The TORCH (towards a revolution in COPD health) survival study protocol

Only long-term home oxygen therapy has been shown in randomised controlled trials to increase survival in chronic obstructive pulmonary disease (COPD). There have been no trials assessing the effect of inhaled corticosteroids and long-acting bronchodilators, alone or in combination, on mortality in patients with COPD, despite their known benefit in reducing symptoms and exacerbations. The "TOwards a Revolution in COPD Health" (TORCH) survival study is aiming to determine the impact of salmeterol/fluticasone propionate (SFC) combination and the individual components on the survival of COPD patients. TORCH is a multicentre, randomised, double-blind, parallel-group, placebo-controlled study. Approximately 6,200 patients with moderate-to-severe COPD were randomly assigned to b.i.d. treatment with either SFC (50/500 microg), fluticasone propionate (500 microg), salmeterol (50 microg) or placebo for 3 yrs. The primary end-point is all-cause mortality; secondary end-points are COPD morbidity relating to rate of exacerbations and health status, using the St George's Respiratory Questionnaire. Other end-points include other mortality and exacerbation end-points, requirement for long-term oxygen therapy, and clinic lung function. Safety end-points include adverse events, with additional information on bone fractures. The first patient was recruited in September 2000 and results should be available in 2006. This paper describes the "TOwards a Revolution in COPD Health" study and explains the rationale behind it.

Exercise rehabilitation following intensive care unit discharge for recovery from critical illness

Background: Skeletal muscle wasting and weakness are significant complications of critical illness, associated with the degree of illness severity and periods of reduced mobility during mechanical ventilation. They contribute to the profound physical and functional deficits observed in survivors. These impairments may persist for many years following discharge from the intensive care unit (ICU) and may markedly influence health-related quality of life. Rehabilitation is a key strategy in the recovery of patients following critical illness. Exercise based interventions are aimed at targeting this muscle wasting and weakness. Physical rehabilitation delivered during ICU admission has been systematically evaluated and shown to be beneficial. However its effectiveness when initiated after ICU discharge has yet to be established. Objectives: To assess the effectiveness of exercise rehabilitation programmes, initiated after ICU discharge, on functional exercise capacity and health-related quality of life in adult ICU survivors who have been mechanically ventilated for more than 24 hours. Search methods:We searched the following databases: the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library), OvidSP MEDLINE, Ovid SP EMBASE, and CINAHL via EBSCO host to 15th May 2014. We used a specific search strategy for each database. This included synonyms for ICU and critical illness, exercise training and rehabilitation. We searched the reference lists of included studies and contacted primary authors to obtain further information regarding potentially eligible studies. We also searched major clinical trials registries (Clinical Trials and Current Controlled Trials) and the personal libraries of the review authors. We applied no language or publication restriction. We reran the search in February 2015. We will deal with any studies of interest when we update the review.  Selection criteria:We included randomized controlled trials (RCTs), quasi-RCTs, and controlled clinical trials (CCTs) that compared an exercise interventioninitiated after ICU discharge to any other intervention or a control or ‘usual care’ programme in adult (≥18years) survivors ofcritical illness. Data collection and analysis:We used standard methodological procedures expected by The Cochrane Collaboration. Main results:We included six trials (483 adult ICU participants). Exercise-based interventions were delivered on the ward in two studies; both onthe ward and in the community in one study; and in the community in three studies. The duration of the intervention varied according to the length of stay in hospital following ICU discharge (up to a fixed duration of 12 weeks).Risk of bias was variable for all domains across all trials. High risk of bias was evident in all studies for performance bias, although blinding of participants and personnel in therapeutic rehabilitation trials can be pragmatically challenging. Low risk of bias was at least 50% for all other domains across all trials, although high risk of bias was present in one study for random sequence generation (selection bias), incomplete outcome data (attrition bias) and other sources. Risk of bias was unclear for remaining studies across the domains.All six studies measured effect on the primary outcome of functional exercise capacity, although there was wide variability in natureof intervention, outcome measures and associated metrics, and data reporting. Overall quality of the evidence was very low. Only two studies using the same outcome measure for functional exercise capacity, had the potential for pooling of data and assessment of heterogeneity. On statistical advice, this was considered inappropriate to perform this analysis and study findings were therefore qualitatively described. Individually, three studies reported positive results in favour of the intervention. A small benefit (versus. control)was evident in anaerobic threshold in one study (mean difference, MD (95% confidence interval, CI), 1.8 mlO2/kg/min (0.4 to 3.2),P value = 0.02), although this effect was short-term, and in a second study, both incremental (MD 4.7 (95% CI 1.69 to 7.75) Watts, P value = 0.003) and endurance (MD 4.12 (95% CI 0.68 to 7.56) minutes, P value = 0.021) exercise testing demonstrated improvement.Finally self-reported physical function increased significantly following a rehabilitation manual (P value = 0.006). Remaining studies found no effect of the intervention.Similar variability in with regard findings for the primary outcome of health-related quality of life were also evident. Only two studies evaluated this outcome. Following statistical advice, these data again were considered inappropriate for pooling to determine overall effect and assessment of heterogeneity. Qualitative description of findings was therefore undertaken. Individually, neither study reported differences between intervention and control groups for health-related quality of life as a result of the intervention. Overall quality of the evidence was very low.Mortality was reported by all studies, ranging from 0% to 18.8%. Only one non-mortality adverse event was reported across all patients in all studies (a minor musculoskeletal injury). Withdrawals, reported in four studies, ranged from 0% to 26.5% in control groups,and 8.2% to 27.6% in intervention groups. Loss to follow-up, reported in all studies, ranged from 0% to 14% in control groups, and 0% to 12.5% in intervention groups. Authors’ conclusions:We are unable, at this time, to determine an overall effect on functional exercise capacity, or health-related quality of life, of an exercise based intervention initiated after ICU discharge in survivors of critical illness. Meta-analysis of findings was not appropriate. This was due to insufficient study number and data. Individual study findings were inconsistent. Some studies reported a beneficial effect of the intervention on functional exercise capacity, and others not. No effect was reported on health-related quality of life. Methodological rigour was lacking across a number of domains influencing quality of the evidence. There was also wide variability in the characteristics of interventions, outcome measures and associated metrics, and data reporting.If further trials are identified, we may be able to determine the effect of exercise-based interventions following ICU discharge, on functional exercise capacity and health-related quality of life in survivors of critical illness.

UK medical graduates’ preparedness for practice (P4P): A multi-site qualitative study

Introduction Previous research has demonstrated mixed findings in terms of graduates’ P4P in terms of their knowledge and skills, and interpersonal, systemic and technological aspects (Monrouxe et al. 2014). Few studies have included diverse stakeholders from multiple sites and employing longitudinal methods. We therefore aimed to understand the extent to which UK medical graduates are prepared for practice as Foundation doctors. Methods Cross-sectional qualitative narrative interview and longitudinal audio-diary (LAD) studies with participants from England, Scotland, Wales and Northern Ireland. Study 1 comprised 27 group and 84 individual interviews (n=185) with participants representing different stakeholders (F1s, fully registered trainees, clinical educators, undergraduate/postgraduate deans/foundation programme directors, other healthcare professionals, employers, policy makers, government representatives, and patient/public representatives). Study 2 comprised LADs with 26 F1s over 4-months. Results Participants found it hard initially to conceptualise the term ‘preparedness for practice’. We identified 2187 personal incident narratives (i.e. stories of P4P experiences) across our data: 506 (23%) were classed as ‘prepared’, 730 (33%) as ‘unprepared’ and 951 (44%) as ‘unspecified’. We identified factors that facilitated (e.g. supportive supervisors/colleagues, opportunities for shadowing) and hindered (e.g. unsupportive or disrespectful colleagues, poor organization, understaffing) transitions into and through the Foundation programme. The LADs suggested that trainees felt more confident and competent over time, but that such development was not always linear as challenging circumstances (e.g. new rotations) sometimes made trainees feel unprepared for situations where they had previously indicated preparedness. Conclusion Our findings add to the existing evidence on medical graduates’ P4P in the UK (e.g. Goldacre et al. 2008; Illing et al. 2013). Our findings support the role of assistantships and supportive supervisors for smoothing transitions from student to F1. Further longitudinal and action research studies are now needed to follow students through their final-year assistantships and into their F2 year.

Risks of high-powered motorcycles among younger adults

OBJECTIVES:
We assessed whether policies designed to safeguard young motorcyclists would be effective given shifts in ownership toward high-powered motorcycles.
METHODS:
We investigated population-wide motor vehicle driver and motorcyclist casualties (excluding passengers) recorded in Britain between 2002 and 2009. To adjust for exposure and measure individual risk, we used the estimated number of trips of motorcyclists and drivers, which had been collected as part of a national travel survey.
RESULTS:
Motorcyclists were 76 times more likely to be killed than were drivers for every trip. Older motorcyclist age-strongly linked to experience, skill set, and riding behavior-did not abate the risks of high-powered motorcycles. Older motorcyclists made more trips on high-powered motorcycles.
CONCLUSIONS:
Tighter engine size restrictions would help reduce the use of high-powered motorcycles. Policymakers should introduce health warnings on the risks of high-powered motorcycles and the benefits of safety equipment.

From Substance Use to Homelessness or Vice Versa?

Homelessness is associated with substance use, but whether substance use precedes or follows homelessness is unclear. We investigate the nature of the relationship between homelessness and substance use using data from the unique Australian panel dataset Journeys Home collected in 4 surveys over the period from October 2011 to May 2013. Our data refer to 1325 individuals who were homeless or at risk of becoming homeless. We investigate dynamics in homelessness and substance use over the survey period. We find that the two are closely related: homeless individuals are more likely to be substance users and substance users are more likely to be homeless. These relationships, however, are predominantly driven by observed and unobserved individual characteristics which cause individuals to be both more likely to be homeless and to be substance users. Once we take these personal characteristics into account it seems that homelessness does not affect substance use, although we cannot rule out that alcohol use increases the probability that an individual becomes homeless. These overall relationships also hide some interesting heterogeneity by ‘type’ of homelessness

New exoplanets from the SuperWASP-North survey

We present the current status of the WASP search for transiting exoplanets, focusing on recent planet discoveries from SuperWASP-North and the joint equatorial region (-20≤Dec≤+20) observed by both WASP telescopes. We report the results of monitoring of WASP planets, and discuss how these contribute to our understanding of planet properties and their diversity.

'The Blazing Torch': New Light on English Balladry as a Multi-Media Matrix

This paper investigates the inter-twining histories of two highly successful broadside ballads during the seventeenth century. Neither has been systematically studied before. A set of cultural relationships is opened for consideration by these songs: first, between the two ballads, which are different in several ways but set to the same tune; second, between the selected songs and other ballads on comparable themes; and third, between different editions of the two featured songs. In discussing each of these relationships, attention is paid not only to the texts but to the pictures and the tunes that helped to bring balladry to life for early-modern consumers. It is argued that balladry should be studied as an interconnected web and that individual publications drew significance from the manner in which they associated themselves – through shared pictures, tunes and narratives – with other examples of the genre.

Multiloop robust H∞ control design based on the dynamic PLS approach to chemical processes

In this paper, a multiloop robust control strategy is proposed based on H∞ control and a partial least squares (PLS) model (H∞_PLS) for multivariable chemical processes. It is developed especially for multivariable systems in ill-conditioned plants and non-square systems. The advantage of PLS is to extract the strongest relationship between the input and the output variables in the reduced space of the latent variable model rather than in the original space of the highly dimensional variables. Without conventional decouplers, the dynamic PLS framework automatically decomposes the MIMO process into multiple single-loop systems in the PLS subspace so that the controller design can be simplified. Since plant/model mismatch is almost inevitable in practical applications, to enhance the robustness of this control system, the controllers based on the H∞ mixed sensitivity problem are designed in the PLS latent subspace. The feasibility and the effectiveness of the proposed approach are illustrated by the simulation results of a distillation column and a mixing tank process. Comparisons between H∞_PLS control and conventional individual control (either H∞ control or PLS control only) are also made

Quantification of Type VI secretion system activity in macrophages infected with Burkholderia cenocepacia

The Gram-negative bacterial type VI Secretion System (T6SS) delivers toxins to kill orinhibit the growth of susceptible bacteria, while others target eukaryotic cells. Deletionof atsR, a negative regulator of virulence factors in B. cenocepacia K56-2, increasesT6SS activity. Macrophages infected with a K56-2 ΔatsR mutant display dramaticalterations in their actin cytoskeleton architecture that rely on the T6SS, which isresponsible for the inactivation of multiple Rho-family GTPases by an unknownmechanism. We employed a strategy to standardize the bacterial infection ofmacrophages and densitometrically quantify the T6SS-associated cellular phenotype,which allowed us to characterize the phenotype of systematic deletions of each genewithin the T6SS cluster and ten vgrG encoding genes in K56-2 ΔatsR. None of thegenes from the T6SS core cluster and the individual vgrGs were directly responsiblefor the cytoskeletal changes in infected cells. However, a mutant strain with all vgrGgenes deleted was unable to cause macrophage alterations. Despite not being able toidentify a specific effector protein responsible for the cytoskeletal defects inmacrophages, our strategy resulted in the identification of the critical core componentsand accessory proteins of the T6SS assembly machinery and provides a screeningmethod to detect T6SS effectors targeting the actin cytoskeleton in macrophages byrandom mutagenesis.

The VLT-FLAMES Tarantula Survey XXII. Multiplicity properties of the B-type stars

We investigate the multiplicity properties of 408 B-type stars observed in the 30 Doradus region of the Large Magellanic Cloud with multi-epoch spectroscopy from the VLT-FLAMES Tarantula Survey (VFTS). We use a cross-correlation method to estimate relative radial velocities from the helium and metal absorption lines for each of our targets. Objects with significant radial-velocity variations (and with an amplitude larger than 16 km s^-1) are classified as spectroscopic binaries. We find an observed spectroscopic binary fraction (defined by periods of <10^3.5 d and mass ratios >0.1) for the B-type stars, f<inf>B</inf>(obs) = 0.25 ± 0.02, which appears constant across the field of view, except for the two older clusters (Hodge 301 and SL 639). These two clusters have significantly lower binary fractions of 0.08 ± 0.08 and 0.10 ± 0.09, respectively. Using synthetic populations and a model of our observed epochs and their potential biases, we constrain the intrinsic multiplicity properties of the dwarf and giant (i.e. relatively unevolved) B-type stars in 30 Dor. We obtain a present-day binary fraction f<inf>B</inf>(true) = 0.58 ± 0.11, with a flat period distribution. Within the uncertainties, the multiplicity properties of the B-type stars agree with those for the O stars in 30 Dor from the VFTS.

Implications of aligning full registration of doctors with medical school graduation:a qualitative study of stakeholder perspectives

OBJECTIVES: The Shape of Training report recommended that full registration is aligned with medical school graduation. As part of a General Medical Council-funded study about the preparedness for practice of UK medical graduates, we explored UK stakeholders' views about this proposal using qualitative interviews (30 group and 87 individual interviews) and Framework Analysis.

SETTING: Four UK study sites, one in each country.Save

PARTICIPANTS: 185 individuals from eight stakeholder groups: (1) foundation year 1 (F1) doctors (n=34); (2) fully registered trainee doctors (n=33); (3) clinical educators (n=32); (4) undergraduate/postgraduate Deans, and Foundation Programme Directors (n=30); (5) other healthcare professionals (n=13); (6) employers (n=7); (7) policy and government (n=11); (8) patient and public representatives (n=25).

RESULTS: We identified four main themes: (1) The F1 year as a safety net: patients were protected by close trainee supervision and 'sign off' to prevent errors; trainees were provided with a safe environment for learning on the job; (2) Implications for undergraduate medical education: if the proposal was accepted, a 'radical review' of undergraduate curricula would be needed; undergraduate education might need to be longer; (3) Implications for F1 work practice: steps to protect healthcare team integration and ensure that F1 doctors stay within competency limits would be required; (4) Financial, structural and political implications: there would be cost implications for trainees; clarification of responsibilities between undergraduate and postgraduate medical education would be needed. Typically, each theme comprised arguments for and against the proposal.

CONCLUSIONS: A policy change to align the timing of full registration with graduation would require considerable planning and preliminary work. These findings will inform policymakers' decision-making. Regardless of the decision, medical students should take on greater responsibility for patient care as undergraduates, assessment methods in clinical practice and professionalism domains need development, and good practice in postgraduate supervision and support must be shared.

Living to the range limit: consumer isotopic variation increases with environmental stress

Background: Theoretically, each species’ ecological niche is phylogenetically-determined and expressed spatially as the species’ range. However, environmental stress gradients may directly or indirectly decrease individual performance, such that the precise process delimiting a species range may not be revealed simply by studying abundance patterns. In the intertidal habitat the vertical ranges of marine species may be constrained by their abilities to tolerate thermal and desiccation stress, which may act directly or indirectly, the latter by limiting the availability of preferred trophic resources. Therefore, we expected individuals at greater shore heights to show greater variation in diet alongside lower indices of physiological condition.

Methods: We sampled the grazing gastropod Echinolittorina peruviana from the desert coastline of northern Chile at three shore heights, across eighteen regionally-representative shores. Stable isotope values (δ13C and δ15N) were extracted from E. peruviana and its putative food resources to estimate Bayesian ellipse area, carbon and nitrogen ranges and diet. Individual physiological condition was tracked by muscle % C and % N.

Results: There was an increase in isotopic variation at high shore levels, where E. peruviana’s preferred resource, tide-deposited particulate organic matter (POM), appeared to decrease in dietary contribution, and was expected to be less abundant. Both muscle % C and % N of individuals decreased with height on the shore.

Discussion: Individuals at higher stress levels appear to be less discriminating in diet, likely because of abiotic forcing, which decreases both consumer mobility and the availability of a preferred resource. Abiotic stress might be expected to increase trophic variation in other selective dietary generalist species. Where this coincides with a lower physiological condition, this may be a direct factor in setting their range limit.

A compendium of modelling techniques

This Integration Insight provides a brief overview of the most popular modelling techniques used to analyse complex real-world problems, as well as some less popular but highly relevant techniques. The modelling methods are divided into three categories, with each encompassing a number of methods, as follows: 1) Qualitative Aggregate Models (Soft Systems Methodology, Concept Maps and Mind Mapping, Scenario Planning, Causal (Loop) Diagrams), 2) Quantitative Aggregate Models (Function fitting and Regression, Bayesian Nets, System of differential equations / Dynamical systems, System Dynamics, Evolutionary Algorithms) and 3) Individual Oriented Models (Cellular Automata, Microsimulation, Agent Based Models, Discrete Event Simulation, Social Network
Analysis). Each technique is broadly described with example uses, key attributes and reference material.

Diversidade linguística e desenvolvimento profissional de professores: um estudo no 1º ciclo do ensino básico

O estudo apresentado centra-se em duas temáticas fundamentais: o desenvolvimento profissional docente e a sensibilização à diversidade linguística e cultural nos primeiros anos de escolaridade. Assim, entende-se o desenvolvimento profissional de professores, por um lado, como um processo contínuo e em permanente (re)construção que se inscreve na prática docente e que precisa de a ter como referente e, por outro, como um processo que se expande numa visão da educação onde cabe a abordagem de diferentes línguas como espaço de promoção do respeito e da valorização da diversidade linguística e cultural, do plurilinguismo como valor e competência e de uma educação para a cidadania mais global e mais plural. Este estudo procura analisar o contributo da participação em projetos de sensibilização à diversidade linguística e cultural no 1º Ciclo do Ensino Básico para o desenvolvimento profissional de professores generalistas. Para o efeito, analisaram-se dois grupos de professoras generalistas que participaram em dois projetos diferentes durante o ano letivo de 2008/2009. Num grupo, as professoras, pertencendo à mesma escola, observaram práticas de sala de aula planificadas e desenvolvidas nas suas turmas por uma professora/investigadora. No outro, as docentes integraram uma oficina de formação que decorreu na instituição de Ensino Superior e que tinha como finalidade preparar professores de vários níveis de ensino para o desenvolvimento de uma educação em línguas promotora do plurilinguismo. Neste contexto, as professoras que integravam este grupo planificaram e desenvolveram projetos de investigação-ação, em conjunto com as formadoras/investigadoras, implementando práticas de sensibilização à diversidade linguística e cultural com os seus alunos e recolhendo dados dessas mesmas práticas. Em ambos os contextos analisados, os dados foram recolhidos através de um inquérito por questionário e uma reflexão individual de caracterização escrita por todas as professoras participantes no estudo. Foram ainda realizados um inquérito por entrevista a cada professora e uma sessão de focus group com todas as docentes. A investigadora participou sempre nos momentos de trabalho conjunto, estando como observadora direta. A análise dos dados seguiu uma metodologia de natureza qualitativa, assente numa perspetiva interpretativo-fenomenológica, que permitiu aceder ao conhecimento das professoras envolvidas no estudo sobre si, sobre a profissão, sobre o currículo e sobre o contexto de trabalho. O estudo desenvolvido permitiu concluir que importa criar espaços de formação que assentem num acompanhamento sistemático aos professores, tendo em conta os seus contextos específicos de trabalho. Os resultados evidenciaram que percursos de formação baseados na articulação teoria e prática, na partilha e discussão com outros profissionais e no contacto com práticas concretas de sala de aula permitem que os professores desenvolvam uma atitude mais reflexiva e crítica, adquirindo uma maior consciência de si e do papel que desempenham na escola e na sociedade atuais. Finalmente, este trabalho de investigação revelou ainda que o envolvimento em projetos de sensibilização à diversidade linguística e cultural contribui para que os professores se sintam protagonistas de uma gestão curricular que, através de uma educação em línguas mais plural, promove valores de cidadania e de justiça social desde os primeiros anos de escolaridade.

Coping, fatores psicossociais e capacidade para o trabalho

O coping desempenha um importante papel na saúde individual e rendimento organizacional. Tal como o coping é um tema de interesse recente e promissor na área da psicologia da saúde ocupacional, também os fatores psicossociais do trabalho têm ganho um crescente interesse no domínio da saúde ocupacio-nal. No entanto, pouco se sabe acerca das configurações de coping mais salu-togénicas no mundo do trabalho, e menos ainda acerca da participação dos fatores psicossociais na definição das mesmas. Esta última perspetiva assume os fatores psicossociais não como causas de stresse, mas enquanto recursos de coping. Com o presente estudo, desejávamos saber se as pessoas com melhor saúde no trabalho usam estratégias de coping diferentes daquelas com menor saúde, bem como se a escolha dessas estratégias é influenciada pelos fatores psicossociais do trabalho. Pretendia-se ainda caracterizar o coping dos trabalhadores mais saudáveis e produtivos, e perceber que fatores psicosso-ciais contribuem para o mesmo. Foram estudados 2960 profissionais de traba-lhos mentais, sendo 31% (n=909) profissionais de saúde e 69% (n=2051) pro-fissionais de outras áreas. Além das variáveis sociodemográficas, avaliou-se o coping (Brief COPE), os fatores psicossociais do trabalho (COPSOQ) e o índi-ce de capacidade para o trabalho (ICT), enquanto indicador de saúde ocupa-cional. Desenhou-se um estudo transversal e quantitativo, com níveis de análi-se descritivo, exploratório, correlacional e preditivo. Os resultados confirmaram as hipóteses de estudo e permitem concluir genericamente que (1) o coping diferencia e determina a saúde no trabalho, (2) os fatores psicossociais do trabalho influenciam o coping, ainda que modestamente, e (3) o coping dos profissionais de saúde é estruturalmente diferente do coping dos não profissio-nais de saúde. Os resultados possibilitam ainda estabelecer perfis de bom e de mau coping no trabalho e concorrem para definir estratégias de intervenção psicológica para o desenvolvimento do reportório de coping dos profissionais de trabalhos mentais, bem como estratégias de gestão (de recursos humanos) para a melhoria do ambiente psicossocial do trabalho. Por fim, os resultados estimulam algumas considerações teóricas e metodológicas que sugerem direções futuras para o estudo dos efeitos da relação do coping com o ambien-te psicossocial do trabalho na saúde e bem-estar individual, no rendimento organizacional e na qualidade de vida no trabalho. Julgamos, por fim, que os resultados obtidos podem contribuir para aprimorar os mecanismos de coping dos profissionais e para ajustar o ambiente psicossocial do trabalho.