Canada. Based on a comparison of these cases, we identify three kinds of game changers, those that catalyze social innovation, which we define as “seminal,” those that disrupt the continuity of social innovation, which we label exogenous shocks, and those that provide opportunities for novel combinations and recombinations, which we label as endogamous game changers

The Endocrine and Metabolic Characteristics of a Large Bardet-Biedl Syndrome Clinic Population

Bardet-Biedl syndrome (BBS) is a rare autosomal recessive disorder in which previous reports have described obesity and a metabolic syndrome.Describe the endocrine and metabolic characteristics of a large BBS population compared with matched controls.Case-control.Hospital clinic.A clinical/genetic diagnosis of BBS.None.Prevalence of metabolic syndrome.One hundred and fifty-two subjects were studied. Eight-four (55.3%) were male and mean (±SD) age was 33.2±1.0 years. Compared with age, gender and BMI matched controls, fasting glucose and insulin levels were significantly higher in BBS subjects (glucose: BBS: 5.2±1.2mmol/l vs control 4.9±0.9mmol/l, p=0.04; insulin: BBS: 24.2±17.0pmol/l vs control 14.2±14.8pmol/l, p<0.001). Serum triglycerides were significantly higher in BBS subjects (2.0±1.2mmol/l) compared with controls (1.3± 0.8mmol/l p<0.001) but total cholesterol/HDL/LDL were similar in both groups. Systolic blood pressure was higher in the BBS group (BBS 135±18 mmHg vs controls 129±16mmHg (p=0.02). Alanine transaminase (ALT) was raised in 34 (26.8%) BBS subjects, compared to 5 (8.9%) controls (p=0.01). The presence of a metabolic syndrome, using IDF criteria, was significantly higher in the BBS group (54.3%) compared to controls (26% p<0.001). Twenty-six (19.5%) of BBS males were hypogonadal (serum testosterone 9.9±5.3 mmol/l) but significant pituitary abnormalities were uncommon. Subclinical hypothyroidism was present in 24/125 (19.4%) patients with BBS compared with 3/65 (4.6%) controls (p=0.01).Insulin resistance and the metabolic syndrome are increased in adult BBS compared with matched controls. Increased subclinical hypothyroidism in the BBS cohort is a novel finding that needs further investigation