Challenges and opportunities for implementing nature-based coastal protection in an urbanised coastal city based on public perceptions.

There has been an increase in recognition of the benefits of employing nature-based coastal protection strategies to adapt to the impacts of climate change (e.g., increased storminess, sea-level rise). To enable broader use of nature-based methods, coastal managers and policymakers need to consider the placement and social acceptance of any methods considered. Most published spatial planning models for nature-based coastal protection currently do not utilise social data during site selection. We conducted a public survey of 452 respondents from Singapore, a highly urbanised coastal city-state, to assess Singaporean's perceptions of climate change impacts on coastal areas and their support of nature-based coastal protection. We also assessed the respondents willingness to accept trade-offs for the prioritisation of nature-based coastal protection and subsequently spatially mapped them. The results showed a high awareness of the potential impacts of climate change on coastal areas. Nature-based coastal protection was highly supported as the associated benefits, such as protection of wildlife and their habitats and climate change reduction, were aligned with public values of coastal areas. However, nature-based coastal protection may not be prioritised over human-made structures due to the perception that they are less effective, and respondents may not be willing to undergo 1) replacement of their favourite coastal area, 2) increased taxes, and 3) relocation, for their prioritisation. Through spatially mapping the relevant trade-offs, we found that only 11.1% of coastal areas had moderate or high likelihood of social barriers to nature-based coastal protection, highlighting their potential in Singapore. These findings underscore the importance of incorporating social factors in government land use planning decisions.

Assessing the role of natural kelp forests in modifying seawater chemistry.

Climate change is causing widespread impacts on seawater pH through ocean acidification (OA). Kelp forests, in some locations can buffer the effects of OA through photosynthesis. However, the factors influencing this variation remain poorly understood. To address this gap, we conducted a literature review and field deployments of pH and dissolved oxygen (DO) loggers within four habitats: intact kelp forest, moderate kelp cover, sparse kelp cover and barrens at one site in Port Phillip Bay, a wind-wave dominated coastal embayment in Victoria, Australia. Additionally, a wave logger was placed directly in front of the intact kelp forest and barrens habitats. Most studies reported that kelp increased seawater pH and DO during the day, compared to controls without kelp. This effect was more pronounced in densely populated forests, particularly in shallow, sheltered conditions. Our field study was broadly consistent with these observations, with intact kelp habitat having higher seawater pH than habitats with less kelp or barrens and higher seawater DO compared to barrens, particularly in the afternoon and during calmer wave conditions. Although kelp forests can provide local refuges to biota from OA, the benefits are variable through time and may be reduced by declines in kelp density and increased wave exposure.

The Spectrum of State Approaches to Medicaid Maternity Care Contracting.

Policy Points Maternal health is influenced by the quality and accessibility of care before, during, and after pregnancy. Nationwide, Medicaid covers nearly one in two births and uses managed care as a central means for carrying out these responsibilities. Thus, managed care plays a fundamental role in assuring timely, equitable, quality care and improving maternal health outcomes. A close review of managed care contracts makes evident that the absence of a national set of maternal health standards has caused challenges in setting expectations for managed care performance. State Medicaid agencies adopt a variety of approaches and underlying philosophies for contracting. CONTEXT: Managed care is how Medicaid agencies principally furnish maternity care. For this reason, the contracts that Medicaid agencies enter into with managed care organizations have attracted strong interest as a means of improving maternal health access, quality, and equity. However, limited research has documented the extent to which states use these agreements to set binding expectations across the maternal health continuum and how states approach the task of maternal health contracting. METHODS: To explore maternal health contracting within Medicaid Managed Care, this study took a three-phase, sequential approach: (1) an extensive literature review to identify clinical guidelines and expert recommendations regarding maternal health "best practices" for people with elevated health and social needs, (2) a review of the managed care contracts in use across 40 states and Washington, DC, to determine the extent to which they incorporate these best practices, and (3) interviews conducted with four state Medicaid agencies to better understand how states approach maternal health when developing their contracts. FINDINGS: The evidence on maternal health best practices reveals nearly 60 "best practices," although the literature review also underscored the extent to which these recommendations are fragmented across numerous professional bodies and government agencies and are thus difficult for Medicaid agencies to ascertain. The contracts themselves reflect an approach to the maternal health continuum in a fragmented and incomplete way. Thematic analysis of interviews with state Medicaid agencies revealed three key approaches to contracting for maternity care: an "organic" approach, an "intentional" approach, and an approach "grounded" in state strategy. CONCLUSIONS: The absence of comprehensive, integrated guidelines reflecting the full maternal health continuum likely complicates the contracting task and contributes to incomplete, ambiguous contracts. A major step would be the development of a "best practices tool" that helps state Medicaid agencies translate evidence into comprehensive, clear contracting expectations.

Exposure to urban particulate matter (UPM) impairs mitochondrial dynamics in BV2 cells, triggering a mitochondrial biogenesis response.

World Health Organisation data suggest that up to 99% of the global population are exposed to air pollutants above recommended levels. Impacts to health range from increased risk of stroke and cardiovascular disease to chronic respiratory conditions, and air pollution may contribute to over 7 million premature deaths a year. Additionally, mounting evidence suggests that in utero or early life exposure to particulate matter (PM) in ambient air pollution increases the risk of neurodevelopmental impairment with obvious lifelong consequences. Identifying brain-specific cellular targets of PM is vital for determining its long-term consequences. We previously established that microglial-like BV2 cells were particularly sensitive to urban (U)PM-induced damage including reactive oxygen species production, which was abrogated by a mitochondrially targeted antioxidant. Here we extend those studies to find that UPM treatment causes a rapid impairment of mitochondrial function and increased mitochondrial fragmentation. However, there is a subsequent restoration of mitochondrial and therefore cell health occurring concomitantly with upregulated measures of mitochondrial biogenesis and mitochondrial load. Our data highlight that protecting mitochondrial function may represent a valuable mechanism to offset the effects of UPM exposure in the neonatal brain. KEY POINTS: Air pollution represents a growing risk to long-term health especially in early life, and the CNS is emerging a target for airborne particulate matter (PM). We previously showed that microglial-like BV2 cells were vulnerable to urban (U)PM exposure, which impaired cell survival and promoted reactive oxygen species production. Here we find that, following UPM exposure, BV2 mitochondrial membrane potential is rapidly reduced, concomitant with decreased cellular bioenergetics and increased mitochondrial fission. However, markers of mitochondrial biogenesis and mitochondrial mass are subsequently induced, which may represent a cellular mitigation strategy. As mitochondria are more vulnerable in the developing brain, exposure to air pollution may represent a greater risk to lifelong health in this cohort; conversely, promoting mitochondrial integrity may offset these risks.

Teaching Ultrasound-Guided Venous Cannulation to Newly Qualified Doctors.

Background Venous cannulation is an essential task that allows the intravenous administration of fluids and medications. In the United Kingdom, this task is often performed by newly qualified Foundation Year 1 (FY1) doctors; however, difficulties are commonly encountered. The usage of ultrasound increases the chance of successful cannulation, provided the operator has been trained. Some medical schools now include ultrasound in their undergraduate curricula, though this is far from universal. Methods Forty-eight FY1s received a one-hour teaching session on ultrasound-guided venous cannulation, delivered by near-peer Education Fellows. FY1s completed questionnaires immediately after the teaching session, and a follow-up questionnaire three months later. Findings 44.44% of FY1s felt "fairly" or "very" confident in ultrasound-guided venous cannulation at follow-up, compared to 6.66% before the session. Sixty-three attempts were made in the month before the follow-up survey, compared to six in the month prior to the teaching session. The success rate at follow-up was 60% (38/63), up from 50% (3/6) prior to the session. One third fewer cannulas were escalated to senior doctors (72 vs 48), although there was little change in escalations to anesthetists, from 15 vs 18. FY1s identified the lack of ultrasound machines on the wards as a barrier to using ultrasound-guided venous cannulation more often. Conclusion A short, near-peer teaching session can improve FY1s' confidence, usage, and success rates in ultrasound-guided venous cannulation.

Current extent and future opportunities for living shorelines in Australia.

Living shorelines aim to enhance the resilience of coastlines to hazards while simultaneously delivering co-benefits such as carbon sequestration. Despite the potential ecological and socio-economic benefits of living shorelines over conventional engineered coastal protection structures, application is limited globally. Australia has a long and diverse coastline that provides prime opportunities for living shorelines using beaches and dunes, vegetation, and biogenic reefs, which may be either natural ('soft' approach) or with an engineered structural component ('hybrid' approach). Published scientific studies, however, have indicated limited use of living shorelines for coastal protection in Australia. In response, we combined a national survey and interviews of coastal practitioners and a grey and peer-reviewed literature search to (1) identify barriers to living shoreline implementation; and (2) create a database of living shoreline projects in Australia based on sources other than scientific literature. Projects included were those that had either a primary or secondary goal of protection of coastal assets from erosion and/or flooding. We identified 138 living shoreline projects in Australia through the means sampled starting in 1970; with the number of projects increasing through time particularly since 2000. Over half of the total projects (59 %) were considered to be successful according to their initial stated objective (i.e., reducing hazard risk) and 18 % of projects could not be assessed for their success based on the information available. Seventy percent of projects received formal or informal monitoring. Even in the absence of peer-reviewed support for living shoreline construction in Australia, we discovered local and regional increases in their use. This suggests that coastal practitioners are learning on-the-ground, however more generally it was stated that few examples of living shorelines are being made available, suggesting a barrier in information sharing among agencies at a broader scale. A database of living shoreline projects can increase knowledge among practitioners globally to develop best practice that informs technical guidelines for different approaches and helps focus attention on areas for further research.

Complexity-functioning relationships differ across different environmental conditions.

Habitat complexity is widely considered an important determinant of biodiversity, and enhancing complexity can play a key role in restoring degraded habitats. However, the effects of habitat complexity on ecosystem functioning - as opposed to biodiversity and community structure - are relatively poorly understood for artificial habitats, which dominate many coastlines. With Greening of Grey Infrastructure (GGI) approaches, or eco-engineering, increasingly being applied around the globe, it is important to understand the effects that modifying habitat complexity has on both biodiversity and ecological functioning in these highly modified habitats. We assessed how manipulating physical (primary substrate) and/or biogenic habitat (bivalves) complexity on intertidal artificial substrata affected filtration rates, net and gross primary productivity (NPP and GPP, respectively) and community respiration (CR) - as well as abundance of filter feeders and macro-algae and habitat use by cryptobenthic fish across six locations in three continents. We manipulated both physical and biogenic complexity using 1) flat or ridged (2.5 cm or 5 cm) settlement tiles that were either 2) unseeded or seeded with oysters or mussels. Across all locations, increasing physical and biogenic complexity (5 cm seeded tiles) had a significant effect on most ecological functioning variables, increasing overall filtration rates and community respiration of the assemblages on tiles but decreasing productivity (both GPP and NPP) across all locations. There were no overall effects of increasing either type of habitat complexity on cryptobenthic fish MaxN, total time in frame or macro-algal cover. Within each location, there were marked differences in the effects of habitat complexity. In Hobart, we found higher filtration, filter feeder biomass and community respiration on 5 cm tiles compared to flat tiles. However, at this location, both macro-algae cover and GPP decreased with increasing physical complexity. Similarly in Dublin, filtration, filter feeder biomass and community respiration were higher on 5 cm tiles compared to less complex tiles. In Sydney, filtration and filter feeder biomass were higher on seeded than unseeded tiles, and fish MaxN was higher on 5 cm tiles compared to flat tiles. On unseeded tiles in Sydney, filter feeder biomass also increased with increasing physical complexity. Our findings suggest that GGI solutions via increased habitat complexity are likely to have trade-offs among potentially desired functions, such as productivity and filtration rates, and variable effects on cryptobenthic fish communities. Importantly, our results show that the effects of GGI practices can vary markedly according to the environmental context and therefore should not be blindly and uniformly applied across the globe.

Achieving conservation and restoration outcomes through ecologically beneficial aquaculture.

A range of conservation and restoration tools are needed to safeguard the structure and function of aquatic ecosystems. Aquaculture, the culturing of aquatic organisms, often contributes to the numerous stressors that aquatic ecosystems face, yet some aquaculture activities can also deliver ecological benefits. We reviewed the literature on aquaculture activities that may contribute to conservation and restoration outcomes, either by enhancing the persistence or recovery of one or more target species or by moving aquatic ecosystems toward a target state. We identified 12 ecologically beneficial outcomes achievable via aquaculture: species recovery, habitat restoration, habitat rehabilitation, habitat protection, bioremediation, assisted evolution, climate change mitigation, wild harvest replacement, coastal defense, removal of overabundant species, biological control, and ex situ conservation. This list may be expanded as new applications are discovered. Positive intentions do not guarantee positive ecological outcomes, so it is critical that potentially ecologically beneficial aquaculture activities be evaluated via clear and measurable indicators of success to reduce potential abuse by greenwashing. Unanimity on outcomes, indicators, and related terminology will bring the field of aquaculture-environment interactions into line with consensus standards in conservation and restoration ecology. Broad consensus will also aid the development of future certification schemes for ecologically beneficial aquaculture.

Se necesita una gama de herramientas de conservación y restauración para salvaguardar la estructura y función de los ecosistemas acuáticos. La acuacultura (el cultivo de organismos acuáticos) generalmente contribuye a los numerosos estresantes que soportan los ecosistemas acuáticos, aunque algunas actividades de la acuacultura también pueden proporcionar beneficios ecológicos. Revisamos la literatura sobre las actividades de acuacultura que pueden contribuir a los resultados de conservación y restauración, ya sea al incrementar la persistencia o recuperación de una o más especies objetivo o al llevar a los ecosistemas acuáticos hacia un estado objetivo. Identificamos doce resultados con beneficios ecológicos que pueden lograrse con la acuacultura: recuperación de la especie, recuperación del hábitat, restauración del hábitat, rehabilitación del hábitat, protección del hábitat, bioreparación, evolución asistida, mitigación del cambio climático, sustitución de la captura silvestre, defensa costera, eliminación de las especies sobreabundantes, control biológico y conservación ex situ. Esta lista puede expandirse conforme se descubren nuevas aplicaciones. Las intenciones positivas no garantizan resultados ecológicos positivos, así que es importante que se evalúen las actividades de acuacultura con un posible beneficio ecológico por medio de indicadores del éxito claros y medibles para reducir el abuso potencial por ecoblanqueo o greenwashing. La unanimidad en los resultados, indicadores y terminología relacionada armonizará las interacciones entre la acuacultura y el ambiente con los estándares de la conservación y la ecología de la restauración. Un consenso generalizado también ayudará con el desarrollo de futuros esquemas de certificación para la acuacultura con beneficios ecológicos. Obtención de resultados de conservación y restauración a través de la acuacultura con beneficios ecológicos.

'That's how we got around it': a qualitative exploration of healthcare professionals' experiences of care provision for asylum applicants' with limited English proficiency in UK contingency accommodation.

OBJECTIVES: The inadequate provision of language interpretation for people with limited English proficiency (LEP) is a determinant of poor health, yet interpreters are underused. This research explores the experiences of National Health Service (NHS) staff providing primary care for people seeking asylum, housed in contingency accommodation during COVID-19. This group often have LEP and face multiple additional barriers to healthcare access. Language discrimination is used as a theoretical framework. The potential utility of this concept is explored as a way of understanding and addressing inequities in care. DESIGN: Qualitative research using semistructured interviews and inductive thematic analysis. SETTING: An NHS primary care service for people seeking asylum based in contingency accommodation during COVID-19 housing superdiverse residents speaking a wide spectrum of languages. PARTICIPANTS: Ten staff including doctors, nurses, mental health practitioners, healthcare assistants and students participated in semistructured online interviews. Some staff were redeployed to this work due to the pandemic. RESULTS: All interviewees described patients' LEP as significant. Inadequate provision of interpretation services impacted the staff's ability to provide care and compromised patient safety. Discrimination, such as that based on migration status, was recognised and challenged by staff. However, inequity based on language was not articulated as discrimination. Instead, insufficient and substandard interpretation was accepted as the status quo and workarounds used, such as gesticulating or translation phone apps. The theoretical lens of language discrimination shows how this propagates existing social hierarchies and further disadvantages those with LEP. CONCLUSIONS: This research provides empirical evidence of how the inadequate provision of interpreters forces the hand of healthcare staff to use shortcuts. Although this innovative 'tinkering' allows staff to get the job done, it risks normalising structural gaps in care provision for people with LEP. Policy-makers must rethink their approach to interpretation provision which prioritises costs over quality. We assert that the concept of language discrimination is a valuable framework for clinicians to better identify and articulate unfair treatment on the grounds of LEP.

Evidence for EpCAM and Cytokeratin Expressing Epithelial Cells in Normal Human and Murine Blood and Bone Marrow.

Epithelial cells have been identified in the blood and bone marrow of patients with cancer and other diseases. However, the presence of normal epithelial cells in the blood and bone marrow of healthy individuals has yet to be identified in a consistent way. Presented here is a reproducible method for isolating epithelial cells from healthy human and murine blood and bone marrow (BM) using flow cytometry and immunofluorescence (IF) microscopy. Epithelial cells in healthy individuals were first identified and isolated via flow cytometry using epithelial cell adhesion molecule (EpCAM). These EpCAM+ cells were confirmed to express keratin using immunofluorescence microscopy in Krt1-14;mTmG transgenic mice. Human blood samples had 0.18% ± 0.0004 EpCAM+ cells (SEM; n=7 biological replicates, 4 experimental replicates). In human BM, 3.53% ± 0.006 (SEM; n=3 biological replicates, 4 experimental replicates) of mononuclear cells were EpCAM+. In mouse blood, EpCAM+ cells constituted 0.45% ± 0.0006 (SEM; n=2 biological replicates, 4 experimental replicates), and in mouse BM, 5.17% ± 0.001 (SEM; n=3 biological replicates, 4 experimental replicates) were EpCAM+. In mice, all the EpCAM+ cells were immunoreactive to pan-cytokeratin, as determined by IF microscopy. Results were confirmed using Krt1-14;mTmG transgenic mice, with low (8.6 native GFP+ cells per 106 cells analyzed; 0.085% of viable cells), but significant numbers (p < 0.0005) of GFP+ cells present in normal murine BM, that were not the result of randomness compared with multiple negative controls. Further, EpCAM+ cells in mouse blood were more heterogeneous than CD45+ cells (0.58% in BM; 0.13% in blood). These observations conclude that cells expressing cytokeratin proteins are reproducibly detectable among mononuclear cells from human and murine blood and BM. We demonstrate a method of tissue harvesting, flow cytometry, and immunostaining that can be used to identify and determine the function of these pan-cytokeratin epithelial cells in healthy individuals.

Impacts of anthropogenic climate change on tropical montane forests: an appraisal of the evidence.

In spite of their small global area and restricted distributions, tropical montane forests (TMFs) are biodiversity hotspots and important ecosystem services providers, but are also highly vulnerable to climate change. To protect and preserve these ecosystems better, it is crucial to inform the design and implementation of conservation policies with the best available scientific evidence, and to identify knowledge gaps and future research needs. We conducted a systematic review and an appraisal of evidence quality to assess the impacts of climate change on TMFs. We identified several skews and shortcomings. Experimental study designs with controls and long-term (≥10 years) data sets provide the most reliable evidence, but were rare and gave an incomplete understanding of climate change impacts on TMFs. Most studies were based on predictive modelling approaches, short-term (<10 years) and cross-sectional study designs. Although these methods provide moderate to circumstantial evidence, they can advance our understanding on climate change effects. Current evidence suggests that increasing temperatures and rising cloud levels have caused distributional shifts (mainly upslope) of montane biota, leading to alterations in biodiversity and ecological functions. Neotropical TMFs were the best studied, thus the knowledge derived there can serve as a proxy for climate change responses in under-studied regions elsewhere. Most studies focused on vascular plants, birds, amphibians and insects, with other taxonomic groups poorly represented. Most ecological studies were conducted at species or community levels, with a marked paucity of genetic studies, limiting understanding of the adaptive capacity of TMF biota. We thus highlight the long-term need to widen the methodological, thematic and geographical scope of studies on TMFs under climate change to address these uncertainties. In the short term, however, in-depth research in well-studied regions and advances in computer modelling approaches offer the most reliable sources of information for expeditious conservation action for these threatened forests.

Homelessness, Politics, and Policy: Predicting Spatial Variation in COVID-19 Cases and Deaths.

When COVID-19 began to spread in the United States, the first public health orders were to hunker down at home. But for the vulnerable people experiencing homelessness, especially those sleeping outdoors, retreating to a private dwelling was not possible. This suggests that places with greater homelessness would also have elevated COVID-19 infections. This paper examines how spatial variation in unsheltered homelessness was related to the cumulative number of cases and deaths from COVID-19. Although Continuums of Care (CoCs) with more households receiving welfare, without internet service, and more disabled residents had a higher rate of COVID-19-related cases and deaths, CoCs with more unsheltered homelessness had fewer COVID-19-related deaths. More research is needed to explain this counterintuitive result, but it may reflect the bicoastal pattern of homelessness which is higher where government intervention, community sentiment, and compliance with rules to promote the common welfare are greater. In fact, local politics and policies mattered. CoCs with more volunteering and a higher share of votes for the 2020 Democratic presidential candidate also had fewer COVID-19 cases and deaths. Yet, other policies did not matter. Having more homeless shelter beds, publicly assisted housing units, residents in group quarters, or greater use of public transportation had no independent associations with pandemic outcomes.

The coastal protection and blue carbon benefits of hybrid mangrove living shorelines.

Hybrid living shorelines use a combination of engineered structures with natural ecosystems to achieve coastal protection and habitat restoration outcomes, with added co-benefits such as carbon sequestration. Rock fillets constructed along eroding estuarine banks are designed to accumulate sediment, establish mangroves, and stabilise the shoreline. There is, however, a lack of data to support whether rock fillets are achieving these goals. We used a chronosequence of rock fillets to determine their effect on mangrove development, bank stabilisation and carbon sequestration in four estuaries in New South Wales, Australia. Aboveground biomass and adult density increased with age of rock fillets, and mangrove structure was similar to a natural fringing mangrove after 15 years. The rock fillets accumulated sediment, which reduced the eroded estuary bank height, however, little effect of the fillets on bank slope was observed. Sediment carbon stocks were not different between rock fillets, eroding estuary banks and natural fringing mangroves. Rock fillet design had a significant effect on mangrove structure and coastal protection function, with greater wave transmission through lower rock fillets, suggesting design optimisation is needed. As the construction cost of the rock fillets was equal or less than traditional rock revetments, where suitable they present a more economic and environmentally sustainable solution to estuarine erosion management.

Involving patients and carers in patient safety in primary care: A qualitative study of a co-designed patient safety guide.

BACKGROUND: Involving patients is a key premise of national and international policies on patient safety, which requires understanding how patients or carers want to be involved and developing resources to support this. This paper examines patients' and carers' views of being involved in patient safety in primary care and their views of potentially using a co-designed patient safety guide for primary care (PSG-PC) to foster both involvement and their safety. METHODS: A qualitative study using semistructured face-to-face interviews with 18 patients and/or carers in primary care. Interviews were transcribed and analysis was conducted using an inductive thematic approach. RESULTS: Overall participants expressed enthusiasm for the PSG-PC as a tool to support patients and carers to be involved in patient safety in primary care. However, for some participants being involved in patient safety was seen as taking on the role of General Practitioner and had the potential to add an additional workload for patients. Participants' willingness or ability to be involved in patient safety was influenced by a range of factors including an invisible, often underacknowledged role of everyday safety for patients' interactions with primary care; the levels of involvement that patients wanted in their care and safety and the work of embedding the PSG-PC for patients into their routine interactions with primary care. Participants identified components of the PSG-PC that would be useful to them, in particular, if they had a responsibility for caring for a family member if they had more complex care or long-term conditions. CONCLUSION: Involving patients and carers in patient safety needs a tailored and personalized approach that enables patients and carers to use resources like the PSG-PC routinely and helps challenge assumptions about their willingness and ability to be involved in patient safety. Doing so would raise awareness of opportunities to be involved in safety in line with personal preference. PATIENT OR PUBLIC CONTRIBUTION: Patient and public involvement were central to the research study. This included working in partnership to develop the PSG-PC with patients and carers and throughout our study including in the design of the study, recruiting participants, interpretation of findings.

Experimental evidence for a hidden network of higher-order interactions in a diverse arthropod community.

Transcending pairwise interactions in ecological networks remains a challenge.1,2,3,4,5 Higher-order interactions (HOIs), the modulation of a pairwise interaction by a third species,6 are thought to play a particularly important role in stabilizing coexistence and maintaining species diversity.7,8,9,10,11,12 However, HOIs have so far only been demonstrated in models9,10,11,12,13,14 or isolated experimental systems including only a few interacting species.7,8,15 Their ubiquity and importance at a community level in the real world remain unknown. We hypothesized that a complex network of HOIs could be constantly modifying pairwise interactions and shaping ecological communities and that consequently the outcome of pairwise interactions would be a product of many influences from distinct sources. Using field experiments, we tested how multiple interactions within a diverse arthropod community associated with the tropical shrub Baccharis dracunculifolia D.C. (Asteraceae) were modified by the removal of ant species or live or hatched insect galls (a non-trophic engineering effect) of the dominant galler species. We revealed an extensive hidden network of HOIs modifying each other and the "visible" pairwise interactions. Most pairwise interactions were affected indirectly by the manipulation of non-interacting taxonomic groups. The pervasiveness of these interaction modifications challenges pairwise approaches to understanding interaction outcomes and could shift our thinking about the structure and persistence of ecological communities. Investigating coexistence mechanisms involving interaction modulation by HOIs may be key to elucidating the underlying causes of the stability and persistence of ecological communities.

Buried island transposition flap for joint Plastic-Neurosurgical management of spinal wound dehiscence - a technical note and single Centre experience.

INTRODUCTION: Spinal surgical wound infection can lead to tissue voids between the spine and skin that can be difficult to reconstruct. Previously described techniques include myocutaneous flaps or perforator based fasciocutaneous flaps. However, these procedures can be time-consuming and surgically challenging. AIMS: This study aimed to assess the effectiveness of a novel technique employing a buried island transposition (BIT) flap, for the repair of non-irradiated dehisced spinal wounds. METHODS: Fifteen patients with failed conservative management of infected midline posterior spinal wounds, underwent wound repair using a local buried islanded de-epithelialized double-breasted fasciocutaneous transposition flap, performed by joint input from the neurosurgical and plastic surgical teams. RESULTS: Mean age was 58 years (range, 31-76 years) with male-to-female ratio of 8:7. The BIT flap was used to repair four wounds in the cervical spine with underlying fixation; four wounds in the thoracic spine with underlying fixation; and seven wounds in the lumbar-sacral spine, of which three had underlying fixation. Pre-operatively, each of the wounds were either dehiscent with exposed hardware, or had large defects unsuitable for primary closure following debridement. There was no procedure-related mortality. All patients demonstrated good wound healing with no subsequent repeat surgery or removal of spinal fixation at mean 24-month follow-up. CONCLUSION: We successfully used a novel buried island transposition flap that has not previously been described in repair of spinal wounds. This technique, which led in all cases to good wound healing and prevented removal of metalwork, has comparable efficacy but increased ease of use compared to traditional techniques. It requires redundant skin at the wound site.

Unintended consequences of patient online access to health records: a qualitative study in UK primary care.

BACKGROUND: Health systems are seeking to harness digital tools to promote patient autonomy and increase the efficiency of care worldwide. The NHS Long Term Plan created the right for patients to access 'digital first' primary care by 2023-2024, including online patient access to full medical records. AIM: To identify and understand the unintended consequences of online patient access to medical records. DESIGN AND SETTING: Qualitative interview study in 10 general practices in South West and North West England. METHOD: Semi-structured individual interviews with 13 patients and 16 general practice staff with experience of patient online access to health records. RESULTS: Online access generated unintended consequences that negatively impacted patients' understanding of their health care, with patients finding surprising or difficult to interpret information. Online access impacted GPs' documentation practices, such as when GPs pre-emptively attempted to minimise potential misunderstandings to aid patient understanding of their health care. In other cases, this negatively impacted the quality of the records and patient safety when GPs avoided documenting speculations or concerns. Contrary to assumptions that workload would be reduced, online access introduced extra work, such as managing and monitoring access, and taking measures to prevent possible harm to patients. CONCLUSION: The unintended consequences described by both staff and patients show that, to achieve the intended consequences set out in NHS policy, additional work is necessary to prepare records for sharing and to prepare patients about what to expect. It is crucial that practices are adequately supported and resourced to manage the unintended consequences of online access, now that it is the default position. A table of potential unintended consequences and mitigation measures is provided to aid practice managers and clinicians implementing online access.

How Does Medicaid Managed Care Address the Needs of Beneficiaries with Opioid Use Disorders? A Deep Dive into Contract Design.

Many people who experience opioid use disorder rely on Medicaid. The high penetration of managed care systems into Medicaid raises the importance of understanding states' expectations regarding coverage, access to care, and health system performance and effectively elevates agreements between states and plans into blueprints for coverage and care. Federal law broadly regulates these structured agreements while leaving a high degree of discretion to states and plans. In this study, researchers reviewed the provisions of 15 state Medicaid managed care contract related to substance use disorder (SUD) treatment to identify whether certain elements of SUD treatment were a stated expectation and the extent to which the details of those expectations varied across states in ways that ultimately could affect evaluation of performance and health outcomes. We found that while all states include SUD treatment as a stated contract expectation, discussions around coverage of specific services and nationally recognized guidelines varied. These variations reflect key state choices regarding how much deference to afford their plans in coverage design and plan administration and reveal important differences in purchasing expectations that could carry implications for efforts to examine similarities and differences in access, quality, and health outcomes within managed care across the states.