Common pitfalls, and how to avoid them, in child and adolescent psychopharmacology: Part II

As Faculty of the British Association for Psychopharmacology course on child and adolescent psychopharmacology, we present here what we deem are the most common pitfalls, and how to avoid them, in child and adolescent psychopharmacology. In this paper, we specifically addressed common pitfalls in the pharmacological treatment of autism and intellectual disability, eating disorders, neuropsychiatric correlates of epilepsy, and psychosis. Pitfalls in relation to the treatment of other disorders are addressed in a separate paper (Part I).

Common pitfalls, and how to avoid them, in child and adolescent psychopharmacology: Part I

As Faculty of the British Association for Psychopharmacology course on child and adolescent psychopharmacology, we present here what we deem are the most common pitfalls, and how to avoid them, in child and adolescent psychopharmacology. In this paper, we specifically addressed common pitfalls in the pharmacological treatment of attention-deficit/hyperactivity disorder, anxiety, bipolar disorder, depression, obsessive-compulsive disorder and related disorders, and tic disorder. Pitfalls in the treatment of other disorders are addressed in a separate paper (part II).

Doing research in non-specialist mental health services for children and young people: lessons learnt from a process evaluation of the ICALM (Interpersonal Counselling for Adolescent Low Mood) feasibility randomised controlled trial

BACKGROUND

The rising prevalence of adolescent mild depression in the UK and the paucity of evidence-based interventions in non-specialist sectors where most cases present, creates an urgent need for early psychological interventions. Randomised controlled trials (RCTs) are considered the gold standard for obtaining unbiased estimates of intervention effectiveness. However, the complexity of mental health settings poses great challenges for effectiveness evaluations. This paper reports learning from an embedded process evaluation of the ICALM RCT which tested the feasibility of delivering Interpersonal Counselling for Adolescents (IPC-A) plus Treatment as Usual (TAU) versus TAU only for adolescent (age 12-18) mild depression by non-qualified mental health professionals in non-specialist sectors.

METHODS

A qualitative mixed methods process evaluation, drawing on Bronfenbrenner's socioecological model to investigate key influences on trial delivery across macro-(e.g. policy), meso-(e.g. service characteristics) and micro-(e.g. on-site trial processes) contextual levels. Data collection methods included 9 site questionnaires, 4 observations of team meetings, policy documents, and 18 interviews with stakeholders including therapists, heads of service and managers. Thematic analysis focused on understanding how contextual features shaped trial implementation.

RESULTS

The ICALM trial concluded in 2022 having only randomised 14 out of the target 60 young people. At a macro-level, trial delivery was impacted by the COVID-19 pandemic, with services reporting a sharp increase in cases of (social) anxiety over low mood, and backlogs at central referral points which prolonged waiting times for mild cases (e.g. low mood). An interaction between high demand and lack of capacity at a meso-service level led to low prioritisation of trial activities at a micro-level. Unfamiliarity with research processes (e.g. randomisation) and variation in TAU support also accentuated the complexities of conducting an RCT in this setting.

CONCLUSIONS

Conducting a RCT of IPC-A in non-specialist services is not feasible in the current context. Failure to conduct effectiveness trials in this setting has clinical implications, potentially resulting in escalation of mild mental health problems. Research done in this setting should adopt pragmatic and innovative recruitment and engagement approaches (e.g. creating new referral pathways) and consider alternative trial designs, e.g. cluster, stepped-wedge or non-controlled studies using complex systems approaches to embrace contextual complexity.

TRIAL REGISTRATION

ISRCTN registry, ISRCTN82180413. Registered on 31 December 2019.

Total and temporal patterning of physical activity in adolescents and associations with mental wellbeing

BACKGROUND

There is limited understanding of the extent to which differences in physical activity across the day and week may be associated with mental wellbeing. Such an understanding is needed for better targeting of interventions. In this study, we describe total and temporal patterning of physical activity across the week in adolescents (age 13-14y) and assess their prospective associations with mental wellbeing.

METHODS

1,983 13-14-year-old adolescent participants based in Cambridgeshire and Essex, recruited between 2016 and 2017 into the Get Others Active Trial provided data at baseline and 4 months. Physical activity was measured at baseline using wrist-worn accelerometers across different time segments (whole week, weekday schooltime, weekday out of school, and weekend), and operationalized as average movement-related acceleration for each time segment. Mental Wellbeing at baseline and 4 months was measured using the Warwick Edinburgh MentalWellbeing Scale. Associations between physical activity across different time segments (whole week, weekday schooltime, weekday out of school, and weekend) and mental wellbeing at 4 months were investigated using sex-stratified multi-level regression models, adjusted for covariates, and both adjusted and unadjusted for baseline mental wellbeing.

RESULTS

Our analyses found positive associations between physical activity and mental wellbeing at 4 months, unadjusted for baseline wellbeing. Among girls, positive associations were shown when considering physical activity across the whole week 0.07 (95% CI, 0.03-0.12), and across all separate time periods studied: weekday schooltime 0.07 (95% CI, 0.02-0.11), weekday out-of-school time 0.07 (95% CI, 0.03-0.12), and weekend 0.07 (95% CI, 0.02-0.11). For boys, similar associations were observed for activity across the week 0.07 (95% CI, 0.03-0.11), during weekday schooltime 0.08 (95% CI, 0.04-0.12), and weekday out-of-school time 0.07 (95% CI, 0.03-0.11), but not the weekend 0.01 (95% CI, -0.03-0.05). For both girls and boys, associations were attenuated below significance after adjusting for baseline wellbeing.

CONCLUSIONS

This longitudinal analysis showed positive associations between physical activity and later mental wellbeing in both male and female adolescents across most time segments. Higher physical activity throughout the week may be associated with better mental wellbeing in the adolescent population. Further research is required to understand determinants of change in wellbeing over time.

TRIAL REGISTRATION

Registration Number: ISRCTN31583496. Registered: 18/02/2014.

Effects on child and adolescent health of climate change mitigation policies: A systematic review of modelling studies

There is a growing body of modelling evidence that demonstrates the potential for immediate and substantial benefits to adult health from greenhouse gas mitigation actions, but the effects on the health of younger age groups is largely unknown. We conducted a systematic review to identify the available published evidence of the modelled effects on child and adolescent health (≤18 years of age) of greenhouse gas mitigation. We searched six databases of peer-reviewed studies published between January 1, 1990 and July 27, 2022, screened 27,282 original papers and included 23 eligible papers. All included studies were set in high- and middle-income countries; and all studies modelled the effects of interventions that could mitigate greenhouse gas emissions and improve air quality. Most of the available evidence suggests positive benefits for child and adolescent respiratory health from greenhouse gas mitigation actions that simultaneously reduce air pollution (specifically PM2.5 and nitrogen dioxide). We found scant evidence on child and adolescent health from regions more vulnerable to climate change, or on mitigation interventions that could affect exposures other than air pollution.

A multiscale accuracy assessment of moisture content predictions using time-lapse electrical resistivity tomography in mine tailings

Accurate and large-scale assessment of volumetric water content (VWC) plays a critical role in mining waste monitoring to mitigate potential geotechnical and environmental risks. In recent years, time-lapse electrical resistivity tomography (TL-ERT) has emerged as a promising monitoring approach that can be used in combination with traditional invasive and point-measurements techniques to estimate VWC in mine tailings. Moreover, the bulk electrical conductivity (EC) imaged using TL-ERT can be converted into VWC in the field using petrophysical relationships calibrated in the laboratory. This study is the first to assess the scale effect on the accuracy of ERT-predicted VWC in tailings. Simultaneous and co-located monitoring of bulk EC and VWC are carried out in tailings at five different scales, in the laboratory and in the field. The hydrogeophysical datasets are used to calibrate a petrophysical model used to predict VWC from TL-ERT data. Overall, the accuracy of ERT-predicted VWC is [Formula: see text], and the petrophysical models determined at sample-scale in the laboratory remain valid at larger scales. Notably, the impact of temperature and pore water EC evolution plays a major role in VWC predictions at the field scale (tenfold reduction of accuracy) and, therefore, must be properly taken into account during the TL-ERT data processing using complementary hydrogeological sensors. Based on these results, we suggest that future studies using TL-ERT to predict VWC in mine tailings could use sample-scale laboratory apparatus similar to the electrical resistivity Tempe cell presented here to calibrate petrophysical models and carefully upscale them to field applications.

The impact of patient skin colour on diagnostic ability and confidence of medical students

Previous literature has explored unconscious racial biases in clinical education and medicine, finding that people with darker skin tones can be underrepresented in learning resources and managed differently in a clinical setting. This study aimed to examine whether patient skin colour can affect the diagnostic ability and confidence of medical students, and their cognitive reasoning processes. We presented students with 12 different clinical presentations on both white skin (WS) and non-white skin (NWS). A think aloud (TA) study was conducted to explore students' cognitive reasoning processes (n = 8). An online quiz was also conducted where students submitted a diagnosis and confidence level for each clinical presentation (n = 185). In the TA interviews, students used similar levels of information gathering and analytical reasoning for each skin type but appeared to display increased uncertainty and reduced non-analytical reasoning methods for the NWS images compared to the WS images. In the online quiz, students were significantly more likely to accurately diagnose five of the 12 clinical presentations (shingles, cellulitis, Lyme disease, eczema and meningococcal disease) on WS compared to NWS (p < 0.01). With regards to students' confidence, they were significantly more confident diagnosing eight of the 12 clinical presentations (shingles, cellulitis, Lyme disease, eczema, meningococcal disease, urticaria, chickenpox and Kawasaki disease) on WS when compared to NWS (p < 0.01). These findings highlight the need to improve teaching resources to include a greater diversity of skin colours exhibiting clinical signs, to improve students' knowledge and confidence, and ultimately, to avoid patients being misdiagnosed due to the colour of their skin.

Medical education through an invasion: insights from an elective programme for Ukrainian medical students at the University of Cambridge

Medical students in Ukraine have faced extraordinary disruption to their clinical studies with both the COVID-19 pandemic and subsequent Russian military invasion forcing a majority of their learning to be conducted remotely. Over the summer of 2022, the School of Clinical Medicine, University of Cambridge hosted 20 medical students from Kharkiv National Medical University for a seven-week intensive clinical elective programme. The aim was to provide an immersive clinical placement that would help students to attain the necessary knowledge and experience to become competent and confident practising doctors. This perspective piece aims to support the development of future equivalent exchanges through outlining the placement's context, its planning and implementation, evidence of placement impact, and finally reflections and learning points.

Child Survival and Annual Crop Yield Reductions in Rural Burkina Faso: Critical Windows of Vulnerability Around Early-Life Development

Populations that are reliant on subsistence farming are particularly vulnerable to climatic effects on crop yields. However, empirical evidence on the role of the timing of exposure to crop yield deficits in early-life development is limited. We examined the relationship between child survival and annual crop yield reductions at different stages of early-life development in a subsistence farming population in Burkina Faso. Using shared frailty Cox proportional hazards models adjusting for confounders, we analyzed 57,288 children under 5 years of age followed by the Nouna Health and Demographic Surveillance System (1994-2016) in relation to provincial food-crop yield levels experienced in 5 nonoverlapping time windows (12 months before conception, gestation, birth-age 5.9 months, ages 6.0 months-1.9 years, and ages 2.0-4.9 years) and their aggregates (birth-1.9 years, first 1,000 days from conception, and birth-4.9 years). Of the nonoverlapping windows, point estimates were largest for child survival related to food-crop yields for the time window of 6.0 months-1.9 years: The adjusted mortality hazard ratio was 1.10 (95% confidence interval: 1.03, 1.19) for a 90th-to-10th percentile yield reduction. These findings suggest that child survival in this setting is particularly vulnerable to cereal-crop yield reductions during the period of nonexclusive breastfeeding.

Sports Utility Vehicles: A Public Health Model of Their Climate and Air Pollution Impacts in the United Kingdom

The emission benefits of shifting towards battery electric vehicles have so far been hampered by a trend towards sports utility vehicles (SUVs). This study assesses the current and future emissions from SUVs and their potential impact on public health and climate targets. We modelled five scenarios of varying SUV sales and electrification rates, and projected associated carbon dioxide (CO2) and nitrogen oxide (NOx) emissions. Multiple linear regression was used to determine the relationship between vehicle characteristics and emissions. Cumulative CO2 emissions were valued using the social cost of carbon approach. Life table analyses were used to project and value life years saved from NOx emission reductions. Larger SUVs were disproportionately high emitters of CO2 and NOx. Replacing these with small SUVs achieved significant benefits, saving 702 MtCO2e by 2050 and 1.8 million life years from NO2 reductions. The largest benefits were achieved when combined with electrification, saving 1181 MtCO2e and gaining 3.7 million life years, with a societal value in the range of GBP 10-100s billion(s). Downsizing SUVs could be associated with major public health benefits from reduced CO2 and NOx emissions, in addition to the benefits of electrification. This could be achieved by demand-side mass-based vehicle taxation and supply-side changes to regulations, by tying emission limits to a vehicle's footprint rather than its mass.

Air pollution and child health impacts of decarbonization in 16 global cities: Modelling study

Most research on the air pollution-related health effects of decarbonization has focused on adults. We assess the potential health benefits that could be achieved in children and young people in a global sample of 16 cities through global decarbonization actions. We modelled annual average concentrations of fine particulate matter (PM_2.5) and nitrogen dioxide (NO₂) at 1x1 km resolution in the cities using a general circulation/atmospheric chemistry model assuming removal of all global combustion-related emissions from land transport, industries, domestic energy use and power generation. We modelled the impact on childhood asthma incidence and adverse birth outcomes (low birthweight, pre-term births) using published exposure-response relationships. Removal of combustion emissions was estimated to decrease annual average PM_2.5 by between 2.9 μg/m³ (8.4%) in Freetown and 45.4 μg/m³ (63.7%) in Dhaka. For NO₂, the range was from 0.3 ppb (7.9%) in Freetown to 18.8 ppb (92.3%) in Mexico City. Estimated reductions in asthma incidence ranged from close to zero in Freetown, Tamale and Harare to 149 cases per 100,000 population in Los Angeles. For pre-term birth, modelled impacts ranged from a reduction of 135 per 100,000 births in Dar es Salaam to 2,818 per 100,000 births in Bhubaneswar and, for low birthweight, from 75 per 100,000 births in Dar es Salaam to 2,951 per 100,000 births in Dhaka. The large variations chiefly reflect differences in the magnitudes of air pollution reductions and estimated underlying disease rates. Across the 16 cities, the reduction in childhood asthma incidence represents more than one-fifth of the current burden, and an almost 10% reduction in pre-term and low birthweight births. Decarbonization actions that remove combustion-related emissions contributing to ambient PM_2.5 and NO₂ would likely lead to substantial but geographically-varied reductions in childhood asthma and adverse birth outcomes, though there are uncertainties in causality and the precision of estimates.

Multivariable Prediction Modeling of Antidepressant Initiation in Unipolar Depressed Adolescents: A Secondary Analysis of the IMPACT Trial

Introduction: This secondary analysis of data collected in a randomized controlled trial (RCT) for the treatment of depression in adolescents aimed to test prediction models relating antidepressant (AD) initiation to clinical variables. Methods: The primary study was an RCT where adolescents (ages 11-17) with depression were assigned one of three outpatient psychotherapies over 86 weeks. The current study tested five registered prediction models using data on adolescents not taking ADs at baseline (N = 337). Outcomes of interest included: AD initiation, change in depression severity, and self-injurious thoughts and behaviors (SITBs). Results: Findings from registered analytic strategies were not consistent with our a priori hypotheses; rather we unexpectedly observed a relationship between initiation of AD and increased risk of suicide attempts and suicidal ideation during the same time interval (p > 0.01). Sensitivity analyses found that: (1) higher depressive symptom severity and self-harm each predicted future AD initiation (p < 0.05), and (2) new-onset SITB was associated with AD initiation (p < 0.01). Conclusions: Taken together, our results suggest that depression symptoms severity and SITBs may prompt AD initiation. Researchers may wish to further explore causal pathways relevant to the association ADs between SITBs. Clinicians need to be cognizant of high-quality guideline recommendations when prescribing ADs to adolescents.

Do socioeconomic inequities arise during school-based physical activity interventions? An exploratory case study of the GoActive trial

OBJECTIVE

To investigate socioeconomic inequities in the intervention and evaluation process of the GoActive school-based physical activity intervention and demonstrate a novel approach to evaluating intervention-related inequalities.

DESIGN

Exploratory post-hoc secondary data analysis of trial data.

SETTING

The GoActive trial was run in secondary schools across Cambridgeshire and Essex (UK), between September 2016 and July 2018.

PARTICIPANTS

13-14 years old adolescents (n=2838, 16 schools).

METHODS

Socioeconomic inequities across six stages in the intervention and evaluation process were evaluated: (1) provision of and access to resources; (2) intervention uptake; (3) intervention effectiveness (accelerometer-assessed moderate-to-vigorous physical activity (MVPA)); (4) long-term compliance; (5) response in evaluation; and (6) impact on health. Data from self-report and objective measures were analysed by individual-level and school-level socioeconomic position (SEP) using a combination of classical hypothesis tests and multilevel regression modelling.

RESULTS

Stage: (1) There was no difference in the provision of physical activity resources by school-level SEP (eg, quality of facilities (0-3), low=2.6 (0.5); high=2.5 (0.4). (2) Students of low-SEP engaged significantly less with the intervention (eg, website access: low=37.2%; middle=45.4%; high=47.0%; p=0.001). (3) There was a positive intervention effect on MVPA in adolescents of low-SEP (3.13 min/day, 95% CI -1.27 to 7.54, but not middle/high (-1.49; 95% CI -6.54 to 3.57). (4) At 10 months post-intervention, this difference increased (low SEP: 4.90; 95% CI 0.09 to 9.70; middle/high SEP: -2.76; 95% CI -6.78 to 1.26). (5) There was greater non-compliance to evaluation measures among adolescents of low-SEP (eg, % accelerometer compliance (low vs high): baseline: 88.4 vs 92.5; post-intervention: 61.6 vs 69.2; follow-up: 54.5 vs 70.2. (6) The intervention effect on body mass index (BMI) z-score was more favourable in adolescents of low-SEP (low SEP: -0.10; 95% CI -0.19 to 0.00; middle/high: 0.03; 95% CI -0.05 to 0.12).

CONCLUSIONS

These analyses suggest the GoActive intervention had a more favourable positive effect on MVPA and BMI in adolescents of low-SEP, despite lower intervention engagement. However, differential response to evaluation measures may have biassed these conclusions. We demonstrate a novel way of evaluating inequities within young people's physical activity intervention evaluations.

TRIAL REGISTRATION NUMBER

ISRCTN31583496.

The contribution of demographic changes to future heat-related health burdens under climate change scenarios

Anthropogenic climate change will have a detrimental impact on global health, including the direct impact of higher ambient temperatures. Existing projections of heat-related health outcomes in a changing climate often consider increasing ambient temperatures alone. Population growth and structure has been identified as a key source of uncertainty in future projections. Age acts as a modifier of heat risk, with heat-risk generally increasing in older age-groups. In many countries the population is ageing as lower birth rates and increasing life expectancy alter the population structure. Preparing for an older population, in particular in the context of a warmer climate should therefore be a priority in public health research and policy. We assess the level of inclusion of population growth and demographic changes in research projecting exposure to heat and heat-related health outcomes. To assess the level of inclusion of population changes in the literature, keyword searches of two databases were implemented, followed by reference and citation scans to identify any missed papers. Relevant papers, those including a projection of the heat health burden under climate change, were then checked for inclusion of population scenarios. Where sensitivity to population change was studied the impact of this on projections was extracted. Our analysis suggests that projecting the heat health burden is a growing area of research, however, some areas remain understudied including Africa and the Middle East and morbidity is rarely explored with most studies focusing on mortality. Of the studies pairing projections of population and climate, specifically SSPs and RCPs, many used pairing considered to be unfeasible. We find that not including any projected changes in population or demographics leads to underestimation of health burdens of on average 64 %. Inclusion of population changes increased the heat health burden across all but two studies.

Impact on mortality of pathways to net zero greenhouse gas emissions in England and Wales: a multisectoral modelling study

BACKGROUND

The UK is legally committed to reduce its greenhouse gas emissions to net zero by 2050. We aimed to understand the potential impact on population health of two pathways for achieving this target through the integrated effects of six actions in four sectors.

METHODS

In this multisectoral modelling study we assessed the impact on population health in England and Wales of six policy actions relating to electricity generation, transport, home energy, active travel, and diets relative to a baseline scenario in which climate actions, exposures, and behaviours were held constant at 2020 levels under two scenarios: the UK Climate Change Committee's Balanced Pathway of technological and behavioural measures; and its Widespread Engagement Pathway, which assumes more substantial changes to consumer behaviours. We quantified the impacts of each policy action on mortality using a life table comprising all exposures, behaviours, and health outcomes in a single model.

FINDINGS

Both scenarios are predicted to result in substantial reductions in mortality by 2050. The Widespread Engagement Pathway achieves a slightly greater reduction in outdoor fine particulate matter air pollution of 3·2 μg/m³ (33%) and, under assumptions of appropriate ventilation, a greater improvement in indoor air pollution (a decrease in indoor-generated fine particulate matter from 9·4 μg/m³ to 4·6 μg/m³) and winter temperatures (increasing from 17·8°C to 18·1°C), as well as appreciably greater changes in levels of active travel (27% increase in metabolic equivalent hours per week of walking and cycling) by 2050. Additionally, the greater reduction in red meat consumption (50% compared with 35% under the Balanced Pathway) by 2050 results in greater consumption of fruits (17-18 g/day), vegetables (22-23 g/day), and legumes (5-7 g/day). Combined actions under the Balanced Pathway result in more than 2 million cumulative life-years gained over 2021-50; the estimated gain under the Widespread Engagement Pathway is greater, corresponding to nearly 2·5 million life-years gained by 2050 and 13·7 million life-years gained by 2100.

INTERPRETATION

Reaching net zero greenhouse gas emissions is likely to lead to substantial benefits for public health in England and Wales, with the cumulative net benefits being correspondingly greater with a pathway that entails faster and more ambitious changes, especially in physical activity and diets.

FUNDING

National Institute for Health Research and the Wellcome Trust.

Common practical questions - and answers - at the British Association for Psychopharmacology child and adolescent psychopharmacology course

The British Association for Psychopharmacology course on child and adolescent psychopharmacology has been run for more than 20 years and is currently a very popular course, attracting around 140 delegates/year from across the United Kingdom and abroad. As Faculty of recent sessions of the course, we have selected the most common questions we have been asked in recent years and provided evidence-based and/or expert-informed answers. We have included 27 questions and answers related to attention-deficit/hyperactivity disorder, anxiety and depressive disorders, autism spectrum disorder, bipolar disorder, eating disorders, epilepsy (in differential diagnosis or comorbid with mental health conditions), obsessive-compulsive disorder, personality disorders, psychotic spectrum disorders, and tics/Tourette syndrome in children and young people. We hope that this article will be helpful for prescribers in their daily clinical practice and we look forward to further, high-level evidence informing the answers to these and other questions in child and adolescent psychopharmacology.

Let's just ask them. Perspectives on urban dwelling and air quality: A cross-sectional survey of 3,222 children, young people and parents

This research aimed to capture and synthesise the views of children, young people, parents and expectant parents (CYPP) about the cities where they live, with a specific focus on air pollution (AP), in order to support the generation of evidence-informed policy that reflects CYPP's perspectives, ultimately contributing to the development of child-centered, healthier, sustainable cities. The Children, Cities and Climate (CCC) project used targeted social media adverts to recruit CYPP to complete an online survey with a combination of open and closed questions in order to collect perceptions about air quality in their home cities, the main sources of AP, and how they would improve their cities. The survey was completed by 3,222 CYPP in 59 of the most polluted cities in 14 countries. Nearly two in five (39%) CYPP cited AP as one of the worst things about their city, with motor transport perceived as the main contributor. CYPP reported differing views on whether their cities were becoming better (43%) or worse (34%) places to live (33% reported it was 'staying the same'). Numerous specific ideas to improve cities and urban air quality emerged, alongside an emphasis on also addressing structural barriers to change. A clear set of principles that should guide how city leaders act was also described, including the need to engage with young people meaningfully. CYPPs articulated good and bad experiences of urban living and perceived AP and traffic as pressing concerns. They provided a clear set of suggestions for improving their cities. Further efforts to engage young people on these issues are warranted.

A Review on Applications of Time-Lapse Electrical Resistivity Tomography Over the Last 30 Years : Perspectives for Mining Waste Monitoring

Mining operations generate large amounts of wastes which are usually stored into large-scale storage facilities which pose major environmental concerns and must be properly monitored to manage the risk of catastrophic failures and also to control the generation of contaminated mine drainage. In this context, non-invasive monitoring techniques such as time-lapse electrical resistivity tomography (TL-ERT) are promising since they provide large-scale subsurface information that complements surface observations (walkover, aerial photogrammetry or remote sensing) and traditional monitoring tools, which often sample a tiny proportion of the mining waste storage facilities. The purposes of this review are as follows: (i) to understand the current state of research on TL-ERT for various applications; (ii) to create a reference library for future research on TL-ERT and geoelectrical monitoring mining waste; and (iii) to identify promising areas of development and future research needs on this issue according to our experience. This review describes the theoretical basis of geoelectrical monitoring and provides an overview of TL-ERT applications and developments over the last 30 years from a database of over 650 case studies, not limited to mining operations (e.g., landslide, permafrost). In particular, the review focuses on the applications of ERT for mining waste characterization and monitoring and a database of 150 case studies is used to identify promising applications for long-term autonomous geoelectrical monitoring of the geotechnical and geochemical stability of mining wastes. Potential challenges that could emerge from a broader adoption of TL-ERT monitoring for mining wastes are discussed. The review also considers recent advances in instrumentation, data acquisition, processing and interpretation for long-term monitoring and draws future research perspectives and promising avenues which could help improve the design and accuracy of future geoelectric monitoring programs in mining wastes.

The relationship between greenspace and personal exposure to PM2.5 during walking trips in Delhi, India

The presence of urban greenspace may lead to reduced personal exposure to air pollution via several mechanisms, for example, increased dispersion of airborne particulates; however, there is a lack of real-time evidence across different urban contexts. Study participants were 79 adolescents with asthma who lived in Delhi, India and were recruited to the Delhi Air Pollution and Health Effects (DAPHNE) study. Participants were monitored continuously for exposure to PM_2.5 (particulate matter with an aerodynamic diameter of less than 2.5 μm) for 48 h. We isolated normal day-to-day walking journeys (n = 199) from the personal monitoring dataset and assessed the relationship between greenspace and personal PM_2.5 using different spatial scales of the mean Normalised Difference Vegetation Index (NDVI), mean tree cover (TC), and proportion of surrounding green land use (GLU) and parks or forests (PF). The journeys had a mean duration of 12.7 (range 5, 53) min and mean PM_2.5 personal exposure of 133.9 (standard deviation = 114.8) μg/m³. The within-trip analysis showed weak inverse associations between greenspace markers and PM_2.5 concentrations only in the spring/summer/monsoon season, with statistically significant associations for TC at the 25 and 50 m buffers in adjusted models. Between-trip analysis also indicated inverse associations for NDVI and TC, but suggested positive associations for GLU and PF in the spring/summer/monsoon season; no overall patterns of association were evident in the autumn/winter season. Associations between greenspace and personal PM_2.5 during walking trips in Delhi varied across metrics, spatial scales, and season, but were most consistent for TC. These mixed findings may partly relate to journeys being dominated by walking along roads and small effects on PM_2.5 of small pockets of greenspace. Larger areas of greenspace may, however, give rise to observable spatial effects on PM_2.5, which vary by season.

Exposure to urban greenspace and pathways to respiratory health: An exploratory systematic review

BACKGROUND/OBJECTIVE

Urban greenspace may have a beneficial or adverse effect on respiratory health. Our objective was to perform an exploratory systematic review to synthesise the evidence and identify the potential causal pathways relating urban greenspace and respiratory health.

METHODS

We followed PRISMA guidelines on systematic reviews and searched five databases for eligible studies during 2000-2021. We incorporated a broad range of urban greenspace and respiratory health search terms, including both observational and experimental studies. Screening, data extraction, and risk of bias, assessed using the Navigation Guide criteria, were performed independently by two authors. We performed a narrative synthesis and discuss suggested pathways to respiratory health.

RESULTS

We identified 108 eligible papers (n = 104 observational, n = 4 experimental). The most common greenspace indicators were the overall greenery or vegetation (also known as greenness), green land use/land cover of physical area classes (e.g., parks, forests), and tree canopy cover. A wide range of respiratory health indicators were studied, with asthma prevalence being the most common. Two thirds (n = 195) of the associations in these studies were positive (i.e., beneficial) with health, with 31% (n = 91) statistically significant; only 9% (n = 25) of reported associations were negative (i.e., adverse) with health and statistically significant. The most consistent positive evidence was apparent for respiratory mortality. There were n = 35 (32%) 'probably low' and n = 73 (68%) 'probably high' overall ratings of bias. Hypothesised causal pathways for health benefits included lower air pollution, more physically active populations, and exposure to microbial diversity; suggested mechanisms with poorer health included exposure to pollen and other aeroallergens.

CONCLUSION

Many studies showed positive association between urban greenspace and respiratory health, especially lower respiratory mortality; this is suggestive, but not conclusive, of causal effects. Results underscore the importance of contextual factors, greenspace metric employed, and the potential bias of subtle selection factors, which should be explored further.

Another Wrinkle with Age: Aged Collagen and Intra-peritoneal Metastasis of Ovarian Cancer

Background

Age is the most significant risk factor for ovarian cancer (OvCa), the deadliest gynecologic malignancy. Metastasizing OvCa cells adhere to the omentum, a peritoneal structure rich in collagen, adipocytes, and immune cells. Ultrastructural changes in the omentum and the omental collagen matrix with aging have not been evaluated.

Aim

The aim of this study was to test the hypothesis that age-related changes in collagen in the ovarian tumor microenvironment promote OvCa metastatic success in the aged host.

Methods/Results

Young (3-6 months) and aged mice (20-23 months) were used to study the role of aging in metastatic success. Intra-peritoneal (IP) injection of ID8Trp53 ^-/- ovarian cancer cells showed enhanced IP dissemination in aged vs young mice. In vitro assays using purified collagen demonstrated reduced collagenolysis of aged fibers, as visualized using scanning electron microscopy (SEM) and quantified with a hydroxyproline release assay. Omental tumors in young and aged mice showed similar collagen deposition; however enhanced intra-tumoral collagen remodeling was seen in aged mice probed with a biotinylated collagen hybridizing peptide (CHP). In contrast, second harmonic generation (SHG) microscopy showed significant differences in collagen fiber structure and organization in omental tissue and SEM demonstrated enhanced omental fenestration in aged omenta. Combined SHG and Alexa Fluor-CHP microscopy in vivo demonstrated that peri-tumoral collagen was remodeled more extensively in young mice. This collagen population represents truly aged host collagen, in contrast to intra-tumoral collagen that is newly synthesized, likely by cancer associated fibroblasts (CAFs).

Conclusions

Our results demonstrate that tumors in an aged host can grow with minimal collagen remodeling, while tumors in the young host must remodel peri-tumoral collagen to enable effective proliferation, providing a mechanism whereby age-induced ultrastructural changes in collagen and collagen-rich omenta establish a permissive pre-metastatic niche contributing to enhanced OvCa metastatic success in the aged host.

Cross-sectional and longitudinal associations between psychotic and depressive symptoms in depressed adolescents

Adults with major depressive disorder (MDD) with psychotic features (delusions and/or hallucinations) have more severe symptoms and a worse prognosis. Subclinical psychotic symptoms are more common in adolescents than adults. However, the effects of psychotic symptoms on outcome of depressive symptoms have not been well studied in adolescents. Depressed adolescents aged 11-17 with and without psychotic symptoms were compared on depression severity scores at baseline and at 28- or 42-week follow-up in two large UK cohorts. Psychotic symptoms were weakly associated with more severe depression at baseline in both cohorts. At follow-up, baseline psychotic symptoms were only associated with depressive symptoms in one sample; in the other, the effect size was close to zero. This supports the DSM5 system of psychotic symptoms being a separate code to severity rather than the ICD10 system which only allows the diagnosis of psychotic depression with severe depression. There was no clear support for psychotic symptoms being a baseline marker of treatment response.

Prospective Pathways From Impulsivity to Non-Suicidal Self-Injury Among Youth

Non-suicidal self-injury (NSSI) is a common behavior, particularly among adolescents and young adults. Impulsivity has been implicated as an important factor associated with NSSI, however prospective longitudinal research is lacking. Moreover, the relationship between impulsivity and other risk factors for NSSI is unclear. By examining longitudinal models including impulsivity, attachment, and distress we hope to elucidate the nature of the association between impulsivity and NSSI. 1,686 community-recruited young people (ages 14-25) with no NSSI in the past year were followed up for one year, completing self-report measures of the above factors. Impulsivity independently predicted new onset of NSSI over and above other risk factors, indicating heightened impulsivity is a prospective risk factor for NSSI. Psychological distress mediated the parenting-NSSI association.

The CUSSH programme: supporting cities' transformational change towards health and sustainability

This paper describes a global research programme on the complex systemic connections between urban development and health. Through transdisciplinary methods the Complex Urban Systems for Sustainability and Health (CUSSH) project will develop critical evidence on how to achieve the far-reaching transformation of cities needed to address vital environmental imperatives for planetary health in the 21st Century. CUSSH’s core components include: (i) a review of evidence on the effects of climate actions (both mitigation and adaptation) and factors influencing their implementation in urban settings; (ii) the development and application of methods for tracking the progress of cities towards sustainability and health goals; (iii) the development and application of models to assess the impact on population health, health inequalities, socio-economic development and environmental parameters of urban development strategies, in order to support policy decisions; (iv) iterative in-depth engagements with stakeholders in partner cities in low-, middle- and high-income settings, using systems-based participatory methods, to test and support the implementation of the transformative changes needed to meet local and global health and sustainability objectives; (v) a programme of public engagement and capacity building. Through these steps, the programme will provide transferable evidence on how to accelerate actions essential to achieving population-level health and global climate goals through, amongst others, changing cities’ energy provision, transport infrastructure, green infrastructure, air quality, waste management and housing.

Health effects in people relocating between environments of differing ambient air pollution concentrations: A literature review

People who relocate to a new environment may experience health effects from a change in ambient air pollution. We undertook a literature review of studies of such relocations and health effects and report the results as a narrative analysis. Fifteen articles of heterogeneous designs met the inclusion criteria. Four short-term (relocation duration less than six months) and three long-term (relocation duration six months or greater) studies reported evidence of the effect of relocation on physiological outcome, biomarkers or symptoms. All had potential weaknesses of design or analysis but, as a whole, their results are broadly consistent in suggesting short-term adverse effects of air pollutants or their reversibility. One long-term study provided evidence that changes in air pollution exposure during adolescence have a measurable effect on lung function growth. Four cohort studies were also identified that used relocation to strengthen evidence of air-pollution-exposure relationships by using a design that incorporates effective randomization of exposure or the use of relocation to improve exposure classification. However, three studies of relocation during pregnancy provided limited evidence to conclude an effect of relocation-related change in exposure on pregnancy outcome. Overall, most relocation studies are consistent with short- or long-term adverse effects of air pollution on biological function or mortality, but many studies of change in exposure have design weaknesses that limit the robustness of interpretation. We outline principles for improved design and analysis to help strengthen future studies for the insights they can provide from their quasi-experimental designs, including on the nature and timing of functional changes of relocation-related changes in exposure to ambient air pollution.

CerealsDB: A Whistle-Stop Tour of an Open Access SNP Resource

The CerealsDB website, created by members of the Functional Genomics Group at the University of Bristol, provides access to a database containing SNP and genotyping data for hexaploid wheat and, to a lesser extent, its progenitors and several of its relatives. The site is principally aimed at plant breeders and research scientists who wish to obtain information regarding SNP markers; for example, obtain primers used for their identification or the sequences upon which they are based. The database underpinning the website contains circa one million putative varietal SNPs of which several hundreds of thousands have been experimentally validated on a range of common genotyping platforms. For each SNP marker, the site also hosts the allelic scores for thousands of elite wheat varieties, landrace cultivars, and wheat relatives. Tools are available to help negotiate and visualize the datasets. The website has been designed to be simple and straightforward to use and is completely open access.

Projecting the impacts of housing on temperature-related mortality in London during typical future years

Climate change means the UK will experience warmer winters and hotter summers in the future. Concurrent energy efficiency improvements to housing may modify indoor exposures to heat or cold, while population aging may increase susceptibility to temperature-related mortality. We estimate heat and cold mortality and energy consumption in London for typical (non-extreme) future climates, given projected changes in population and housing. Building physics models are used to simulate summertime and wintertime indoor temperatures and space heating energy consumption of London dwellings for 'baseline' (2005-2014) and future (2030s, 2050s) periods using data from the English Housing Survey, historical weather data, and projected future weather data with temperatures representative of 'typical' years. Linking to population projections, we calculate future heat and cold attributable mortality and energy consumption with demolition, construction, and alternative scenarios of energy efficiency retrofit. At current retrofit rates, around 168-174 annual cold-related deaths per million population would typically be avoided by the 2050s, or 261-269 deaths per million under ambitious retrofit rates. Annual heat deaths would typically increase by 1 per million per year under the current retrofit rate, and 12-13 per million under ambitious rates without population adaptation to heat. During typical future summers, an estimated 38-73% of heat-related deaths can be avoided using external shutters on windows, with their effectiveness lower during hotter weather. Despite warmer winters, ambitious retrofit rates are necessary to reduce typical annual energy consumption for heating below baseline levels, assuming no improvement in heating system efficiencies. Concerns over future overheating in energy efficient housing are valid but increases in heat attributable mortality during typical and hot (but not extreme) summers are more than offset by significant reductions in cold mortality and easily mitigated using passive measures. More ambitious retrofit rates are critical to reduce energy consumption and offer co-benefits for reducing cold-related mortality.

The Impact of Rainfall Variability on Diets and Undernutrition of Young Children in Rural Burkina Faso

Background: Climate change and consequent increases in rainfall variability may have negative consequences for the food production of subsistence farmers in West Africa with adverse impacts on nutrition and health. We explored the pathway from rainfall through diet up to child undernutrition for rural Burkina Faso. Methods: The study used data of a dynamic cohort with 1,439 children aged 7-60 months from the Nouna Health and Demographic Surveillance Site (HDSS) for 2017 to 2019. We assessed data on diets, height, weight, household characteristics, and daily precipitation (from 1981 to 2019). Principal component analysis was used to identify distinct child dietary patterns (Dietary Pattern Scores, DPS). These were related to 15 rainfall indicators by area to obtain a precipitation variability score (PVS) through reduced rank regression (RRR). Associations between the PVS and anthropometric measures, height-for-age (HAZ), and weight-for-height (WHZ), were examined using multi-level regression analysis. Results: Stunting (HAZ < -2) and wasting (WHZ < -2) were seen in 24 and 6% of the children. Three main dietary patterns were identified (market-based, vegetable-based, and legume-based diets) and showed mixed evidence for associations with child undernutrition. The RRR-derived PVS explained 14% of the total variance in these DPS. The PVS was characterized by more consecutive dry days during the rainy season, higher cumulative rainfall in July and more extremely wet days. A 1-point increase in the PVS was associated with a reduction of 0.029 (95% CI: -0.06, 0.00, p < 0.05) in HAZ in the unadjusted, and an increase by 0.032 (95% CI: 0.01, 0.06, p < 0.05) in WHZ in the fully adjusted model. Conclusion: Rainfall variability was associated with dietary patterns in young children of a rural population of Burkina Faso. Increased rainfall variability was associated with an increase in chronic undernutrition, but not in acute undernutrition among young children.

Covid-19 mobility restrictions: impacts on urban air quality and health

In 2020, Covid-19-related mobility restrictions resulted in the most extensive human-made air-quality changes ever recorded. The changes in mobility are quantified in terms of outdoor air pollution (concentrations of PM_2.5 and NO₂) and the associated health impacts in four UK cities (Greater London, Cardiff, Edinburgh and Belfast). After applying a weather-corrected machine learning (ML) technique, all four cities show NO₂ and PM_2.5 concentration anomalies in 2020 when compared with the ML-predicted values for that year. The NO₂ anomalies are -21% for Greater London, -19% for Cardiff, -27% for Belfast and -41% for Edinburgh. The PM_2.5 anomalies are 7% for Greater London, -1% for Cardiff, -15% for Edinburgh, -14% for Belfast. All the negative anomalies, which indicate air pollution at a lower level than expected from the weather conditions, are attributable to the mobility restrictions imposed by the Covid-19 lockdowns. Spearman rank-order correlations show a significant correlation between the lowering of NO₂ levels and reduction in public transport (p < 0.05) and driving (p < 0.05), which is associated with a decline in NO₂-attributable mortality. These positive effects of the mobility restrictions on public health can be used to evaluate policies for improved outdoor air quality.

POLICY RELEVANCE

Finding the means to curb air pollution is very important for public health. Empirical evidence at a city scale reveals significant correlations between the reduction in vehicular transport and in ambient NO₂ concentrations. The results provide justification for city-level initiatives to reduce vehicular traffic. Well-designed and effective policy interventions (e.g. the promotion of walking and cycling, remote working, local availability of services) can substantially reduce long-term air pollution and have positive health impacts.

Narrative Matters: 'Who decides what a meaningful life is?' Life, Animated - a refreshing insight into an autistic person's life

Life, Animated (2016), directed by Roger Ross Williams is a documentary that centres around the life of Owen Suskind; an autistic person. In recent decades, the media has become a powerful tool that has been used to typify and inform public opinion surrounding autism. This article analyses the portrayal of autism in Life, Animated and draws out important learning points for clinicians, families, service users and the public.

A multi-scalar perspective on health and urban housing: an umbrella review

With more than half the world's population living in cities, understanding how the built environment impacts human health at different urban scales is crucial. To be able to shape cities for health, an understanding is needed of planetary health impacts, which encompass the human health impacts of human-caused disruptions on the Earth's natural ecosystems. This umbrella review maps health evidence across the spatial scales of the built environment (building; neighbourhood; and wider system, including city, regional and planetary levels), with a specific focus on urban housing. Systematic reviews published in English between January 2011 and December 2020 were searched across 20 databases, with 1176 articles identified and 124 articles screened for inclusion. Findings suggests that most evidence reports on health determinants at the neighbourhood level, such as greenspace, physical and socio-economic conditions, transport infrastructure and access to local services. Physical health outcomes are also primarily reported, with an emerging interest in mental health outcomes. There is little evidence on planetary health outcomes and significant gaps in the research literature are identified. Based on these findings, three potential directions are identified for future research.

Relationship-building around a policy decision-support tool for urban health

Contemporary challenges linked to public health and climate change demand more effective decision-making and urban planning practices, in particular by taking greater account of evidence. In order to do this, trust-building relationships between scientists and urban practitioners through collaborative research programmes is required. Based on a policy-relevant research project, Complex Urban Systems for Sustainability and Health (CUSSH), this project aims to support the transformation of cities to meet environmental imperatives and to improve health with a quantitative health impact assessment. A case study in Rennes, France, focuses on the role of a policy decision-support tool in the production and use of knowledge to support evidence-informed decision-making. Although the primary objective of informing decision-making through evidence-based science is not fulfilled, the use of a decision-making support tool can lay the foundations for relationship-building. It can serve as a support for boundary-spanning activities, which are recognised for their effectiveness in linking science to action. This case study illustrates that the path of knowledge transfer from science to policy can be challenging, and the usefulness of using models may not be where it was thought to have been.

Developing a programme theory for a transdisciplinary research collaboration: Complex Urban Systems for Sustainability and Health

Background: Environmental improvement is a priority for urban sustainability and health and achieving it requires transformative change in cities. An approach to achieving such change is to bring together researchers, decision-makers, and public groups in the creation of research and use of scientific evidence. Methods: This article describes the development of a programme theory for Complex Urban Systems for Sustainability and Health (CUSSH), a four-year Wellcome-funded research collaboration which aims to improve capacity to guide transformational health and environmental changes in cities. Results: Drawing on ideas about complex systems, programme evaluation, and transdisciplinary learning, we describe how the programme is understood to "work" in terms of its anticipated processes and resulting changes. The programme theory describes a chain of outputs that ultimately leads to improvement in city sustainability and health (described in an 'action model'), and the kinds of changes that we expect CUSSH should lead to in people, processes, policies, practices, and research (described in a 'change model'). Conclusions: Our paper adds to a growing body of research on the process of developing a comprehensive understanding of a transdisciplinary, multiagency, multi-context programme. The programme theory was developed collaboratively over two years. It involved a participatory process to ensure that a broad range of perspectives were included, to contribute to shared understanding across a multidisciplinary team. Examining our approach allowed an appreciation of the benefits and challenges of developing a programme theory for a complex, transdisciplinary research collaboration. Benefits included the development of teamworking and shared understanding and the use of programme theory in guiding evaluation. Challenges included changing membership within a large group, reaching agreement on what the theory would be 'about', and the inherent unpredictability of complex initiatives.

Developing a programme theory for a transdisciplinary research collaboration: Complex Urban Systems for Sustainability and Health

Background: Environmental improvement is a priority for urban sustainability and health and achieving it requires transformative change in cities. An approach to achieving such change is to bring together researchers, decision-makers, and public groups in the creation of research and use of scientific evidence.

Methods: This article describes the development of a programme theory for Complex Urban Systems for Sustainability and Health (CUSSH), a four-year Wellcome-funded research collaboration which aims to improve capacity to guide transformational health and environmental changes in cities.

Results: Drawing on ideas about complex systems, programme evaluation, and transdisciplinary learning, we describe how the programme is understood to “work” in terms of its anticipated processes and resulting changes. The programme theory describes a chain of outputs that ultimately leads to improvement in city sustainability and health (described in an ‘action model’), and the kinds of changes that we expect CUSSH should lead to in people, processes, policies, practices, and research (described in a ‘change model’).

Conclusions: Our paper adds to a growing body of research on the process of developing a comprehensive understanding of a transdisciplinary, multiagency, multi-context programme. The programme theory was developed collaboratively over two years. It involved a participatory process to ensure that a broad range of perspectives were included, to contribute to shared understanding across a multidisciplinary team. Examining our approach allowed an appreciation of the benefits and challenges of developing a programme theory for a complex, transdisciplinary research collaboration. Benefits included the development of teamworking and shared understanding and the use of programme theory in guiding evaluation. Challenges included changing membership within a large group, reaching agreement on what the theory would be ‘about’, and the inherent unpredictability of complex initiatives.

A system dynamics-based scenario analysis of residential solid waste management in Kisumu, Kenya

The problem of solid waste management presents an issue of increasing importance in many low-income settings, including the progressively urbanised context of Kenya. Kisumu County is one such setting with an estimated 500 t of waste generated per day and with less than half of it regularly collected. The open burning and natural decay of solid waste is an important source of greenhouse gas (GHG) emissions and atmospheric pollutants with adverse health consequences. In this paper, we use system dynamics modelling to investigate the expected impact on GHG and PM_2.5 emissions of (i) a waste-to-biogas initiative and (ii) a regulatory ban on the open burning of waste in landfill. We use life tables to estimate the impact on mortality of the reduction in PM_2.5 exposure. Our results indicate that combining these two interventions can generate over 1.1 million tonnes of cumulative savings in GHG emissions by 2035, of which the largest contribution (42%) results from the biogas produced replacing unclean fuels in household cooking. Combining the two interventions is expected to reduce PM_2.5 emissions from the waste and residential sectors by over 30% compared to our baseline scenario by 2035, resulting in at least around 1150 cumulative life years saved over 2021–2035. The contribution and novelty of this study lies in the quantification of a potential waste-to-biogas scenario and its environmental and health impact in Kisumu for the first time.

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We present a system dynamics study of solid waste management in Kisumu, Kenya.

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Scenarios involve a waste-to-biogas initiative and a ban on open burning in landfill.

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Combined scenario generates 1.1m tonnes cumulative GHG savings by 2035.

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Largest contribution (42%) is from biogas substituting traditional cooking fuels.

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Combined scenario may save 1,150 cumulative life years by 2035, plus ~220 more p.a.

Personal exposure monitoring of PM2.5 among US diplomats in Kathmandu during the COVID-19 lockdown, March to June 2020

The 2019 Novel Coronavirus SARS-CoV 2 (COVID-19¹) pandemic has severely impacted global health, safety, economic development and diplomacy. The government of Nepal issued a lockdown order in the Kathmandu Valley for 80 days from 24 March to 11 June 2020. This paper reports associated changes in ambient PM_2.5 measured at fixed-site monitors and changes in personal exposure to PM_2.5 monitored by APT Minima by four American diplomats who completed monitoring before and during lockdown (24 h for each period per person, 192 person-hours in total). Time activities and use of home air pollution mitigation measures (use of room air cleaners (RACs), sealing of homes) were recorded by standardized diary. We compared PM_2.5 exposure level by microenvironment (home (cooking), home (other activities), at work, commuting, other outdoor environment) in terms of averaged PM_2.5 concentration and the contribution to cumulative personal exposure (the product of PM_2.5 concentration and time spent in each microenvironment). Ambient PM_2.5 measured at fixed-sites in the US Embassy and in Phora Durbar were 38.2% and 46.7% lower than during the corresponding period in 2017-2019. The mean concentration of PM_2.5 to which US diplomats were exposed was very much lower than the concentrations of ambient levels measured at fixed site monitors in the city both before and during lockdown. Within-person comparisons suggest personal PM_2.5 exposure was 50.0% to 76.7% lower during lockdown than before it. Time spent outdoors and cooking at home were large contributors to cumulative personal exposure. Low indoor levels of PM_2.5 were achieved at work and home through use of RACs and measures to seal homes against the ingress of polluted air from outside. Our observations indicate the potential reduction in exposure to PM_2.5 with large-scale changes to mainly fossil-fuel related emissions sources and through control of indoor environments and activity patterns.

A tool for assessing the climate change mitigation and health impacts of environmental policies: the Cities Rapid Assessment Framework for Transformation (CRAFT)

Background: A growing number of cities, including Greater London, have set ambitious targets, including detailed policies and implementation plans, to reach global goals on sustainability, health, and climate change. Here we present a tool for a rapid assessment of the magnitude of impact of specific policy initiatives to reach these targets. The decision-support tool simultaneously quantifies the environmental and health impacts of specified selected policies. Methods: The 'Cities Rapid Assessment Framework for Transformation (CRAFT)' tool was applied to Greater London. CRAFT quantifies the effects of ten environmental policies on changes in (1) greenhouse gas (GHG) emissions, (2) exposures to environmental hazards, (3) travel-related physical activity, and (4) mortality (the number of attributable deaths avoided in one typical year). Publicly available data and epidemiological evidence were used to make rapid quantitative estimates of these effects based on proportional reductions in GHG emissions and environmental exposures from current baseline levels and to compute the mortality impacts. Results: The CRAFT tool estimates that, of roughly 50,000 annual deaths in Greater London, the modelled hazards (PM 2.5 (from indoor and outdoor sources), outdoor NO 2, indoor radon, cold, overheating) and low travel-related physical activity are responsible for approximately 10,000 premature environment-related deaths. Implementing the selected polices could reduce the annual mortality number by about 20% (~1,900 deaths) by 2050. The majority of these deaths (1,700) may be avoided through increased uptake in active travel. Thus, out of ten environmental policies, the 'active travel' policy provides the greatest health benefit. Also, implementing the ten policies results in a GHG reduction of around 90%. Conclusions: The CRAFT tool quantifies the effects of city policies on reducing GHG emissions, decreasing environmental health hazards, and improving public health. The tool has potential value for policy makers through providing quantitative estimates of health impacts to support and prioritise policy options.

The CUSSH programme: learning how to support cities’ transformational change towards health and sustainability

The Complex Urban Systems for Sustainability and Health (CUSSH) project is a global research programme on the complex systemic connections between urban development and health. Through transdisciplinary methods it will develop critical evidence on how to achieve the far-reaching transformation of cities needed to address vital environmental imperatives for planetary health in the 21st century. CUSSH’s core components include: (i) a review of evidence on the effects of climate actions (both mitigation and adaptation) and factors influencing their implementation in urban settings; (ii) the development and application of methods for tracking the progress of cities towards sustainability and health goals; (iii) the development and application of models to assess the impact on population health, health inequalities, socio-economic development and environmental parameters of urban development strategies, in order to support policy decisions; (iv) iterative in-depth engagements with stakeholders in partner cities in low-, middle- and high-income settings, using systems-based participatory methods, to test and support the implementation of the transformative changes needed to meet local and global health and sustainability objectives; (v) a programme of public engagement and capacity building. Through these steps, the programme will provide transferable evidence on how to accelerate actions essential to achieving population-level health and global climate goals through, amongst others, changing cities’ energy provision, transport infrastructure, green infrastructure, air quality, waste management and housing.

Surgery and opioids: evidence-based expert consensus guidelines on the perioperative use of opioids in the United Kingdom

There are significant concerns regarding prescription and misuse of prescription opioids in the perioperative period. The Faculty of Pain Medicine at the Royal College of Anaesthetists have produced this evidence-based expert consensus guideline on surgery and opioids along with the Royal College of Surgery, Royal College of Psychiatry, Royal College of Nursing, and the British Pain Society. This expert consensus practice advisory reproduces the Faculty of Pain Medicine guidance. Perioperative stewardship of opioids starts with judicious opioid prescribing in primary and secondary care. Before surgery, it is important to assess risk factors for continued opioid use after surgery and identify those with chronic pain before surgery, some of whom may be taking opioids. A multidisciplinary perioperative care plan that includes a prehabilitation strategy and intraoperative and postoperative care needs to be formulated. This may need the input of a pain specialist. Emphasis is placed on optimum management of pain pre-, intra-, and postoperatively. The use of immediate-release opioids is preferred in the immediate postoperative period. Attention to ensuring a smooth care transition and communication from secondary to primary care for those taking opioids is highlighted. For opioid-naive patients (patients not taking opioids before surgery), no more than 7 days of opioid prescription is recommended. Persistent use of opioid needs a medical evaluation and exclusion of chronic post-surgical pain. The lack of grading of the evidence of each individual recommendation remains a major weakness of this guidance; however, evidence supporting each recommendation has been rigorously reviewed by experts in perioperative pain management.

The school policy, social, and physical environment and change in adolescent physical activity: An exploratory analysis using the LASSO

PURPOSE

We examined the association between the school policy, social and physical environment and change in adolescent physical activity (PA) and explored how sex and socioeconomic status modified potential associations.

METHODS

Data from the GoActive study were used for these analyses. Participants were adolescents (n = 1765, mean age±SD 13.2±0.4y) from the East of England, UK. Change in longitudinal accelerometer assessed moderate-to-vigorous physical activity (MVPA) was the outcome. School policy, social and physical environment features (n = 267) were exposures. The least absolute shrinkage and selection operator variable selection method (LASSO) was used to determine exposures most relevant to the outcome. Exposures selected by the LASSO were added to a multiple linear regression model with estimates of change in min/day of MVPA per 1-unit change in each exposure reported. Post-hoc analyses, exploring associations between change in variables selected by the LASSO and change in MVPA, were undertaken to further explain findings.

FINDINGS

No school policy or physical environment features were selected by the LASSO as predictors of change in MVPA. The LASSO selected two school social environment variables (participants asking a friend to do physical activity; friend asking a participant to do physical activity) as potential predictors of change in MVPA but no significant associations were found in subsequent linear regression models for all participants (β [95%CI] -1.01 [-2.73;0.71] and 0.65 [-2.17;0.87] min/day respectively). In the post-hoc analyses, for every unit increase in change in participants asking a friend to do PA and change in a friend asking participants to do PA, an increase in MVPA of 2.78 (1.55;4.02) and 1.80 (0.48;3.11) min/day was predicted respectively.

CONCLUSIONS

The school social environment is associated with PA during adolescence. Further exploration of how friendships during adolescence may be leveraged to support effective PA promotion in schools is warranted.

Seroprevalence of SARS-CoV-2 infection in healthcare workers in a large teaching hospital in the North West of England: a period prevalence survey

OBJECTIVES

Since its emergence in late 2019, SARS-CoV-2 has caused a global pandemic that has significantly challenged healthcare systems. Healthcare workers have previously been shown to have experienced higher rates of infection than the general population. We aimed to assess the extent of infection in staff working in our healthcare setting.

DESIGN

A retrospective analysis of antibody results, compared with staff demographic data, and exposure to patients with COVID-19 infection.

SETTING

A large teaching hospital in the North West of England.

PARTICIPANTS

4474 staff in diverse clinical and non-patient facing roles who volunteered for SARS-CoV-2 antibody testing by the Roche Elecsys assay between 29 May and 4 July 2020.

RESULTS

Seroprevalence was 17.4%. Higher rates were seen in Asian/Asian British (OR 1.61, 95% CI 1.27 to 2.04) and Black/Black British (OR 2.08, 95% CI 1.25 to 3.45) staff. Staff working in any clinical location were more likely to be seropositive (OR 2.68, 95% 2.27 to 3.15). Staff were at an increased risk of seropositivity as the 'per 100 COVID-19 bed-days change' increased in the clinical area in which they worked (OR 1.12, 95% 1.10 to 1.14). Staff working in critical care were no more likely to have detectable antibodies than staff working in non-clinical areas. Symptoms compatible with COVID-19 were reported in 41.8% and antibodies were detected in 30.7% of these individuals. In staff who reported no symptoms, antibodies were detected in 7.7%. In all staff who had detectable antibodies, 25.2% reported no symptoms.

CONCLUSIONS

Staff working in clinical areas where patients with COVID-19 were nursed were more likely to have detectable antibodies. The relationship between seropositivity in healthcare workers and the increase in 'per 100 COVID-19 bed-days' of the area in which they worked, although statistically significant, was weak, suggesting other contributing factors to the risk profile. Of staff with detectable antibodies and therefore evidence of prior infection, a quarter self-reported that they had experienced no compatible symptoms. This has implications for potential unrecorded transmission in both staff and patients.