Productivity declines threaten East African soda lakes and the iconic Lesser Flamingo.

Soda lakes are some of the most productive aquatic ecosystems.1 Their alkaline-saline waters sustain unique phytoplankton communities2,3 and provide vital habitats for highly specialized biodiversity including invertebrates, endemic fish species, and Lesser Flamingos (Phoeniconaias minor).1,4 More than three-quarters of Lesser Flamingos inhabit the soda lakes of East Africa5; however, populations are in decline.6 Declines could be attributed to their highly specialized diet of cyanobacteria7 and dependence on a network of soda lake feeding habitats that are highly sensitive to climate fluctuations and catchment degradation.8,9,10,11,12 However, changing habitat availability has not been assessed due to a lack of in situ water quality and hydrology data and the irregular monitoring of these waterbodies.13 Here, we combine satellite Earth observations and Lesser Flamingo abundance observations to quantify spatial and temporal trends in productivity and ecosystem health over multiple decades at 22 soda lakes across East Africa. We found that Lesser Flamingo distributions are best explained by phytoplankton biomass, an indicator of food availability. However, timeseries analyses revealed significant declines in phytoplankton biomass from 1999 to 2022, most likely driven by substantial rises in lake water levels. Declining productivity has reduced the availability of healthy soda lake ecosystems, most notably in equatorial Kenya and northern Tanzania. Our results highlight the increasing vulnerability of Lesser Flamingos and other soda lake biodiversity in East Africa, particularly with increased rainfall predicted under climate change.14,15,16 Without improved lake monitoring and catchment management practices, soda lake ecosystems could be pushed beyond their environmental tolerances. VIDEO ABSTRACT.

Systematic literature review of treatments used for refractory or unexplained chronic cough in adults.

BACKGROUND: Refractory or unexplained chronic cough (RCC or UCC) is difficult to manage and is usually treated by the off-label use of drugs approved for other indications. OBJECTIVE: The objectives of this systematic literature review (SLR) were to identify and characterize the current published body of evidence for the efficacy and safety of treatments for RCC or UCC. METHODS: The SLR was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. The SLRs pre-defined population included patients ≥18 years of age who were diagnosed with chronic cough. The review was not restricted to any intervention type or study comparator, nor by timeframe. RESULTS: A total of 20 eligible publications from 19 unique trials were included. Seventeen of these trials were randomized controlled trials and most (14/17) were placebo-controlled. There was considerable variability between trials in the definition of RCC or UCC, participant exclusion and inclusion criteria, outcome measurement timepoints, and the safety and efficacy outcomes assessed. Several trials identified significant improvements in cough frequency, severity, or health-related quality of life measures while participants were on treatment, although these improvements did not persist in any of the studies that included a post-treatment follow-up timepoint. CONCLUSIONS: In the absence of an approved therapy, placebo remains the most common comparator in trials of potential RCC or UCC treatments. The between-study comparability of the published evidence is limited by heterogeneity of study design, study populations, and outcomes measures, as well as by concerns regarding study size and risk of bias.

Chronic cough: more than just a persistent cough: a systematic literature review to understand the impact of chronic cough on quality of life.

PURPOSE: Chronic cough (CC), defined as a cough persisting ≥ 8 weeks, can have a substantial negative impact on health-related quality of life (HRQoL). This is exacerbated by challenges with timely diagnosis and a lack of approved therapies. A systematic literature review (SLR) was conducted to identify evidence on HRQoL and health state utility values associated with refractory CC or unexplained CC. METHODS: Electronic database searches were supplemented with searches of conference proceedings and health technology assessment body websites. Two independent reviewers assessed all citations for inclusion based on predefined inclusion/exclusion criteria. Key inclusion criteria were patient populations with CC and reporting of patient-reported outcomes or utilities using generic or disease-specific measures. RESULTS: Following screening, 65 studies were identified for inclusion in the SLR. Of these, 23 studies assessed HRQoL among patients with CC who were not treated or treated with unspecified interventions, and 42 studies in patients who were treated with specified interventions. The studies indicated a substantial decrement to HRQoL as a result of CC, characterized by generic and disease-specific patient-reported outcome measures. HRQoL was impacted across multiple domains, including physical, psychological, and social functioning. The studies also demonstrated the potential for treatments to have a significant positive impact on HRQoL. CONCLUSIONS: CC can substantially affect HRQoL in patients, across physical, psychological, and social domains. Although treatments can improve HRQoL in these patients, the available evidence is limited. There remains an unmet need for approved pharmacological treatments to alleviate CC and improve HRQoL for these patients.

Understanding the economic burden of chronic cough: a systematic literature review.

Chronic cough (CC) is associated with high healthcare resource utilization (HCRU) due to challenges in diagnosis and treatment and is anticipated to have a substantial economic impact. This systematic literature review (SLR) sought to identify evidence on the cost-effectiveness of treatments and the economic burden associated with CC. Electronic database searches were supplemented with searches of conference proceedings and health technology assessment body websites. Two independent reviewers assessed all citations for inclusion based on predefined inclusion/exclusion criteria. Key inclusion criteria were patient population with CC, and outcomes related to cost-effectiveness and HCRU and costs. After screening, one cost-effectiveness analysis was identified, alongside eight studies reporting HCRU and costs related to CC. Though evidence was limited, studies suggest that patients with CC incur higher costs and use more resources than those with acute cough. Types of resource use reported included healthcare contacts and prescriptions, diagnostic tests, referrals and specialist evaluations, and treatment use. There is a paucity of literature on HCRU and costs in CC, and very limited cost-effectiveness analyses. The economic burden appears higher in these patients however, without direct comparison to the general population it is difficult to determine the total impact. The increased burden is expected to be a result of the challenges with diagnosis and lack of approved treatments. However, limited conclusions can be drawn in the absence of further data. Future studies should endeavor to quantify the HCRU and cost attributable to patients with CC.

Budget impact analysis of Jivi (damoctocog alfa pegol, Bay 94-9027) in severe hemophilia A in Japan.

OBJECTIVE: Hemophilia A (HA) is a genetic bleeding disorder characterized by a deficiency of clotting factor VIII (FVIII) requiring lifelong prophylactic treatment typically with conventional standard half-life recombinant FVIII (rFVIII). Lifelong prophylaxis impacts budget, patient adherence, and long-term outcomes. The consequent economic and treatment burden may be reduced by using novel extended half-life rFVIII. The objective of this analysis was to estimate the budget impact of introducing Jivi (damoctocog alfa pegol, BAY 94-9027), hereafter referred to as BAY 94-9027, as an on-demand and prophylactic treatment for severe HA from a Japanese payer's perspective. METHODS: A global budget impact model was adapted to the Japanese setting using data obtained via a targeted literature review of Japanese sources. The model considered a five-year time horizon for a market without and with BAY 94-9027. Using annual per-patient costs, the total cost of on-demand and prophylactic treatment of adolescent and adult patients with severe HA (without inhibitors) were analyzed. The model used summary of product characteristics (SmPC) and clinical trial dosing, and unit costs from the National Health Insurance (NHI) drug price database. Comparators considered in the model comprised of currently available products in Japan. Projected BAY 94-9027 uptake ranged from 4% to 9% over the five years (2020-2024). RESULTS: Introduction of BAY 94-9027 for the treatment of severe HA is estimated to decrease the overall budget by 1.5%, with a cost saving of approximately $67 million USD (¥7.4 billion JPY) over five years. Estimated cost savings associated with BAY 94-9027 ranged from $1.4 million USD (¥156 million JPY) in 2020 to $23 million USD (¥2.6 billion JPY) in 2024 for the Japanese healthcare system. LIMITATIONS: There were limitations associated with the study. The Japanese guidelines consulted during the targeted literature review of national data sources in Japan were based on global data as reference sources. Also, studies reporting the bleeding rate, dosing guidelines, and economic burden in the Japanese population identified by the targeted literature review were limited hence global studies were used and may not have been representative of the Japanese population. CONCLUSIONS: BAY 94-9027 can reduce total severe HA treatment costs, driven by lower annual rFVIII utilization, and a narrow weekly dosing range compared to competitor products in the Japanese market.

Analog Resonance Computation: A New Model for Human Cognition.

Early models of human cognition appeared to posit the brain as a collection of discrete digital computing modules with specific data processing functions. More recent theories such as the Hierarchically Mechanistic Mind characterize the brain as a massive hierarchy of interconnected and adaptive circuits whose primary aim is to reduce entropy. However, studies in high workload/stress situations show that human behavior is often error prone and seemingly irrational. Rather than regarding such behavior to be uncharacteristic, this paper suggest that such "atypical" behavior provides the best information on which to base theories of human cognition. Rather than using a digital paradigm, human cognition should be seen as an analog computer based on resonating circuits whose primary driver is to constantly extract information from the massively complex and rapidly changing world around us to construct an internal model of reality that allows us to rapidly respond to the threats and opportunities.

Lurasidone compared to other atypical antipsychotic monotherapies for adolescent schizophrenia: a systematic literature review and network meta-analysis.

This network meta-analysis assessed the efficacy and tolerability of lurasidone versus other oral atypical antipsychotic monotherapies in adolescent schizophrenia. A systematic literature review identified 13 randomized controlled trials of antipsychotics in adolescents with schizophrenia-spectrum disorders. A Bayesian network meta-analysis compared lurasidone to aripiprazole, asenapine, clozapine, olanzapine, paliperidone extended-release (ER), quetiapine, risperidone, and ziprasidone. Outcomes included Positive and Negative Syndrome Scale (PANSS), Clinical Global Impressions-Severity (CGI-S), weight gain, all-cause discontinuation, extrapyramidal symptoms (EPS), and akathisia. Results were reported as median differences for continuous outcomes and odds ratios (ORs) for binary outcomes, along with 95% credible intervals (95% CrI). Lurasidone was significantly more efficacious than placebo on the PANSS (- 7.95, 95% CrI - 11.76 to - 4.16) and CGI-S (- 0.44, 95% CrI - 0.67 to - 0.22) scores. Lurasidone was associated with similar weight gain to placebo and statistically significantly less weight gain versus olanzapine (- 3.62 kg, 95% CrI - 4.84 kg to - 2.41 kg), quetiapine (- 2.13 kg, 95% CrI - 3.20 kg to - 1.08 kg), risperidone (- 1.16 kg, 95% CrI - 2.14 kg to - 0.17 kg), asenapine (- 0.98 kg, 95% CrI - 1.71 kg to - 0.24 kg), and paliperidone ER (- 0.85 kg, 95% CrI - 1.57 kg to - 0.14 kg). The odds of all-cause discontinuation were significantly lower for lurasidone than aripiprazole (OR = 0.28, 95% CrI 0.10-0.76) and paliperidone ER (OR = 0.25, 95% CrI 0.08-0.81) and comparable to other antipsychotics. Rates of EPS and akathisia were similar for lurasidone and other atypical antipsychotics. In this network meta-analysis of atypical antipsychotics in adolescent schizophrenia, lurasidone was associated with similar efficacy, less weight gain, and lower risk of all-cause discontinuation compared to other oral atypical antipsychotics.

The effect of multitasking on the communication skill and clinical skills of medical students.

BACKGROUND: Mental workload is an abstract concept that perceives cognition as the brain having a small and finite capacity to process information, with high levels of workload associated with poor performance and error. While an individual may be able to complete two different tasks individually, a combination of tasks may lead to cognitive overload and poor performance. In many high-risk industries, it is common to measure mental workload and then to redesign tasks until cognitive overload is avoided. This study aimed to measure the effect of multitasking on the mental workload and performance of medical students completing single and combined clinical tasks. METHODS: Medical students who had completed basic clinical skills training in a single undergraduate Medical School completed four standardised tasks for a total of four minutes each, consisting of: inactivity, listening, venepuncture and a combination of listening and venepuncture. Task performance was measured using standard binary checklists and with mental workload measured using a secondary task method. RESULTS: The tasks were successfully completed by 40 subjects and as expected, mental workload increased with task complexity. Combining the two tasks showed no difference in the associated mental workload and performance at venepuncture (p = 0.082) However, during the combined task, listening appeared to deteriorate (p < 0.001). CONCLUSIONS: If staff are expected to simultaneously complete multiple tasks then they may preferentially shed communication tasks in order to maintain their performance of physical tasks, leading to the appearance of poor communication skills. Although this is a small-scale study in medical students it suggests that the active assessment and management of clinician workload in busy clinical settings may be an effective strategy to improve doctor-patient communication.

A pilot study of marking accuracy and mental workload as measures of OSCE examiner performance.

BACKGROUND: The Objective Structured Clinical Examination (OSCE) is now a standard assessment format and while examiner training is seen as essential to assure quality, there appear to be no widely accepted measures of examiner performance. METHODS: The objective of this study was to determine whether the routine training provided to examiners improved their accuracy and reduced their mental workload. Accuracy was defined as the difference between the rating of each examiner and that of an expert group expressed as the mean error per item. At the same time the mental workload of each examiner was measured using a previously validated secondary task methodology. RESULTS: Training was not associated with an improvement in accuracy (p = 0.547) and that there was no detectable effect on mental workload. However, accuracy was improved after exposure to the same scenario (p < 0.001) and accuracy was greater when marking an excellent compared to a borderline performance. CONCLUSIONS: This study suggests that the method of training OSCE examiners studied is not effective in improving their performance, but that average item accuracy and mental workload appear to be valid methods of assessing examiner performance.

Instilling new habits: addressing implicit bias in healthcare professionals.

There appears to be a fundamental inconsistency between research which shows that some minority groups consistently receive lower quality healthcare and the literature indicating that healthcare workers appear to hold equality as a core personal value. Recent evidence using Implicit Association Tests suggests that these disparities in outcome may in part be due to social biases that are primarily unconscious. In some individuals the activation of these biases may be also facilitated by the high levels of cognitive load associated with clinical practice. However, a range of measures, such as counter-stereotypical stimuli and targeted experience with minority groups, have been identified as possible solutions in other fields and may be adapted for use within healthcare settings. We suggest that social bias should not be seen exclusively as a problem of conscious attitudes which need to be addressed through increased awareness. Instead the delivery of bias free healthcare should become a habit, developed through a continuous process of practice, feedback and reflection.

A pilot study of the mental workload of objective structured clinical examination examiners.

CONTEXT: Mental workload is a concept used in many industries to investigate operator performance, but it has only recently been used in the educational setting. It has been suggested that excessive mental workload in assessors may impair the validity of objective structured clinical examination (OSCE)-type assessments. OBJECTIVES: This study aimed to establish the feasibility of measuring the mental workload of examiners during an OSCE assessment and to establish methodologies and baseline values to guide future study design. METHODS: Two previously validated methods of measuring mental workload, the NASA-Task Load Index rating scale and use of a secondary task (response to a prompt from a vibrotactile device), were used to measure the workload of 10 subjects during a formative OSCE. Trainee anaesthetists (n = 24) working in an operating theatre were used as a control group. RESULTS: The mental workload of examiners exceeded that of controls on both measures. Although there was marked inter-subject variability, reliability between stations for individual examiners was robust (α = 0.922). CONCLUSIONS: These data suggest that mental workload is excessive in OSCE examiners. Further studies are required to measure the effect of changes in assessment design and examiner training.

Mental workload as a key factor in clinical decision making.

The decision making process is central to the practice of a clinician and has traditionally been described in terms of the hypothetico-deductive model. More recently, models adapted from cognitive psychology, such as the dual process and script theories have proved useful in explaining patterns of practice not consistent with purely cognitive based practice. The purpose of this paper is to introduce the concept of mental workload as a key determinant of the type of cognitive processing used by clinicians. Published research appears to be consistent with 'schemata' based cognition as the principle mode of working for those engaged in complex tasks under time pressure. Although conscious processing of factual data is also used, it may be the primary mode of cognition only in situations where time pressure is not a factor. Further research on the decision making process should be based on outcomes which are not dependant on conscious recall of past actions or events and include a measure of mental workload. This further appears to support the concept of the patient, within the clinical environment, as the most effective learning resource.

Graduate entry medicine: selection criteria and student performance.

BACKGROUND: Graduate entry medicine raises new questions about the suitability of students with different backgrounds. We examine this, and the broader issue of effectiveness of selection and assessment procedures. METHODS: The data included background characteristics, academic record, interview score and performance in pre-clinical modular assessment for two years intake of graduate entry medical students. Exploratory factor analysis is a powerful method for reducing a large number of measures to a smaller group of underlying factors. It was used here to identify patterns within and between the selection and performance data. PRINCIPAL FINDINGS: Basic background characteristics were of little importance in predicting exam success. However, easily interpreted components were detected within variables comprising the 'selection' and 'assessment' criteria. Three selection components were identified ('Academic', 'GAMSAT', 'Interview') and four assessment components ('General Exam', 'Oncology', 'OSCE', 'Family Case Study'). There was a striking lack of relationships between most selection and performance factors. Only 'General Exam' and 'Academic' showed a correlation (Pearson's r = 0.55, p<0.001). CONCLUSIONS: This study raises questions about methods of student selection and their effectiveness in predicting performance and assessing suitability for a medical career. Admissions tests and most exams only confirmed previous academic achievement, while interview scores were not correlated with any consequent assessment.

Learning opportunities in the clinical setting (LOCS) for medical students: A novel approach.

INTRODUCTION: Graduate-entry medical programmes (GEP) have been introduced into many UK universities. Their shortened 4-year programme may restrict exposure to the clinical environment. The GEP at Swansea University has introduced Learning Opportunities in the Clinical Setting (LOCS), a novel approach, allowing students to choose half day sessions from a list which aimed at bringing experiential clinical learning to first and second year students on the course. METHODS: During the academic years 2007-2008 and 2008-2009, student feedback was collected anonymously online with the options 'very useful', 'useful' or 'not useful' followed by a free text box space to feedback their experience. The text was assessed using qualitative analysis methodology. RESULTS: A total of 730 LOCS feedback comments were analysed, 422 were recorded as 'very useful' (58%), 276 were 'useful' (38%) and 32 'not useful' (4%). Students' feedback were divided into positive (1330) and negative (152) comments. Positive themes were broadly divided into four categories: Positive Teacher experience, Positive Clinical experience, Relevance to the course and significant Personal Development. CONCLUSION: The LOCS system provides an efficient method of providing students with a choice of additional learning opportunities which has proved popular and, in the opinion of students, educationally effective.