Cognitive flexibility in a Tanganyikan bower-building cichlid, Aulonocranus dewindti

Cognitive flexibility, the ability to modify one's decision rules to adapt to a new situation, has been extensively studied in many species. In fish, though, data on cognitive flexibility are scarce, especially in the wild. We studied a lekking species of cichlid fish in Lake Tanganyika, Aulonocranus dewindti. Males create sand bowers as spawning sites and maintain them by removing any objects falling into it. In the first part of our experiment, we investigated the existence of spontaneous decision rules for the maintenance of the bowers. We showed that if a snail shell and a stone are placed in their bower, fish prefer to remove the shell first. In the second phase of our experiment, we took advantage of this spontaneous decision rule to investigate whether this rule was flexible. We tested five individuals in a choice against preference task, in which the fish had to modify their preference rule and remove the stone first to be allowed to then remove the shell and have a clean bower. While there was no overall trend towards flexibility in this task, there was variation at an individual level. Some individuals increased their preference for removing the shell first, deciding quickly and with little exploration of the objects. Others were more successful at choosing against preference and showed behaviours suggesting self-regulatory inhibition abilities. Bower-building cichlids could therefore be a promising model to study cognitive flexibility, and other aspects of animal cognition in the wild.

Aggression and spatial positioning of kin and non-kin fish in social groups

Group-living animals are faced with the challenge of sharing space and local resources amongst group members who may be either relatives or non-relatives. Individuals may reduce the inclusive fitness costs they incur from competing with relatives by either reducing their levels of aggression toward kin, or by maintaining physical separation between kin. In this field study, we used the group-living cichlid Neolamprologus multifasciatus to examine whether within-group aggression is reduced among group members that are kin, and whether kin occupy different regions of their group's territory to reduce kin competition over space and local resources. We determined the kinship relationships among cohabiting adults via microsatellite genotyping and then combined these with spatial and behavioral analyses of groups in the wild. We found that aggressive contests between group members declined in frequency with spatial separation between their shelters. Female kin did not engage in aggressive contests with one another, whereas non-kin females did, despite the fact these females lived at similar distances from one another on their groups' territories. Contests within male-male and male-female dyads did not clearly correlate with kinship. Non-kin male-male and male-female dyads lived at more variable distances from one another on their territories than their corresponding kin dyads. Together, our study indicates that contests among group members can be mediated by relatedness in a sex-dependent manner. We also suggest that spatial relationships can play an important role in determining the extent to which group members compete with one another.

A comprehensive overview by region of condoms, natural family planning, and spermicide as a contraceptive method among men aged 13-54 years attending contraceptive services in England

OBJECTIVES

This study aimed to (1) provide a comprehensive overview of contraceptive methods self-reported by men in England, over 5 years, focusing on condoms in comparison to any male method; and (2) explore condom as a contraceptive method by region and ethnicity.

STUDY DESIGN

Data were from the Sexual and Reproductive Health Services (Contraception) England census data set from 2014/15 to 2018/19. Once missing data were removed, this left a total of 365,292 men. Two binomial logistic regression models were performed. Model 1 examined ethnicity, region, and time on condom as a method of contraception; and Model 2 examined ethnicity, region, and time by any male contraceptive. Descriptive statistics were run for natural family planning and spermicide.

RESULTS

Model 1 revealed a significant model, χ² (15) = 30,976, P < 0.001, and predicted that condoms as a method decreased in London with a greater decrease in Midlands. London saw the lowest rate of decline among the non-White ethnic group, whereas North and South regions increased probability over time. The North started at a higher probability and the South at the lowest. Model 2 also revealed a significant model, χ² (15) = 32,472, P < 0.001, with a similar pattern to Model 1. Contingency tables showed natural family planning and spermicide were the least reported methods and decreased over time.

CONCLUSIONS

As any male contraceptive method appears to be decreasing in both models, reproductive health promotion is required. This study has implications for commissioning funds and for identifying regional areas of further investigation.

Modelling animal contests based on spatio-temporal dynamics

We present a general theoretical model for the spatio-temporal dynamics of animal contests. Inspired by interactions between physical particles, the model is formulated in terms of effective interaction potentials, which map typical elements of contest behaviour into empirically verifiable rules of contestant motion. This allows us to simulate the observable dynamics of contests in various realistic scenarios, notably in dyadic contests over a localized resource. Assessment strategies previously formulated in game-theoretic models, as well as the effects of fighting costs, can be described as variations in our model's parameters. Furthermore, the trends of contest duration associated with these assessment strategies can be derived and understood within the model. Detailed description of the contestants' motion enables the exploration of spatio-temporal properties of asymmetric contests, such as the emergence of chase dynamics. Overall, our framework aims to bridge the growing gap between empirical capabilities and theory in this widespread aspect of animal behaviour.

Modelling the impact of CD4 testing on mortality from TB and cryptococcal meningitis among patients with advanced HIV disease in nine countries

INTRODUCTION

Despite antiretroviral therapy (ART) scale-up among people living with HIV (PLHIV), those with advanced HIV disease (AHD) (defined in adults as CD4 count <200 cells/mm3 or clinical stage 3 or 4), remain at high risk of death from opportunistic infections. The shift from routine baseline CD4 testing towards viral load testing in conjunction with "Test and Treat" has limited AHD identification.

METHODS

We used official estimates and existing epidemiological data to project deaths from tuberculosis (TB) and cryptococcal meningitis (CM) among PLHIV-initiating ART with CD4 <200 cells/mm3 , in the absence of select World Health Organization recommended diagnostic or therapeutic protocols for patients with AHD. We modelled the reduction in deaths, based on the performance of screening/diagnostic testing and the coverage and efficacy of treatment/preventive therapies for TB and CM. We compared projected TB and CM deaths in the first year of ART from 2019 to 2024, with and without CD4 testing. The analysis was performed for nine countries: South Africa, Kenya, Lesotho, Mozambique, Nigeria, Uganda, Zambia, Zimbabwe and the Democratic Republic of Congo.

RESULTS

The effect of CD4 testing comes through increased identification of AHD and consequent eligibility for protocols for AHD prevention, diagnosis and management; algorithms for CD4 testing avert between 31% and 38% of deaths from TB and CM in the first year of ART. The number of CD4 tests required per death averted varies widely by country from approximately 101 for South Africa to 917 for Kenya.

CONCLUSIONS

This analysis supports retaining baseline CD4 testing to avert deaths from TB and CM, the two most deadly opportunistic infections among patients with AHD. However, national programmes will need to weigh the cost of increasing CD4 access against other HIV-related priorities and allocate resources accordingly.

Six months survival and risk factors for attrition for patients detected with cryptococcal antigenemia through screening in Malawi

MAIN OBJECTIVE

A cohort of adult Malawian people living with HIV (PLHIV) testing positive for cryptococcal antigenemia was observed and followed to determine the outcomes and risk factors for attrition.

METHODS CONCEPT

Eligible PLHIV were enrolled at 5 health facilities in Malawi, representing different levels of health care. ART naïve patients, ART defaulters returning to care, and patients with suspected or confirmed ART treatment failure with CD4 <200 cells/μL or clinical stage 3 or 4 were enrolled and received CrAg tests on whole blood specimens from August 2018 to August 2019. Hospitalized PLHIV were enrolled and tested for CrAg from January 2019 to August 2019, regardless of CD4 or clinical stage. Patients with cryptococcal antigenemia were managed per Malawian clinical guidelines and were followed up for six months. Survival and risk factors for attrition at six months were assessed.

RESULTS

A total of 2146 patients were screened and 112 (5.2%) had cryptococcal antigenemia. Prevalence ranged from 3.8% (Mzuzu Central Hospital) to 25.8% (Jenda Rural Hospital). Of the 112 patients with antigenemia, 33 (29.5%) were diagnosed with concurrent CM at the time of enrollment. Six-month crude survival of all patients with antigenemia (regardless of CM status) ranged from 52.3% (assuming lost-to-follow-up (LTFU) patients died) to 64.9% (if LTFU survived). Patients who were diagnosed with concurrent CM by CSF test had poor survival (27.3-39.4%). Patients with antigenemia who were not diagnosed with concurrent CM had 71.4% (if LTFU died)- 89.8% (if LTFU survived) survival at six months. In adjusted analyses, patients with cryptococcal antigenemia detected after admission to inpatient care (aHR: 2.56, 1.07-6.15) and patients with concurrent CM at the time of positive antigenemia result (aHR: 2.48, 1.04-5.92) had significantly higher hazard of attrition at six months.

CONCLUSIONS

Overall, our findings indicate a need for routine access to CrAg screening and pre-emptive fluconazole treatment as a way to detect cryptococcal antigenemia and prevent CM in outpatient and inpatient settings. Rapid access to diagnosis and treatment for cryptococcal meningitis (CM) with gold-standard antifungals is needed to improve survival of patients with advanced HIV in Malawi.

Pan-cancer analysis of fear of cancer recurrence among cancer survivors

Background

Fear of cancer recurrence (FCR) is a phenomenon estimated to affect a large portion of cancer survivors. This study sought to determine whether patients from a National Cancer Institute-designated institution had their clinical needs met relating to FCR.

Patients and methods

Patients referred to the survivorship clinic completed The Clinical Needs Assessment Tool for Cancer Survivors (CNAT-CS). Correlations between responses were calculated and univariable and multivariable logistic regression was used to identify predictors of met or unmet needs related to FCR.

Results

Of 647 patients, 241 (37.2%) reported they did not have clinical needs related to FCR and 386 (59.7%) reported they had clinical needs related to FCR but that the needs had been met. Only 20 (3.09%) reported that clinical needs relating to FCR were unmet. According to univariate logistic regression, sex had no impact on FCR (P = 0.8427), nor did years since diagnosis (P = 0.1014). Results of multivariable regression indicate that the odds ratio of reported FCR as an unmet need (versus not a need) is 0.939; the odds decreased by 6% (P = 0.0023) for every year increase in age. For each unit increase in distress score, the odds of reporting FCR as an unmet need increased by 32% (P = 0.0007).

Conclusions

This study is unique in not only examining the presence of FCR but also whether patients reported that their needs were met for FCR. The study found that most patients had clinical needs for FCR, but the needs were met at the time of the survey. Patients who report higher distress scores are more likely to report FCR as an unmet need. Therefore, cancer survivors reporting high distress scores in clinic visits should be evaluated for FCR.

•

FCR is common among cancer survivors; it can be seen as a met or unmet need by each patient.

•

Identifying factors that influence fear of cancer recurrence as a need met or not include age and distress score.

•

Recognizing FCR as an unmet need is paramount to develop clinics and mitigation strategies to ameliorate this need.

POS1574-PARE PATIENTS REPORT HIGH LEVELS OF CONCERNS ABOUT MEDICATION FOR PSORIATIC AND RHEUMATOID ARTHRITIS: UNMET NEEDS REVEALED BY A UK PILOT WEB SURVEY

Background

Patients with rheumatoid arthritis (RA) and psoriatic arthritis (PsA) are often nonadherent to prescribed symptom-modifying drugs. [1] Concerns about the potential negative effects of medication have been implicated in medication nonadherence. Few evidence-based interventions to address concerns about medication and support medication-taking are available in the UK context.

Objectives

To inform the development of intervention to support people with RA and PsA to manage medication we conducted a survey of unmet needs relating to perceptions of arthritis and arthritis medication, medication-taking behaviour and experience of side effects.

Methods

We recruited people with arthritis via local and national patient groups for participation in an online survey. The survey included clinical and demographic questions, validated measures of treatment (Beliefs about Medication Questionnaire; BMQ) and illness perceptions (brief Illness Perception Questionnaire; bIPQ), medication adherence (Compliance Questionnaire Rheumatology; CQR), and patient-reported side effects. Participants were asked about consequences of taking and not taking their arthritis medication as free text to contextualize scores.

Results

Questionnaire responses from 98 participants (42 with PsA, 56 with RA, 89.8% female) indicated participants typically viewed arthritis negatively with ratings on the bIPQ indicating high emotional impacts, symptoms and affects on everyday life, and doubts about their ability to control their arthritis. Analysis of the BMQ indicated ambivalence about RA/PsA medications; while few people expressed doubts about their personal need for medication, concerns about RA/PsA medications were common, see Figure 1). Most, 85.7% (n=84), reported a side effect in the last month, with a mean of 10 ‘moderately severe’ or ‘very severe’ side effects (m=10.02, sd = 5.98). Just over a quarter (26.0%, n=25) were classed as low adherers using the CQR with 54.6% reporting they had missed some of their arthritis medication over the last year. Free text responses indicated that some participants had additional concerns about medication (e.g. worries about impact on life expectancy) not addressed in the questionnaire measures.

Conclusion

In this pilot survey, many participants reported concerns about medication, doubts about whether medication controls arthritis symptoms, severe side effects and medication nonadherence. Although our small sample is unlikely to be generalizable to all arthritis patients, these findings suggest potential targets for intervention and indicate that some patients have needs for support with medication that are not currently being addressed.

References

[1]Van Den Bemt BJ, Zwikker HE, Van Den Ende CH. Medication adherence in patients with rheumatoid arthritis: a critical appraisal of the existing literature. Expert review of clinical immunology. 2012 May 1;8(4):337-51.

Acknowledgements

We acknowledge the financial assistance of Bath Institute of Rheumatic Diseases, the people who volunteered their time to respond to this survey and the efforts of Elena Mut and Kishwar Khanum in assisting with data collection.

Disclosure of Interests

Sarah Chapman: None declared, Abbie Jordan: None declared, William Tillett Speakers bureau: Abbvie, Amgen, Celgene, Eli-Lilly, Janssen, MSD, Novartis, Pfizer and UCB, Consultant of: Abbvie, Amgen, Celgene, Eli-Lilly, Janssen, MSD, Novartis, Pfizer and UCB, Grant/research support from: Abbvie, Celgene, Eli-Lilly, Janssen, and UCB

Neural activity patterns differ between learning contexts in a social fish

Learning and decision-making are greatly influenced by context. When navigating a complex social world, individuals must quickly ascertain where to gain important resources and which group members are useful sources of such information. Such dynamic behavioural processes require neural mechanisms that are flexible across contexts. Here we examine how the social context influences the learning response during a cue discrimination task and the neural activity patterns that underlie acquisition of this novel information. Using the cichlid fish, Astatotilapia burtoni, we show that learning of the task is faster in social groups than in a non-social context. We quantify the neural activity patterns by examining the expression of Fos, an immediate-early gene, across brain regions known to play a role in social behaviour and learning (such as the putative teleost homologues of the mammalian hippocampus, basolateral amygdala and medial amygdala/BNST complex). We find that neural activity patterns differ between social and non-social contexts. Taken together, our results suggest that while the same brain regions may be involved in the learning of a cue association, the activity in each region reflects an individual's social context.

Correlation Between Polypharmacy and Frailty Among Thai Older Persons Living with HIV

Polypharmacy and frailty are correlated in Persons Living with HIV (PLWH) in the United States, but little is known about their correlation in resource-limited settings. Our cross-section study evaluated the correlation between polypharmacy and frailty among Thai 324 virally suppressed PLWH and 132 uninfected patients aged ≥50 between March 2016 and April 2017. The primary predictor was the number of patient-reported non-antiretroviral therapy (ART) medications. The outcome was having additional domain of the five Fried frailty phenotype domains (0 = normal, 1-2 = prefrail, >3 = frail). Most participants were male (63% PLWH, 67% uninfected) with few comorbidities (1.4 PLWH, 0.9 uninfected) and small median number of non-ART medications (2 PLWH, 1 uninfected). Frailty was uncommon (8.6% PLWH, 3.8% uninfected). Each additional non-ART medication correlated with 6% increased likelihood of having additional frailty domain among PLWH (95% CI: 0.002-0.11, p = .04) but not statistically significant among the uninfected. The association between polypharmacy and frailty is more pronounced in Thai PLWH than in participants without HIV. Further study is warranted to confirm this association in other resource-limited settings and explore potential deprescribing practices.

Patterns of sex-biased dispersal are consistent with social and ecological constraints in a group-living cichlid fish

BACKGROUND

Sex-biased dispersal is a common and widespread phenomenon that can fundamentally shape the genetic structure of the social environments in which animals live. For animals that live in and move between social groups, sex-biased dispersal can result in an asymmetry in the degree of relatedness among cohabiting males and females, which can have strong implications for their social evolution. In this study, we measured the relatedness structure within and across groups of a wild population of Neolamprologus multifasciatus, a highly-social, shell-dwelling cichlid fish endemic to Lake Tanganyika, East Africa. In total, we genotyped 812 fish from 128 social groups at 20 microsatellite loci. Neolamprologus multifasciatus live at high densities, and also experience strong ecological constraints on free movement throughout their habitat. At the same time, they exhibit sex differences in the degree of reproductive competition within their groups and this makes them an excellent model system for studying the factors associated with sex-biased dispersal.

RESULTS

Social groups of N. multifasciatus consist of multiple males and females living together. We found that cohabiting females were unrelated to one another (Lynch-Ritland estimates of relatedness = 0.045 ± 0.15, average ± SD), while males shared much higher, albeit variable, levels of relatedness to other males in their groups (0.23 ± 0.27). We uncovered a pronounced decline in relatedness between males living in separate groups as the spatial separation between them increased, a pattern that was not evident in females. Female dispersal was also markedly constrained by the distribution and availability of nearby territories to which they could emigrate.

CONCLUSIONS

Our results indicate female-biased dispersal in N. multifasciatus. Our study also highlights how the spatial distribution of suitable dispersal destinations can influence the movement decisions of animals. We also emphasize how sex-biased dispersal can influence the relatedness structure of the social environment in which individuals interact and compete with one another.

Fast estimation of plant growth dynamics using deep neural networks

BACKGROUND

In recent years, there has been an increase of interest in plant behaviour as represented by growth-driven responses. These are generally classified into nastic (internally driven) and tropic (environmentally driven) movements. Nastic movements include circumnutations, a circular movement of plant organs commonly associated with search and exploration, while tropisms refer to the directed growth of plant organs toward or away from environmental stimuli, such as light and gravity. Tracking these movements is therefore fundamental for the study of plant behaviour. Convolutional neural networks, as used for human and animal pose estimation, offer an interesting avenue for plant tracking. Here we adopted the Social LEAP Estimates Animal Poses (SLEAP) framework for plant tracking. We evaluated it on time-lapse videos of cases spanning a variety of parameters, such as: (i) organ types and imaging angles (e.g., top-view crown leaves vs. side-view shoots and roots), (ii) lighting conditions (full spectrum vs. IR), (iii) plant morphologies and scales (100 μm-scale Arabidopsis seedlings vs. cm-scale sunflowers and beans), and (iv) movement types (circumnutations, tropisms and twining).

RESULTS

Overall, we found SLEAP to be accurate in tracking side views of shoots and roots, requiring only a low number of user-labelled frames for training. Top views of plant crowns made up of multiple leaves were found to be more challenging, due to the changing 2D morphology of leaves, and the occlusions of overlapping leaves. This required a larger number of labelled frames, and the choice of labelling "skeleton" had great impact on prediction accuracy, i.e., a more complex skeleton with fewer individuals (tracking individual plants) provided better results than a simpler skeleton with more individuals (tracking individual leaves).

CONCLUSIONS

In all, these results suggest SLEAP is a robust and versatile tool for high-throughput automated tracking of plants, presenting a new avenue for research focusing on plant dynamics.

Parentage analysis across age cohorts reveals sex differences in reproductive skew in a group-living cichlid fish, Neolamprologus multifasciatus

Group-living animals are often faced with complex reproductive decisions, namely how to partition within-group reproduction, how to obtain extra-group reproduction, and how these two means of reproduction should be balanced. The solutions to these questions can be difficult to predict because ecological conditions can affect the scopes for within-group and extra-group reproduction in complex ways. For example, individuals that are restricted from moving freely around their habitats may have limited extra-group reproductive opportunities, but at the same time, groups may live in close proximities to one another, which could potentially have the opposite effect. The group-living cichlid fish, Neolamprologus multifasciatus, experiences such ecological conditions, and we conducted an intensive genetic parentage analysis to investigate how reproduction is distributed within and among groups for both males and females. We found that cohabiting males live in 'high-skew' societies, where dominant males monopolize the majority of within-group reproduction, while females live in 'low-skew' societies, where multiple females can produce offspring concurrently. Despite extremely short distances separating groups, we inferred only very low levels of extra-group reproduction suggesting that subordinate males have very limited reproductive opportunities. A strength of our parentage analysis lies in its inclusion of individuals that spanned a wide age range, from young fry to adults. We outline the logistical circumstances when very young offspring may not always be accessible to parentage researchers, and present strategies to overcome the challenges of inferring mating patterns from a wide age range of offspring.

132 GERIATRIC REHABILITATION IN THE COVID-19 ERA: SERVICE INNOVATION AND PATIENT OUTCOMES

Background

Methods

Results

Conclusion

Social and spatial conflict drive resident aggression toward outsiders in a group-living fish

Group-living animals often experience within-group competition for resources like shelter and space, as well as for social status. Because of this conflict, residents may aggressively resist joining attempts by new members. Here, we asked whether different forms of competition mediate this response, specifically competition over 1) shelter, 2) spatial position within groups, and 3) social or sexual roles. We performed experiments on wild groups of Neolamprologus multifasciatus cichlids in Lake Tanganyika, either increasing or decreasing the number of shelters (empty snail shells) within their territories. We predicted that increases in resource abundance would reduce conflict and lower the aggression of residents toward presented conspecifics, while decreases in resources would increase aggression. We explored the effects of social conflict and spatial arrangement by introducing same or opposite sex conspecifics, at greater or lesser distances from resident subterritories. We found that changing the abundance of shells had no detectable effect on the responses of residents to presented conspecifics. Rather, aggression was strongly sex-dependent, with male residents almost exclusively aggressing presented males, and female residents almost exclusively aggressing presented females. For females, this aggression was influenced by the spatial distances between the presented conspecific and the resident female subterritory, with aggression scaling with proximity. In contrast, presentation distance did not influence resident males, which were aggressive to all presented males regardless of location. Overall, our results show that group residents respond to presented conspecifics differently depending on the type of competitive threat these potential joiners pose.

Social network dynamics predict hormone levels and behavior in a highly social cichlid fish

Group living confers many benefits while simultaneously exposing group members to intense competition. An individual's rise to prominence within a group may conflict with the overall functioning of the group. There is therefore a complex and dynamic relationship between the behavioral displays that directly benefit an individual, the consequences of these actions for the community, and how they feed back on individual-level fitness. We used a network analysis approach to study the link between behavior, social stability, and steroid hormone levels in replicate communities of the cichlid fish, Astatotilapia burtoni, which live in social groups with a dominance hierarchy. We demonstrate that individual behavior can have direct and indirect effects on the behavior of others while also affecting group characteristics. Our results show that A. burtoni males form stable social networks, where dominant individuals act as hubs for social interactions. However, there was variation in the temporal stability in these networks, and this variation in stability impacted hormone levels. Dominant males had higher testosterone levels, however, the differences in testosterone levels between dominant and subordinate males were greatest in stable communities. In sum, our analyses provide novel insights into the processes by which individual and community properties interact.

Bronchiectasis is associated with delayed diagnosis and adverse outcomes in the New Zealand Common Variable Immunodeficiency Disorders cohort study

Common variable immunodeficiency disorders (CVID) are multi-system disorders where target organ damage is mediated by infective, autoimmune and inflammatory processes. Bronchiectasis is probably the most common disabling complication of CVID. The risk factors for bronchiectasis in CVID patients are incompletely understood. The New Zealand CVID study (NZCS) is a nationwide longitudinal observational study of adults, which commenced in 2006. In this analysis, the prevalence and risk factors for bronchiectasis were examined in the NZCS. After informed consent, clinical and demographic data were obtained with an interviewer-assisted questionnaire. Linked electronic clinical records and laboratory results were also reviewed. Statistical methods were applied to determine if variables such as early-onset disease, delay in diagnosis and increased numbers of infections were associated with greater risk of bronchiectasis. One hundred and seven adult patients with a diagnosis of CVID are currently enrolled in the NZCS, comprising approximately 70% of patients known to have CVID in New Zealand. Fifty patients (46·7%) had radiologically proven bronchiectasis. This study has shown that patients with compared to those without bronchiectasis have an increased mortality at a younger age. CVID patients with bronchiectasis had a greater number of severe infections consequent to early-onset disease and delayed diagnosis. Indigenous Māori have a high prevalence of CVID and a much greater burden of bronchiectasis compared to New Zealand Europeans. Diagnostic latency has not improved during the study period. Exposure to large numbers of infections because of early-onset disease and delayed diagnosis was associated with an increased risk of bronchiectasis. Earlier diagnosis and treatment of CVID may reduce the risk of bronchiectasis and premature death in some patients.

Pharmacy professionals’ views regarding the future of NHS patient medicines helpline services: A multimethod qualitative study

Introduction

Patient medicines helpline services (PMHS) have been established at some National Health Service (NHS) hospitals in England, to provide medicines-related support to recently discharged hospital patients and carers. However, findings suggest that, due to a lack of resources, considerable variation exists in the operation of PMHS, and that their access, availability, and promotion do not meet national standards regarding helpline provision (1, 2). To develop recommendations for service improvement, this qualitative study sought to examine pharmacy professionals’ views regarding the future of PMHS.

Aim

To examine pharmacy professionals’ perceptions of the future of PMHS, and develop recommendations for service improvement.

Methods

University ethics and Health Research Authority approval were obtained before commencement. Participants comprised pharmacy professionals from acute, mental health, specialist, and community NHS Trusts that provided a PMHS. Invitations to participate in an online qualitative survey and subsequent semi-structured telephone interview were sent via email to pharmacy services at all Trusts that provided a PMHS. Within the survey and the interview schedule was one question “How do you see patient medicines helplines at NHS Trusts developing in the future?” and only the data generated from this open-ended question were analysed for this study. Survey data were collected via SurveyMonkey (n=100). Individuals interested in participating in an interview contacted the research team, resulting in 34 interviews. Interviews were conducted from May-October 2018, and ranged from 16 to 53 minutes. Braun and Clarke’s inductive reflexive thematic analysis was used to analyse the data. Guidelines for enhancing the validity and trustworthiness of qualitative research were used.

Results

Two themes were generated from the survey and interviews. Enhancing value for service users identifies suggestions for improving the value of PMHS for service users. These include providing access methods beyond the telephone, and providing patients/carers with post-discharge follow-up calls from a pharmacist. Improving efficiency identifies that, in the future, and in line with NHS plans for efficiency and shared resources, PMHS may become centralised or provided by community pharmacies. Centralised services were considered to likely have more resources available to provide a patient medicines information service compared to hospital pharmacies. Participants often referred to the Carter report and sustainability and transformation plans, which promote the sharing of resources within regions. However, such a change was perceived to only increase efficiency if patient information can be shared between relevant healthcare settings.

Conclusion

PMHS are perceived by pharmacy professionals as likely to become centralised in the future (i.e., provided regionally or nationally) or provided by community pharmacies. This is dependent upon patients’ information being shared between hospitals and the centralised PMHS or pharmacies. To enhance the value of PMHS for service users, providers could establish other methods of access, such as email and video consultation. A limitation of this study is that it did not seek the perspectives of pharmacy professionals who do not provide a PMHS, other healthcare professionals, nor patients and carers. Considering the uncertainty around the future of PMHS, research should establish the best way to support all patients and carers regarding medicines following hospital discharge.

References

1. Williams MJ, Jones MD, Jordan AL, Scott JA. Operating a patient medicines helpline. A survey study exploring current practice in England using the RE-AIM evaluation framework. BMC Health Serv Res. 2018; doi:10.1186/s12913-018-3690-9

2. Williams M, Jordan A, Scott J, Jones MD. Pharmacy professionals’ experiences and perceptions of providing NHS patient medicines helpline services: a qualitative study. BMC Health Serv Res. 2020; doi.org/10.1186/s12913-020-05182-w.

Economic Dependence and Vulnerability of United States Agricultural Sector on Insect-Mediated Pollination Service

Deficits in insect-mediated pollination service undermine ecosystem biodiversity and function, human nutrition, and economic welfare. Global pollinator supply continues to decline, while production of pollination-dependent crops increases. Using publicly available price and production data and existing pollination field studies, we quantify economic dependence of United States crops on insect-mediated pollination service at the county level and update existing coefficients of insect dependence of sample crops when possible. Economic value dependent on pollination service totals 34.0 billion USD in 2012. Twenty percent of US counties produce 80% of total economic value attributable to insect pollinators. We compile county-level data and consider the spatial relationship between economic value dependent on insect-mediated pollination, region-specific forage suitability, and crop-specific agricultural areas within US landscapes. We identify vulnerable, highly dependent areas where habitat for wild pollinators has been reduced. These results can help inform future efforts to conserve and bolster managed and wild pollinator populations to ensure sustainable production of key agricultural crops.

Decontextualized learning for interpretable hierarchical representations of visual patterns

Apart from discriminative modeling, the application of deep convolutional neural networks to basic research utilizing natural imaging data faces unique hurdles. Here, we present decontextualized hierarchical representation learning (DHRL), designed specifically to overcome these limitations. DHRL enables the broader use of small datasets, which are typical in most studies. It also captures spatial relationships between features, provides novel tools for investigating latent variables, and achieves state-of-the-art disentanglement scores on small datasets. DHRL is enabled by a novel preprocessing technique inspired by generative model chaining and an improved ladder network architecture and regularization scheme. More than an analytical tool, DHRL enables novel capabilities for virtual experiments performed directly on a latent representation, which may transform the way we perform investigations of natural image features, directly integrating analytical, empirical, and theoretical approaches.

Solving post-prandial reduction in performance by adaptive regurgitation in a freshwater fish

Foraging animals must balance benefits of food acquisition with costs induced by a post-prandial reduction in performance. Eating to satiation can lead to a reduction in locomotor and escape performance, which increases risk should a threat subsequently arises, but limiting feeding behaviour may be maladaptive if food intake is unnecessarily reduced in the prediction of threats that do not arise. The efficacy of the trade-off between continued and interrupted feeding therefore relies on information about the future risk, which is imperfect. Here, we find that black carp (Mylopharyngodon piceus) can balance this trade-off using an a posteriori strategy; by eating to satiation but regurgitating already ingested food when a threat arises. While degrees of satiation (DS) equal to or greater than 60% reduce elements of escape performance (turning angle, angular velocity, distance moved, linear velocity), at 40% DS or lower, performance in these tasks approaches levels comparable to that at 0% satiation. After experiencing a chasing event, we find that fish are able to regurgitate already ingested food, thereby changing the amount of food in their gastrointestinal tract to consistent levels that maintain high escape performance. Remarkably, regurgitation results in degrees of satiation between 40 and 60% DS, regardless of whether they had previously fed to 40, 60 or 100% DS. Using this response, fish are able to maximize food intake, but regurgitate extra food to maintain escape performance when they encounter a threat. This novel strategy may be effective for continual grazers and species with imperfect information about the level of threat in their environment.

Cryptococcal meningitis: a review of cryptococcal antigen screening programs in Africa

INTRODUCTION

Cryptococcal meningitis remains a significant contributor to AIDS-related mortality despite widened access to antiretroviral therapy. Cryptococcal antigen (CrAg) can be detected in the blood prior to development of meningitis. Development of highly sensitive and specific rapid diagnostic CrAg tests has helped facilitate the adoption of CrAg screening programs in 19 African countries.

AREAS COVERED

The biological rationale for CrAg screening and the programmatic strategies for its implementation are reviewed. We describe the approach to the investigation of patients with cryptococcal antigenemia and the importance of lumbar puncture to identify individuals who may have cryptococcal meningitis in the absence of symptoms. The limitations of current treatment recommendations and the potential role of newly defined combination antifungal therapies are discussed. A literature review was conducted using a broad database search for cryptococcal antigen screening and related terms in published journal articles dating up to December 2019. Conference abstracts, publicly available guidelines, and project descriptions were also incorporated.

EXPERT OPINION

As we learn more about the risks of cryptococcal antigenemia, it has become clear that the current management paradigm is inadequate. More intensive investigation and management are required to prevent the development of cryptococcal meningitis and reduce mortality associated with cryptococcal antigenemia.

High-resolution, non-invasive animal tracking and reconstruction of local environment in aquatic ecosystems

BACKGROUND

Acquiring high resolution quantitative behavioural data underwater often involves installation of costly infrastructure, or capture and manipulation of animals. Aquatic movement ecology can therefore be limited in taxonomic range and ecological coverage.

METHODS

Here we present a novel deep-learning based, multi-individual tracking approach, which incorporates Structure-from-Motion in order to determine the 3D location, body position and the visual environment of every recorded individual. The application is based on low-cost cameras and does not require the animals to be confined, manipulated, or handled in any way.

RESULTS

Using this approach, single individuals, small heterospecific groups and schools of fish were tracked in freshwater and marine environments of varying complexity. Positional tracking errors as low as 1.09 ± 0.47 cm (RSME) in underwater areas up to 500 m2 were recorded.

CONCLUSIONS

This cost-effective and open-source framework allows the analysis of animal behaviour in aquatic systems at an unprecedented resolution. Implementing this versatile approach, quantitative behavioural analysis can be employed in a wide range of natural contexts, vastly expanding our potential for examining non-model systems and species.

Structural manipulations of a shelter resource reveal underlying preference functions in a shell-dwelling cichlid fish

Many animals can modify the environments in which they live, thereby changing the selection pressures they experience. A common example of such niche construction is the use, creation or modification of environmental resources for use as nests or shelters. Because these resources often have correlated structural elements, it can be difficult to disentangle the relative contribution of these elements to resource choice, and the preference functions underlying niche-construction behaviour remain hidden. Here, we present an experimental paradigm that uses 3D scanning, modelling and printing to create replicas of structures that differ with respect to key structural attributes. We show that a niche-constructing, shell-dwelling cichlid fish, Neolamprologus multifasciatus, has strong open-ended preference functions for exaggerated shell replicas. Fish preferred shells that were fully intact and either enlarged, lengthened or had widened apertures. Shell intactness was the most important structural attribute, followed by shell length, then aperture width. We disentangle the relative roles of different shell attributes, which are tightly correlated in the wild, but nevertheless differentially influence shelter choice and therefore niche construction in this species. We highlight the broad utility of our approach when compared with more traditional methods (e.g. two-choice tasks) for studying animal decision-making in a range of contexts.

Tracking of Primary Human Hepatocytes with Clinical MRI: Initial Results with Tat-Peptide Modified Superparamagnetic Iron Oxide Particles

The transplantation of primary human hepatocytes is a promising approach in the treatment of specific liver diseases. However, little is known about the fate of the cells following application. Magnetic resonance imaging (MRI) could enable real-time tracking and long-term detection of transplanted hepatocytes. The use of superparamagnetic iron oxide particles as cellular contrast agents should allow for the non-invasive detection of labelled cells on high-resolution magnetic resonance images. Experiments were performed on primary human hepatocytes to transfer the method of detecting labelled cells via clinical MRI into human hepatocyte transplantation. For labelling, Tat-peptide modified nano-sized superparamagnetic MagForce particles were used. Cells were investigated via a clinical MR scanner at 3.0 Tesla and the particle uptake within single hepatocytes was estimated using microscopic examinations. The labelled primary human hepatocytes were clearly detectable by MRI, proving the feasibility of this new concept. Therefore, this method is a useful tool to investigate the effects of human hepatocyte transplantation and to improve safety aspects of this method.

Exemptions From Mandatory Immunization After Legally Mandated Parental Counseling

BACKGROUND

The success of health care provider counseling-based interventions to address vaccine hesitancy is not clear. In 2011, Washington State implemented Senate Bill 5005 (SB5005), requiring counseling and a signed form from a licensed health care provider to obtain an exemption. Evaluating the impact of a counseling intervention can provide important insight into population-level interventions that focus on interpersonal communication by a health care provider.

METHODS

We used segmented regression and interaction and aggregation indices to assess the impact of SB5005 on immunization coverage and exemption rates in Washington State from school years 1997-1998 through 2013-2014.

RESULTS

After SB5005 was implemented, there was a significant relative decrease of 40.2% (95% confidence interval: -43.6% to -36.6%) in exemption rates. This translates to a significant absolute reduction of 2.9 percentage points (95% confidence interval: -4.2% to -1.7%) in exemption rates. There were increases in vaccine coverage for all vaccines required for school entrance, with the exception of the hepatitis B vaccine. The probability that kindergarteners without exemptions would encounter kindergarteners with exemptions (interaction index) decreased, and the probability that kindergarteners with exemptions would encounter other such kindergarteners (aggregation index) also decreased after SB5005. Moreover, SB5005 was associated with a decline in geographic clustering of vaccine exemptors.

CONCLUSIONS

States in the United States and jurisdictions in other countries should consider adding parental counseling by health care provider as a requirement for obtaining exemptions to vaccination requirements.

Diagnostic performance of cytology for assessment of hepatic lipid content in dairy cattle

The objective of our study was to characterize the diagnostic performance of cytology for assessing hepatic lipid content (HLC) in dairy cows by comparing microscopic evaluation of lipid vacuolation in touch imprint slide preparations of liver biopsies with quantitative measurement of triglyceride concentration ([TG]; mg/mg of wet weight) in paired biopsy samples. Our study also sought to compare the diagnostic performance of liver cytology, plasma nonesterified fatty acid concentration ([NEFA]), and plasma β-hydroxybutyrate concentration ([BHB]) derived from a measurement performed on whole blood, for assessing HLC. Chemical extraction of TG from liver tissue remains the gold standard for quantifying HLC, largely because available blood tests, although useful for detecting some types of pathology, such as increased lipid mobilization, ketosis, or hepatocellular injury, are nonspecific as to etiology. Veterinary practitioners can sample bovine liver for cytological evaluation in a fast, minimally invasive, and inexpensive manner. Thus, if highly predictive of HLC, cytology would be a practical diagnostic tool for dairy veterinarians. In our study, liver biopsy samples from Holstein cows (219 samples from 105 cows: 52 from cows 2 to 20 d prepartum, 105 from cows 0 to 10 d in milk, 62 from cows 18 to 25 d in milk) were used to prepare cytology slides and to quantify [TG] using the Folch extraction method followed by the Hantzch condensation reaction and spectrophotometric measurement. An ordinal scale (0-4) based on amount of hepatocellular cytoplasm occupied by discrete clear vacuoles was used by 3 blinded, independent observers to rank HLC in Wright-Giemsa-stained slides. Interobserver agreement in cytology scoring was good. Corresponding plasma [NEFA] and [BHB] measurements were available for 187 and 195 of the 219 samples, respectively. Liver [TG] correlated more strongly with cytology score than with NEFA or BHB, and receiver operating characteristic curve analysis showed that cytology had better diagnostic performance than either NEFA or BHB for correctly categorizing [TG] at thresholds of 5, 10, and 15%. Hepatic lipidosis in high-producing dairy cows is of major clinical and economic importance, and this study demonstrates that cytology is an accurate means of assessing HLC. Additional work is indicated to evaluate the diagnostic utility of liver cytology.

Antenatal Pertussis Vaccination: Why are General Practitioners Reluctant? A Mixed Methods StudySetting

Pertussis has a disproportionately higher morbidity and mortality in infants less than 3 months of age. International and national guidelines recommend pertussis vaccination during pregnancy, as a safe and effective way to protect these infants. Antenatal pertussis vaccination uptake rates remain suboptimal, with many health care professionals (HCPs) still not recommending it. The reasons underlying this reluctance on behalf of HCPs have not been fully established. This study aims to evaluate the current practice and attitudes of General Practitioners (GPs) with regard to antenatal pertussis vaccination. An embedded mixed method design was used. The response rate was 41% (n=109). 54% of GPs who responded (n=59) routinely recommend antenatal pertussis vaccination. Safety concerns and a sense of isolation emerged as the major qualitative themes. More safety data, adequate funding from the Health Service Executive (HSE) and support from secondary care may help to increase the GP recommendation rate and enhance vaccination uptake in pregnancy.

Risk factors associated with in-hospital mortality in elderly patients admitted to a regional trauma center after sustaining a fall

BACKGROUND AND AIMS

Falls are a significant cause of mortality in the elderly patients. Despite this, the literature on in-hospital mortality related to elderly falls remains sparse. Our study aims to determine the risk factors associated with in-hospital mortality in elderly patients admitted to a regional trauma center after sustaining a fall.

METHODS

All elderly case records with fall-related injuries between 2003 and 2013 were retrospectively analyzed for demographic characteristics, injury severities, comorbidity factors and clinical outcomes. Logistic regression analysis was used to examine the risk factors associated with in-hospital mortality.

RESULTS

In total, 1026 elderly patients with fall-related injuries were included in the study. The average age of patients was 80.94 ± 8.16 years. Seventy seven percent of the patients had at least one comorbid condition. Majority of the falls occurred at home. More than half of the patients fell from ground level. Overall, the in-hospital mortality rate was 16 %. Head injury constituted the most common injury sustained in patients who died (77 %). In addition to age, ISS, GCS, ICU admission and anemia were significantly (P < 0.05) associated with in-hospital deaths in elderly fall patients.

CONCLUSION

Ground-level falls in the elderly can be devastating and carry a significant mortality rate. Elderly patients with anemia were two times more likely to die in the hospital after sustaining a fall in our study population. Increased focus on anemia which is often underappreciated in elderly fall patients can be beneficial in improving outcomes and reducing in-hospital mortality.