U-Pb-dated flowstones restrict South African early hominin record to dry climate phases.

The Cradle of Humankind (Cradle) in South Africa preserves a rich collection of fossil hominins representing Australopithecus, Paranthropus and Homo1. The ages of these fossils are contentious2-4 and have compromised the degree to which the South African hominin record can be used to test hypotheses of human evolution. However, uranium-lead (U-Pb) analyses of horizontally bedded layers of calcium carbonate (flowstone) provide a potential opportunity to obtain a robust chronology5. Flowstones are ubiquitous cave features and provide a palaeoclimatic context, because they grow only during phases of increased effective precipitation6,7, ideally in closed caves. Here we show that flowstones from eight Cradle caves date to six narrow time intervals between 3.2 and 1.3 million years ago. We use a kernel density estimate to combine 29 U-Pb ages into a single record of flowstone growth intervals. We interpret these as major wet phases, when an increased water supply, more extensive vegetation cover and at least partially closed caves allowed for undisturbed, semi-continuous growth of the flowstones. The intervening times represent substantially drier phases, during which fossils of hominins and other fossils accumulated in open caves. Fossil preservation, restricted to drier intervals, thus biases the view of hominin evolutionary history and behaviour, and places the hominins in a community of comparatively dry-adapted fauna. Although the periods of cave closure leave temporal gaps in the South African fossil record, the flowstones themselves provide valuable insights into both local and pan-African climate variability.

Spotlight influenza: Laboratory-confirmed seasonal influenza in people with acute respiratory illness: a literature review and meta-analysis, WHO European Region, 2004 to 2017.

BackgroundAcross the World Health Organization European Region, there are few estimates of the proportion of people seeking medical care for influenza-like illness or acute respiratory infections and who have laboratory-confirmed seasonal influenza infection.MethodsWe conducted a meta-analysis of data extracted from studies published between 2004 and 2017 and from sentinel data from the European surveillance system (TESSy) between 2004 and 2018. We pooled within-season estimates by influenza type/subtype, setting (outpatient (OP)/inpatient (IP)) and age group to estimate the proportion of people tested who have laboratory-confirmed and medically-attended seasonal influenza in Europe.ResultsIn the literature review, the pooled proportion for all influenza types was 33% (95% confidence interval (CI): 30-36), higher among OP 36% (95% CI: 33-40) than IP 24% (95% CI: 20-29). Pooled estimates for all influenza types by age group were: 0-17 years, 26% (22-31); 18-64 years, 41% (32-50); ≥ 65 years, 33% (27-40). From TESSy data, 33% (31-34) of OP and 24% (21-27) of IP were positive. The highest proportion of influenza A was in people aged 18-64 years (22%, 16-29). By subtype, A(H1N1)pdm09 was highest in 18-64 year-olds (16%, 11-21%) whereas A(H3N2) was highest in those ≥ 65 years (10%, 2-22). For influenza B, the highest proportion of infections was in those aged 18-64 years (15%, 9-24).ConclusionsLaboratory-confirmed influenza accounted for approximately one third of all acute respiratory infections for which medical care was sought during the influenza season.

Google search patterns monitoring the daily health impact of heatwaves in England: How do the findings compare to established syndromic surveillance systems from 2013 to 2017?

One of the implications of climate change is a predicted increase in frequent and severe heatwaves. The impact of heatwaves on the health of the population is captured through real-time syndromic healthcare surveillance systems monitored daily in England during the summer months. Internet search data could potentially provide improved timeliness and help to assess the wider population health impact of heat by capturing a population sub-group who are symptomatic but do not seek healthcare. A retrospective observational study was carried out from June 2013 to September 2017 in England to compare daily trends in validated syndromic surveillance heat-related morbidity indicators against symptom-based heatwave related Google search terms. The degree of correlation was determined with Spearman correlation coefficients and lag assessment was carried out to determine timeliness. Daily increases in frequency in Google search terms during heatwave events correlated well with validated syndromic indicators. Correlation coefficients between search term frequency and syndromic indicators from 2013 to 2017 were highest with the telehealth service NHS 111 (range of 0.684-0.900 by search term). Lag analysis revealed a similar timeliness between the data sources, suggesting Google data did not provide a delayed or earlier signal in the context of England's syndromic surveillance systems. This work highlights the potential benefits for countries which lack established public health surveillance systems to monitor heat-related morbidity and the use of internet search data to assess the wider population health impact of exposure to heat.

Effectiveness of an "Exclusive Intervention Strategy" to increase medical male circumcision uptake among men aged 25-49 years in South Africa.

BACKGROUND: South Africa introduced medical male circumcision (MMC) to reduce HIV incidence. Mathematical modeling suggested that targeting MMC services to men aged 20-34 years could provide the most immediate impact on HIV incidence. However the majority of MMCs performed have been among males aged ≤25 years. We evaluated an intervention package to increase MMC uptake among men aged 25-49 years. METHODS: We conducted a pre-post study to compare the proportion of men (aged 25-49 years) presenting for MMC during the formative (Phase 1) and intervention (Phase 2) phases in Ekurhuleni, Johannesburg, South Africa. The intervention included infrastructure changes that separated adults from adolescents at the MMC site, an exclusive men's health club, adult-specific demand generation materials, and discussions with community members. RESULTS: Overall 2817 enrolled in the study with 1601 from Phase 1 and 1216 in Phase 2. A higher proportion of participants aged 25-49 years accessed MMC in Phase 2 compared to Phase 1 (59.4% vs. 54.9%; Prevalence Ratio = 1.08; 95% Confidence Interval: 1.01-1.15; p = 0.019). Participants with multiple partners in the past 12 months in Phase 2 were more likely to access MMC services compared to participants in Phase 1 (unadjusted Odds Ratio, 1.37; 95% CI:1.17-1.61; p < 0.001). After adjusting for age, multiple partners remained a risk factor in Phase 2 (adjusted OR, 1.39; 95% CI: 1.18-1.63; p < 0.001). CONCLUSIONS: The "Exclusive Intervention Strategy" was associated with a slight increase in the proportion of participants aged 25-49 years accessing MMC services, and an increase in those with HIV risk behaviors, during the intervention phase. These findings may provide important insights to overcoming barriers for accessing MMC services among men aged 25-49 years. TRIAL REGISTRATION: The study is registered at ClinicalTrials.gov , number NCT02352961 .

The role of the assistant practitioner in the clinical setting: a focus group study.

BACKGROUND: Assistant practitioners have knowledge and skills beyond the level of traditional support workers, and work in many clinical settings. However, some assistant practitioners lack a clearly defined role and may be under-used due to issues around accountability and uncertainty about their purpose. This paper explores the assistant practitioner role from the perspectives of assistant practitioners and registered nurses. METHODS: This study aimed to explore the role of the assistant practitioner from the perspectives of assistant practitioners and registered nurses in two NHS hospital trusts in Oxfordshire, United Kingdom. Six qualitative focus groups were undertaken between February-March 2017. Ethical approval was obtained (FREC 2016/05) and written consent was provided by participants. Data was analysed thematically analysed using the Framework method. RESULTS: Nineteen participants (assistant practitioners, n = 12; registered nurses, n = 7) were recruited using convenience sampling. Emerging themes related to 'fluctuating roles and responsibilities of assistant practitioners', 'role differences between registered nurses and assistant practitioners', 'working relationships', 'supervision' and 'redefining nursing pathways'. The Results and Discussion sections highlight a lack of role clarity and blurring of boundaries between the roles of assistant practitioners and registered nurses, with many tasks undertaken by both. This lack of ownership of 'nurse-specific' roles by registered nurses was evident and clear differences were only encountered with regard to accountability. The development of the Nursing Associate role provides managers with the opportunity to redefine staff banding hierarchies to ensure that clinical staff are aware of their role capabilities and limitations and are practicing safely, whilst promoting career development and progression pathways. CONCLUSION: Addressing issues around role clarity can benefit professional development, satisfaction, role identity and ownership for registered nurses and assistant practitioners, by recognising the individual and collective value they bring to the clinical team. The findings can help inform the development of the Nursing Associate role.

Improving the personalisation of care in a district nursing team: a service improvement project.

Service users can benefit in a variety of ways from a personalised approach to care. This service improvement project aimed to improve personalisation for patients being cared for by a community nursing team in the south of England. A plan, study, do, act (PDSA) approach to the project was undertaken with a community nursing team. Both quantitative and qualitative data showed improvement once the focus on personalisation had been improved. Patient and staff satisfaction scores improved and a documentation audit showed the focus on personalisation had increased. Qualitative data suggested that personalisation had also saved staff time, although this measurement was not included in the project. A focus on personalisation can be beneficial for staff and service users.

Evaluating the use of patient pathway scores in medical assessments.

Aim This article describes the modification and testing of a triage tool, the patient pathway assessment score (PPAS), which could be used by all grades of nursing staff to triage patients in a medical assessment area (MAA). The aim was to increase patient satisfaction and reduce waiting times. Method Staff scored all patients using PPAS, but used the existing triage process to assign patients to one of the MAA's two pathways. Two researchers reviewed patients' notes retrospectively to determine which pathway they should have followed and compared this to the outcome that would have occurred if the PPAS score had been used. Results Full, rather than theoretical, use of the PPAS tool could have reduced patient waiting times, as 55 (24%) out of 231 patients would have been allocated to the correct pathway. Conclusion The tool could improve patients' journeys through the MAA by ensuring they are allocated to the correct pathway. It is now implemented in practice.

Mortality during the 2013 heatwave in England--How did it compare to previous heatwaves? A retrospective observational study.

Heatwaves are predicted to increase in frequency and intensity as a result of climate change. The health impacts of these events can be significant, particularly for vulnerable populations when mortality can occur. England experienced a prolonged heatwave in summer 2013. Daily age-group and region-specific all-cause excess mortality during summer 2013 and previous heatwave periods back to 2003 was determined using the same linear regression model and heatwave definition to estimate impact and place observations from 2013 in context. Predicted excess mortality due to heat during this period was also independently estimated. Despite a sustained heatwave in England in 2013, the impact on mortality was considerably less than expected; a small cumulative excess of 195 deaths (95% confidence interval -87 to 477) in 65+ year olds and 106 deaths (95% CI -22 to 234) in <65 year olds was seen, nearly a fifth of excess deaths predicted based on observed temperatures. This impact was also less than seen in 2006 (2323 deaths) and 2003 (2234 deaths), despite a similarly prolonged period of high temperatures. The reasons for this are unclear and further work needs to be done to understand this and further clarify the predicted impact of increases in temperature.

Good practice recommendations for paediatric outpatient parenteral antibiotic therapy (p-OPAT) in the UK: a consensus statement.

There is compelling evidence to support the rationale for managing children on intravenous antimicrobial therapy at home whenever possible, including parent and patient satisfaction, psychological well-being, return to school/employment, reductions in healthcare-associated infection and cost savings. As a joint collaboration between the BSAC and the British Paediatric Allergy, Immunity and Infection Group, we have developed good practice recommendations to highlight good clinical practice and governance within paediatric outpatient parenteral antibiotic therapy (p-OPAT) services across the UK. These guidelines provide a practical approach for safely delivering a p-OPAT service in both secondary care and tertiary care settings, in terms of the roles and responsibilities of members of the p-OPAT team, the structure required to deliver the service, identifying patients and pathologies that are suitable for p-OPAT, ensuring appropriate vascular access, antimicrobial choice and delivery and the clinical governance aspects of delivering a p-OPAT service. The process of writing a business case to support the introduction of a p-OPAT service is also addressed.

1.32 ± 0.11 Ma age for underwater remains constrain antiquity and longevity of the Dominican primate Antillothrix bernensis.

Endemic New World monkeys are an important element of the extinct mammal faunas of the Caribbean's Greater Antilles. Here we report the first geochronometric evidence that the primate Antillothrix bernensis existed in the Dominican Republic during the Pleistocene, based on the uranium-series age of carbonate speleothem that encased a tibia when it was collected in a flooded cave. Three-dimensional geometric morphometrics of laser-scanned living and extinct samples provide evidence to support the hypothesis that this specimen and other Dominican primate tibial remains belong to that same species. U-Th dating of the host cave carbonate returns ages consistently at the 600 ka upper limit of the technique. However, U-Pb, capable of resolving ages of greater antiquity, is more robust in this context, returning a secure age of 1.32 ± 0.11 Ma, which is the oldest chronometric age recorded for a Hispaniolan mammal. While its origins and manner and time of arrival are obscure, the morphometric studies are consistent with phylogenetic analyses that place A. bernensis within the pitheciid clade of the platyrrhines. The species apparently endured for over 1 million years during the climatic perturbations of the Pleistocene, as a frugivorous climbing quadruped, one of two known primate species occupying the hazard prone island of Hispaniola.

Uptake and impact of vaccinating school age children against influenza during a season with circulation of drifted influenza A and B strains, England, 2014/15.

The 2014/15 influenza season was the second season of roll-out of a live attenuated influenza vaccine (LAIV) programme for healthy children in England. During this season, besides offering LAIV to all two to four year olds, several areas piloted vaccination of primary (4-11 years) and secondary (11-13 years) age children. Influenza A(H3N2) circulated, with strains genetically and antigenically distinct from the 2014/15 A(H3N2) vaccine strain, followed by a drifted B strain. We assessed the overall and indirect impact of vaccinating school age children, comparing cumulative disease incidence in targeted and non-targeted age groups in vaccine pilot to non-pilot areas. Uptake levels were 56.8% and 49.8% in primary and secondary school pilot areas respectively. In primary school age pilot areas, cumulative primary care influenza-like consultation, emergency department respiratory attendance, respiratory swab positivity, hospitalisation and excess respiratory mortality were consistently lower in targeted and non-targeted age groups, though less for adults and more severe end-points, compared with non-pilot areas. There was no significant reduction for excess all-cause mortality. Little impact was seen in secondary school age pilot only areas compared with non-pilot areas. Vaccination of healthy primary school age children resulted in population-level impact despite circulation of drifted A and B influenza strains.

Effectiveness of seasonal influenza vaccine in preventing laboratory-confirmed influenza in primary care in the United Kingdom: 2014/15 end of season results.

The 2014/15 influenza season in the United Kingdom (UK) was characterised by circulation of predominantly antigenically and genetically drifted influenza A(H3N2) and B viruses. A universal paediatric influenza vaccination programme using a quadrivalent live attenuated influenza vaccine (LAIV) has recently been introduced in the UK. This study aims to measure the end-of-season influenza vaccine effectiveness (VE), including for LAIV, using the test negative case-control design. The overall adjusted VE against all influenza was 34.3% (95% confidence interval (CI) 17.8 to 47.5); for A(H3N2) 29.3% (95% CI: 8.6 to 45.3) and for B 46.3% (95% CI: 13.9 to 66.5). For those aged under 18 years, influenza A(H3N2) LAIV VE was 35% (95% CI: -29.9 to 67.5), whereas for influenza B the LAIV VE was 100% (95% CI:17.0 to 100.0). Although the VE against influenza A(H3N2) infection was low, there was still evidence of significant protection, together with moderate, significant protection against drifted circulating influenza B viruses. LAIV provided non-significant positive protection against influenza A, with significant protection against B. Further work to assess the population impact of the vaccine programme across the UK is underway.

Enhanced MERS coronavirus surveillance of travelers from the Middle East to England.

During the first year of enhanced MERS coronavirus surveillance in England, 77 persons traveling from the Middle East had acute respiratory illness and were tested for the virus. Infection was confirmed in 2 travelers with acute respiratory distress syndrome and 2 of their contacts. Patients with less severe manifestations tested negative.

Using real-time syndromic surveillance to assess the health impact of the 2013 heatwave in England.

Heatwaves are a seasonal threat to public health. During July 2013 England experienced a heatwave; we used a suite of syndromic surveillance systems to monitor the impact of the heatwave. Significant increases in heatstroke and sunstroke were observed during 7-10 July 2013. Syndromic surveillance provided an innovative and effective service, supporting heatwave planning and providing early warning of the impact of extreme heat thereby improving the public health response to heatwaves.

Use of theoretical and conceptual frameworks in qualitative research.

AIM: To debate the definition and use of theoretical and conceptual frameworks in qualitative research. BACKGROUND: There is a paucity of literature to help the novice researcher to understand what theoretical and conceptual frameworks are and how they should be used. This paper acknowledges the interchangeable usage of these terms and researchers' confusion about the differences between the two. It discusses how researchers have used theoretical and conceptual frameworks and the notion of conceptual models. Detail is given about how one researcher incorporated a conceptual framework throughout a research project, the purpose for doing so and how this led to a resultant conceptual model. REVIEW METHODS: Concepts from Abbott (1988) and Witz ( 1992 ) were used to provide a framework for research involving two case study sites. The framework was used to determine research questions and give direction to interviews and discussions to focus the research. DISCUSSION: Some research methods do not overtly use a theoretical framework or conceptual framework in their design, but this is implicit and underpins the method design, for example in grounded theory. Other qualitative methods use one or the other to frame the design of a research project or to explain the outcomes. An example is given of how a conceptual framework was used throughout a research project. CONCLUSION: Theoretical and conceptual frameworks are terms that are regularly used in research but rarely explained. Textbooks should discuss what they are and how they can be used, so novice researchers understand how they can help with research design. IMPLICATIONS FOR PRACTICE/RESEARCH: Theoretical and conceptual frameworks need to be more clearly understood by researchers and correct terminology used to ensure clarity for novice researchers.

Archaeological evidence of an ethnographically documented Australian Aboriginal ritual dated to the last ice age.

In societies without writing, ethnographically known rituals have rarely been tracked back archaeologically more than a few hundred years. At the invitation of GunaiKurnai Aboriginal Elders, we undertook archaeological excavations at Cloggs Cave in the foothills of the Australian Alps. In GunaiKurnai Country, caves were not used as residential places during the early colonial period (mid-nineteenth century CE), but as secluded retreats for the performance of rituals by Aboriginal medicine men and women known as 'mulla-mullung', as documented by ethnographers. Here we report the discovery of buried 11,000- and 12,000-year-old miniature fireplaces with protruding trimmed wooden artefacts made of Casuarina wood smeared with animal or human fat, matching the configuration and contents of GunaiKurnai ritual installations described in nineteenth-century ethnography. These findings represent 500 generations of cultural transmission of an ethnographically documented ritual practice that dates back to the end of the last ice age and that contains Australia's oldest known wooden artefacts.

Tufas indicate prolonged periods of water availability linked to human occupation in the southern Kalahari.

Detailed, well-dated palaeoclimate and archaeological records are critical for understanding the impact of environmental change on human evolution. Ga-Mohana Hill, in the southern Kalahari, South Africa, preserves a Pleistocene archaeological sequence. Relict tufas at the site are evidence of past flowing streams, waterfalls, and shallow pools. Here, we use laser ablation screening to target material suitable for uranium-thorium dating. We obtained 33 ages covering the last 110 thousand years (ka) and identify five tufa formation episodes at 114-100 ka, 73-48 ka, 44-32 ka, 15-6 ka, and ~3 ka. Three tufa episodes are coincident with the archaeological units at Ga-Mohana Hill dating to ~105 ka, ~31 ka, and ~15 ka. Based on our data and the coincidence of dated layers from other local records, we argue that in the southern Kalahari, from ~240 ka to ~71 ka wet phases and human occupation are coupled, but by ~20 ka during the Last Glacial Maximum (LGM), they are decoupled.

Anaemia in Ugandan preschool-aged children: the relative contribution of intestinal parasites and malaria.

Anaemia is a severe public health issue among African preschool-aged children, yet little effective progress has been made towards its amelioration, in part due to difficulties in unravelling its complex, multifactorial aetiology. To determine the current anaemia situation and assess the relative contribution of malaria, intestinal schistosomiasis and infection with soil-transmitted helminths, two separate cross-sectional epidemiological surveys were carried out in Uganda including 573 and 455 preschool-aged children (≤6 years) living along the shores of Lake Albert and on the islands in Lake Victoria, respectively. Anaemia was found to be a severe public health problem in Lake Albert, affecting 68·9% of children (ninety-five percent confidence intervals (95% CI) 64·9-72·7%), a statistically significant higher prevalence relative to the 27·3% detected in Lake Victoria (95% CI: 23·3-31·7%). After multivariate analysis (controlling for sex and age of the child), the only factor found to be significantly associated with increased odds of anaemia in both lake systems was malaria (Lake Albert, odds ratio (OR)=2·1, 95% CI: 1·4-3·2; Lake Victoria, OR=1·9, 95% CI: 1·2-2·9). Thus intervention strategies primarily focusing on very young children and combating malaria appear to represent the most appropriate use of human and financial resources for the prevention of anaemia in this age group and area. Looking to the future, these activities could be further emphasised within the National Child Health Days(PLUS) agenda.

Closing the praziquantel treatment gap: new steps in epidemiological monitoring and control of schistosomiasis in African infants and preschool-aged children.

Where very young children come into contact with water containing schistosome cercariae, infections occur and schistosomiasis can be found. In high transmission environments, where mothers daily bathe their children with environmentally drawn water, many infants and preschool-aged children have schistosomiasis. This 'new' burden, inclusive of co-infections with Schistosoma haematobium and Schistosoma mansoni, is being formally explored as infected children are not presently targeted to receive praziquantel (PZQ) within current preventive chemotherapy campaigns. Thus an important PZQ treatment gap exists whereby infected children might wait up to 4-5 years before receiving first treatment in school. International treatment guidelines, set within national treatment platforms, are presently being modified to provide earlier access to medication(s). Although detailed pharmacokinetic studies are needed, to facilitate pragmatic dosing in the field, an extended 'dose pole' has been devised and epidemiological monitoring has shown that administration of PZQ (40 mg/kg), in either crushed tablet or liquid suspension, is both safe and effective in this younger age-class; drug efficacy, however, against S. mansoni appears to diminish after repeated rounds of treatment. Thus use of PZQ should be combined with appropriate health education/water hygiene improvements for both child and mother to bring forth a more enduring solution.