Home-based Extended Rehabilitation for Older people (HERO): study protocol for an individually randomised controlled multi-centre trial to determine the clinical and cost-effectiveness of a home-based exercise intervention for older people with frailty as extended rehabilitation following acute illness or injury, including embedded process evaluation.

BACKGROUND: The majority of older people (> 65 years) in hospital have frailty and are at increased risk of readmission or death following discharge home. In the UK, following acute hospitalisation, around one third of older people with frailty are referred on for rehabilitation, termed 'intermediate care' services. Although this rehabilitation can reduce early readmission to hospital (< 30 days), recipients often do not feel ready to leave the service on discharge, suggesting possible incomplete recovery. Limited evidence suggests extended rehabilitation is of benefit in several conditions and there is preliminary evidence that progressive physical exercise can improve mobility and function for older people with frailty, and slow progression to disability. Our aim is to evaluate the effectiveness of the Home-based Older People's Exercise (HOPE) programme as extended rehabilitation for older people with frailty discharged home from hospital or intermediate care services after acute illness or injury. METHODS: A multi-centre individually randomised controlled trial, to evaluate the clinical and cost-effectiveness of the HOPE programme. This individualised, graded and progressive 24-week exercise programme is delivered by NHS physiotherapy teams to people aged 65 and older with frailty, identified using the Clinical Frailty Scale, following discharge from acute hospitalisation and linked intermediate care rehabilitation pathways. The primary outcome is physical health-related quality of life, measured using the physical component summary score of the modified Short Form 36- item health questionnaire (SF36) at 12 months. Secondary outcomes include self-reported physical and mental health, functional independence, death, hospitalisations, care home admissions. Plans include health economic analyses and an embedded process evaluation. DISCUSSION: This trial seeks to determine if extended rehabilitation, via the HOPE programme, can improve physical health-related quality of life for older people with frailty following acute hospitalisation. Results will improve awareness of the rehabilitation needs of older people with frailty, and provide evidence on the clinical and cost-effectiveness of the targeted exercise intervention. There is potential for considerable benefit for health and social care services through widespread implementation of trial findings if clinical and cost-effectiveness is demonstrated. TRIAL REGISTRATION: ISRCTN 13927531 . Registered on April 19, 2017.

Environmental performance of blue foods.

Fish and other aquatic foods (blue foods) present an opportunity for more sustainable diets1,2. Yet comprehensive comparison has been limited due to sparse inclusion of blue foods in environmental impact studies3,4 relative to the vast diversity of production5. Here we provide standardized estimates of greenhouse gas, nitrogen, phosphorus, freshwater and land stressors for species groups covering nearly three quarters of global production. We find that across all blue foods, farmed bivalves and seaweeds generate the lowest stressors. Capture fisheries predominantly generate greenhouse gas emissions, with small pelagic fishes generating lower emissions than all fed aquaculture, but flatfish and crustaceans generating the highest. Among farmed finfish and crustaceans, silver and bighead carps have the lowest greenhouse gas, nitrogen and phosphorus emissions, but highest water use, while farmed salmon and trout use the least land and water. Finally, we model intervention scenarios and find improving feed conversion ratios reduces stressors across all fed groups, increasing fish yield reduces land and water use by up to half, and optimizing gears reduces capture fishery emissions by more than half for some groups. Collectively, our analysis identifies high-performing blue foods, highlights opportunities to improve environmental performance, advances data-poor environmental assessments, and informs sustainable diets.

Local Seal or Imported Meat? Sustainability Evaluation of Food Choices in Greenland, Based on Life Cycle Assessment.

Achieving a sustainable global food chain is becoming particularly acute as modern Western diets are adopted in a growing number of countries and cultures around the world. Understanding the consequences that this shift has on health and sustainability is important. This exploratory study is the first to apply the life cycle assessment (LCA) methodology to analyze the sustainability implication of ongoing dietary shifts in Greenland, where locally hunted seal meat is increasingly being replaced by imported livestock products, primarily pig and poultry produced in Denmark. This dietary shift, indirectly driven by international trade bans such as the EU seal product ban, has sustainability implications. To inform and support more comprehensive analyses and policy discussions, this paper explores the sustainability of these parallel Greenlandic food supply chains. A quantitative comparison of the greenhouse gas emissions of Greenlandic hunted seal and Danish pig and poultry is complemented by a qualitative discussion of nutrition, cultural food preferences, animal welfare, and the use of land, pesticides and antibiotics. Although the variability in the life cycle inventory data collected from Greenlandic hunters was considerable, greenhouse gas emissions of seal meat were consistently lower than those of imported livestock products. Emissions of the latter are dominated by biogenic emissions from feed production and manure management, while these are absent for seal meat, whose emissions instead are dominated by fossil fuel use. The implications of these results for sustainable national food policies in a modern global context as well as important areas for additional research are discussed.

Recirculating Aquaculture Is Possible without Major Energy Tradeoff: Life Cycle Assessment of Warmwater Fish Farming in Sweden.

Seafood is seen as promising for more sustainable diets. The increasing production in land-based closed Recirculating Aquaculture Systems (RASs) has overcome many local environmental challenges with traditional open net-pen systems such as eutrophication. The energy needed to maintain suitable water quality, with associated emissions, has however been seen as challenging from a global perspective. This study uses Life Cycle Assessment (LCA) to investigate the environmental performance and improvement potentials of a commercial RAS farm of tilapia and Clarias in Sweden. The environmental impact categories and indicators considered were freshwater eutrophication, climate change, energy demand, land use, and dependency on animal-source feed inputs per kg of fillet. We found that feed production contributed most to all environmental impacts (between 67 and 98%) except for energy demand for tilapia, contradicting previous findings that farm-level energy use is a driver of environmental pressures. The main improvement potentials include improved by-product utilization and use of a larger proportion of plant-based feed ingredients. Together with further smaller improvement potential identified, this suggests that RASs may play a more important role in a future, environmentally sustainable food system.

CollAborative care and active surveillance for Screen-Positive EldeRs with subthreshold depression (CASPER): a multicentred randomised controlled trial of clinical effectiveness and cost-effectiveness.

BACKGROUND: Efforts to reduce the burden of illness and personal suffering associated with depression in older adults have focused on those with more severe depressive syndromes. Less attention has been paid to those with mild disorders/subthreshold depression, but these patients also suffer significant impairments in their quality of life and level of functioning. There is currently no clear evidence-based guidance regarding treatment for this patient group. OBJECTIVES: To establish the clinical effectiveness and cost-effectiveness of a low-intensity intervention of collaborative care for primary care older adults who screened positive for subthreshold depression. DESIGN: A pragmatic, multicentred, two-arm, parallel, individually randomised controlled trial with a qualitative study embedded within the pilot. Randomisation occurred after informed consent and baseline measures were collected. SETTING: Thirty-two general practitioner (GP) practices in the north of England. PARTICIPANTS: A total of 705 participants aged ≥ 75 years during the pilot phase and ≥ 65 years during the main trial with subthreshold depression. INTERVENTIONS: Participants in the intervention group received a low-intensity intervention of collaborative care, which included behavioural activation delivered by a case manager for an average of six sessions over 7-8 weeks, alongside usual GP care. Control-arm participants received only usual GP care. MAIN OUTCOME MEASURES: The primary outcome measure was a self-reported measure of depression severity, the Patient Health Questionnaire-9 items PHQ-9 score at 4 months post randomisation. Secondary outcome measures included the European Quality of Life-5 Dimensions, Short Form questionnaire-12 items, Patient Health Questionnaire-15 items, Generalised Anxiety Disorder seven-item scale, Connor-Davidson Resilience Scale two-item version, a medication questionnaire and objective data. Participants were followed up for 12 months. RESULTS: In total, 705 participants were randomised (collaborative care n = 344, usual care n = 361), with 586 participants (83%; collaborative care 76%, usual care 90%) followed up at 4 months and 519 participants (74%; collaborative care 68%, usual care 79%) followed up at 12 months. Attrition was markedly greater in the collaborative care arm. Model estimates at the primary end point of 4 months revealed a statistically significant effect in favour of collaborative care compared with usual care [mean difference 1.31 score points, 95% confidence interval (CI) 0.67 to 1.95 score points; p < 0.001]. The difference equates to a standard effect size of 0.30, for which the trial was powered. Treatment differences measured by the PHQ-9 were maintained at 12 months' follow-up (mean difference 1.33 score points, 95% CI 0.55 to 2.10 score points; p = 0.001). Base-case cost-effectiveness analysis found that the incremental cost-effectiveness ratio was £9633 per quality-adjusted life-year (QALY). On average, participants allocated to collaborative care displayed significantly higher QALYs than those allocated to the control group (annual difference in adjusted QALYs of 0.044, 95% bias-corrected CI 0.015 to 0.072; p = 0.003). CONCLUSIONS: Collaborative care has been shown to be clinically effective and cost-effective for older adults with subthreshold depression and to reduce the proportion of people who go on to develop case-level depression at 12 months. This intervention could feasibly be delivered in the NHS at an acceptable cost-benefit ratio. Important future work would include investigating the longer-term effect of collaborative care on the CASPER population, which could be conducted by introducing an extension to follow-up, and investigating the impact of collaborative care on managing multimorbidities in people with subthreshold depression. TRIAL REGISTRATION: Current Controlled Trials ISRCTN02202951. FUNDING: This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 21, No. 8. See the NIHR Journals Library website for further project information.

The narrative psychology of community health workers.

Community health psychology is an approach which promotes community mobilisation as a means of enhancing community capacity and well-being and challenging health inequalities. Much of the research on this approach has been at the more strategic and policy level with less reference to the everyday experiences of community workers who are actively involved in promoting various forms of community change. This article considers the narrative accounts of a sample of 12 community workers who were interviewed about their lives. Their accounts were analysed in terms of narrative content. This revealed the tensions in their everyday practice as they attempted to overcome community divisions and management demands for evidence. Common to all accounts was a commitment to social justice. These findings are discussed with reference to opportunities and challenges in the practice of community work.

By-catch impacts in fisheries: utilizing the IUCN red list categories for enhanced product level assessment in seafood LCAs.

Overexploitation of fish stocks causes concern not only to fisheries managers and conservation biologists, but also engages seafood consumers; more integrated product perspectives would be useful. This could be provided by life cycle assessment (LCA); however, further complements of present LCA methodology are needed to assess seafood production, one being by-catch impacts. We studied the scientific rationale behind using the IUCN Red List of Threatened Species™ for assessment of impacts relating to fish species' vulnerability. For this purpose, the current Red List status of marine fish in Sweden was compared to the advice given in fisheries as well as key life history traits known to indicate sensitivity to high fishing pressure. Further, we quantified the amount of threatened fish (vulnerable, endangered, or critically endangered) that was discarded in demersal trawl fisheries on the Swedish west coast. The results showed that not only did the national Red List of marine fish have a high consistency with advice given in fisheries and indices of vulnerability, the different fishing practices studied were also found to have vastly different amounts of threatened fish discarded per kilo landing. The suggested approach is therefore promising as a carrier of aggregated information on the extent to which seafood production interferes with conservation priorities, in particular for species lacking adequate stock assessment. To enable extensive product comparisons, it is important to increase coverage of fish species by the global IUCN Red List, and to reconsider the appropriate assessment unit (species or stocks) in order to avoid false alarms.

Not all salmon are created equal: life cycle assessment (LCA) of global salmon farming systems.

We present a global-scale life cycle assessment of a major food commodity, farmed salmon. Specifically, we report the cumulative energy use, biotic resource use, and greenhouse gas, acidifying, and eutrophying emissions associated with producing farmed salmon in Norway, the UK, British Columbia (Canada), and Chile, as well as a production-weighted global average. We found marked differences in the nature and quantity of material/energy resource use and associated emissions per unit production across regions. This suggests significant scope for improved environmental performance in the industry as a whole. We identify key leverage points for improving performance, most notably the critical importance of least-environmental cost feed sourcing patterns and continued improvements in feed conversion efficiency. Overall, impacts were lowest for Norwegian production in most impact categories, and highest for UK farmed salmon. Our results are of direct relevance to industry, policy makers, eco-labeling programs, and consumers seeking to further sustainability objectives in salmon aquaculture.