REVEILLE2 thermosensitive splicing: a molecular basis for the integration of nocturnal temperature information by the Arabidopsis circadian clock.

Cold stress is one of the major environmental factors that limit growth and yield of plants. However, it is still not fully understood how plants account for daily temperature fluctuations, nor how these temperature changes are integrated with other regulatory systems such as the circadian clock. We demonstrate that REVEILLE2 undergoes alternative splicing after chilling that increases accumulation of a transcript isoform encoding a MYB-like transcription factor. We explore the biological function of REVEILLE2 in Arabidopsis thaliana using a combination of molecular genetics, transcriptomics, and physiology. Disruption of REVEILLE2 alternative splicing alters regulatory gene expression, impairs circadian timing, and improves photosynthetic capacity. Changes in nuclear gene expression are particularly apparent in the initial hours following chilling, with chloroplast gene expression subsequently upregulated. The response of REVEILLE2 to chilling extends our understanding of plants immediate response to cooling. We propose that the circadian component REVEILLE2 restricts plants responses to nocturnal reductions in temperature, thereby enabling appropriate responses to daily environmental changes.

Co-creation of a student-implemented allied health service in a First Nations remote community of East Arnhem Land, Australia.

OBJECTIVES: To co-create a culturally responsive student-implemented allied health service in a First Nations remote community and to determine the feasibility and acceptability of the service. DESIGN: Co-creation involved a pragmatic iterative process, based on participatory action research approaches. Feasibility and acceptability were determined using a mixed-method pre/postdesign. SETTING: The service was in Nhulunbuy, Yirrkala and surrounding remote First Nations communities of East Arnhem Land, Northern Territory, Australia. PARTICIPANTS: Co-creation of the service was facilitated by the Northern Australia Research Network, guided by Indigenous Allied Health Australia leadership, with East Arnhem local community organisations and community members. Co-creation of the day-to-day service model involved local cultural consultants, service users and their families, staff of community organisations, students, supervisors, placement coordinators and a site administrator. FINDINGS: A reciprocal learning service model was co-created in which culturally responsive practice was embedded. The service was feasible and acceptable: it was delivered as intended; resources were adequate; the service management system was workable; and the service was acceptable. Health outcome measures, however, were not appropriate to demonstrate impact, particularly through the lens of the people of East Arnhem. Recommendations for the service included: continuing the reciprocal learning service model in the long term; expanding to include all age groups; and connecting with visiting and community-based services. CONCLUSION: The co-created service was feasible and acceptable. To demonstrate the impact of the service, measures of health service impact that are important to First Nations people living in remote communities of northern Australia are required.

Marŋgithirri guŋga'yunarawu ga guŋga'yunyarawu marŋgithinyarawu Learning to connect and connecting to learn: Preparing the rural and remote allied health workforce through a co-created student-implemented service in East Arnhem, Australia.

OBJECTIVES: To explore the process of learning for allied health students providing a student-implemented service for older Yolŋu in remote East Arnhem, Northern Territory, Australia. DESIGN: An exploratory qualitative study following an 8-week student-implemented service. SETTING: Nhulunbuy and Yirrkala and surrounding remote Aboriginal communities of the East Arnhem Region of the Northern Territory. PARTICIPANTS: Data were collected from: 4 students who implemented the service; 4 professional supervisors, 3 placement coordinators, a Yolŋu cultural consultant and a care manager from a local community organisation, all of whom supported implementation of the service; and 7 older Yolŋu and their families who were recipients of the service. INTERVENTIONS: A student-implemented service for older Yolŋu delivered by allied health students from James Cook University. Clinical, cultural and pastoral supervision and support was provided by Flinders University, James Cook University, Indigenous Allied Health Australia and 2 Yolŋu cultural consultants and 2 local community organisations. MAIN OUTCOME MEASURES: Semi-structured interviews with those who implemented, supported and received the service. Data were analysed thematically using an inductive approach. RESULTS: 'Learning to connect and connecting to learn' described how allied health students were learning to provide a service for older Yolŋu. Four interrelated processes connected their learning: 'preparing and supporting', 'bonding and responding', 'growing and enriching' and 'working and weaving'. CONCLUSION: The co-created student-implemented service provided a unique learning opportunity for allied health students on how to provide a culturally safe service in a remote Aboriginal community in northern Australia.

A National Survey on Patient Provider Agreements When Prescribing Opioids for Chronic Pain.

BACKGROUND: Many national guidelines recommend the use of patient provider agreements (PPAs) when prescribing opioids for chronic pain. There are no standards for PPA content, readability, or administration processes. OBJECTIVE: Conduct a national survey of providers who use PPAs to describe the process of administering them, assess views on their utility, and obtain PPAs to evaluate thematic content and readability. DESIGN: Cross-sectional electronic survey and request for PPAs. PARTICIPANTS: Registrants for the Safer/Competent Opioid Prescribing Education (SCOPE of Pain) Program between March 2013 and June 2017. MAIN MEASURES: Respondents' reports on how PPAs are administered and views on their usefulness. A sample of PPAs assessed for themes and readability. KEY RESULTS: Using a convenience sample of 62,530 SCOPE of Pain registrants, we obtained a cohort of 430 individuals from 43 states who use PPAs. The majority of respondents worked in primary care (64%) and pain (18%) specialties. Reviewing PPAs with patients was primarily done by prescribers (80%), and the average perceived time to administer PPAs was 13 min. Although 66% of respondents thought PPAs were "often" or "always" worth the effort, only 28% considered them "often" or "always" effective in reducing opioid misuse. The PPA reading burden surpassed recommended patient education standards, with only 2.5% at or below fifth-grade reading level. PPAs focused more on rules and consequences of patients' non-compliance than on a shared treatment plan. CONCLUSIONS: Most respondents perceive patient provider agreements (PPAs) as time-consuming and minimally effective in reducing opioid misuse yet still view them as valuable. PPAs are written far above recommended reading levels and serve primarily to convey consequences of non-compliance. Because PPAs are recommended by national safer opioid prescribing guidelines as a risk mitigation strategy, it would be beneficial to develop a standard PPA and study its effectiveness.

Noninvasive Oxygenation Strategies in Immunocompromised Patients With Acute Hypoxemic Respiratory Failure: A Pairwise and Network Meta-Analysis of Randomized Controlled Trials.

INTRODUCTION: Acute hypoxemic respiratory failure (AHRF) is a leading cause of intensive care unit (ICU) admission among immunocompromised patients. Invasive mechanical ventilation is associated with increased morbidity and mortality. OBJECTIVE: To evaluate the efficacy of various oxygenation strategies including noninvasive ventilation (NIV), high-flow nasal cannula (HFNC), and conventional oxygen therapy in immunocompromised patients with AHRF. METHODS: Electronic databases including PubMed, Embase, and the Cochrane Library were reviewed from inception to December 2018. We included all randomized controlled trials (RCTs) comparing different modalities of initial oxygenation strategies in immunocompromised patients with AHRF. Our primary outcome was the need for intubation and invasive mechanical ventilation while secondary outcomes were ICU acquired infections and short- and long-term mortality. Data were extracted separately and independently by 2 reviewers. We performed a Bayesian network meta-analysis to calculate odds ratio (OR) and Bayesian 95% credible intervals (CrIs). RESULTS: Nine RCTs were included (1570 patients, mean age 61.1 ± 13.8 years with 64% male). Noninvasive ventilation was associated with a significantly reduced intubation rate compared with standard oxygen therapy (OR: 0.53; 95% CrI: 0.26-0.91). There were no significant reductions of intubation between NIV versus HFNC (OR: 0.83; 95% CrI: 0.35-2.11) or HFNC versus standard oxygen therapy (OR: 0.65; 95% CrI: 0.26-1.24). There were no significant differences between all groups regarding short-term (28-day or ICU) mortality or long-term (90-day or hospital) mortality or ICU-acquired infections (P > 0.05). CONCLUSION: Among immunocompromised patients with AHRF, NIV was associated with a significant reduction of intubation compared with standard oxygen therapy. There were no significant differences among all oxygenation strategies regarding mortality and ICU-acquired infections.

Emotion Regulation in Elementary School-Aged Children with a Maternal History of Suicidal Behavior: A Pilot Study.

Parental history of suicidal behavior is associated with an increased risk of early onset suicidal behavior in their offspring. The objective of this pilot study was to compare clinical characteristics, temperament, and emotion regulation in children, aged 6-9 years, with (PH+) and without (PH-) a maternal history of suicidal behavior to determine which factors could be markers of early vulnerability. At baseline, PH+ children, compared to PH- children, demonstrated more difficulties with temperament, emotion regulation, and experienced more life events in the year prior to their baseline appointment. At study follow-ups, however, no differences were found between PH+ and PH- children. Results suggest there are some signals of early vulnerability present in children with a maternal history of suicidal behavior and recruitment/retention of this group of youth is feasible.

EZ-Root-VIS: A Software Pipeline for the Rapid Analysis and Visual Reconstruction of Root System Architecture.

If we want to understand how the environment has shaped the appearance and behavior of living creatures, we need to compare groups of individuals that differ in genetic makeup and environment experience. For complex phenotypic features, such as body posture or facial expression in humans, comparison is not straightforward because some of the contributing factors cannot easily be quantified or averaged across individuals. Therefore, computational methods are used to reconstruct representative prototypes using a range of algorithms for filling in missing information and calculating means. The same problem applies to the root system architecture (RSA) of plants. Several computer programs are available for extracting numerical data from root images, but they usually do not offer customized data analysis or visual reconstruction of RSA. We developed Root-VIS, a free software tool that facilitates the determination of means and variance of many different RSA features across user-selected sets of root images. Furthermore, Root-VIS offers several options to generate visual reconstructions of root systems from the averaged data to enable screening and modeling. We confirmed the suitability of Root-VIS, combined with a new version of EZ-Rhizo, for the rapid characterization of genotype-environment interactions and gene discovery through genome-wide association studies in Arabidopsis (Arabidopsis thaliana).

"It's like a mirror image of my illness": Exploring Patient Perceptions About Illness Using Health Mind Mapping-a Qualitative Study.

BACKGROUND: A patient's self-management of chronic disease is influenced in part by their explanatory model of illness (EMI) and daily lived experiences (DLE). Unfortunately, assessing patient's EMI and using this information to engage patients in chronic illness self-management continues to be a challenge. OBJECTIVE: "Health mind mapping" (HMM) is a novel process that captures a patient's EMI and DLE through the use of a graphic representation of ideas. We aimed to explore patient's experiences using HMM. DESIGN: Qualitative study utilizing semi-structured interviews. PARTICIPANTS: Adult patients with uncontrolled type 2 diabetes from a primary care clinic. APPROACH: A facilitator guided 20 participants through the process of developing a health mind map. Subsequently, each participant completed a semi-structured interview about their experience with the process and perceptions about how their maps could be used. The process and interviews were video and audio recorded. We conducted a content analysis of the maps and a thematic analysis, using an inductive approach, of the interview data. RESULTS: Participants explored a wide range of EMs and DLEs in their HMM process. Participants reported that the HMM process (1) helped to develop insight about self and illness; (2) was a catalyst for wanting to take actions to improve illness; and (3) represented an opportunity to actively share illness experiences. They reported potential uses of the map: (1) to communicate about their illness to others in their social network; (2) to communicate about their illness to providers; (3) to help others with diabetes manage their illness; and (4) to encourage ongoing engagement in diabetes self-care. CONCLUSIONS: Participants reported that HMM helped them develop new insight about their illness and was a catalyst for encouraging them to take control of their illness. HMM has the potential to facilitate communication with providers and engage patients in collaborative goal setting to improve self-care in chronic illness.

The 'invisible homeless' - challenges faced by families bringing up their children in a remote Australian Aboriginal community.

BACKGROUND: Insufficient and inadequate housing remain serious and enduring problems in remote Aboriginal communities in the Northern Territory (NT) of Australia. Housing is recognised as a key determinant of persisting inequities between Aboriginal and other Australians in health, as well as education and employment outcomes which in turn impact on health. In our qualitative study exploring strengths and challenges related to early childhood in a remote NT community, insufficient housing emerged as the greatest challenge families experience in 'growing up' their children. METHODS: The "Growing up children in two worlds" study engaged Yolŋu (Aboriginal) and other researchers in a culturally responsive qualitative research process. Methods included video ethnography and in-depth interviews with six case study families as well as participant observation and interviews with a wide range of other community members. Data collection and analysis occurred through an iterative and collaborative process and the findings related to housing are the focus of this article. RESULTS: Concerns about crowded and insecure housing were pervasive in the study community where many families are, in effect, homeless. Most rely on extended family to provide accommodation and some never find a secure and stable space in which to bring up their children. Absence of control over their living conditions is a key element underlying many of the sources of distress associated with crowded housing. The lack of food security, sharing sickness and disturbances in the night affecting sleep are just some of the challenges that generate conflict between family members and impact on health, wellbeing, work and school attendance. Although interaction with other family members is highly valued, the ambition of most participants is for independent and secure accommodation in which they can safely 'grow up' their children. CONCLUSIONS: Yolŋu who live with the consequences of crowded and insecure housing want their voices to be heard. They best understand the challenges they face and their perspectives must inform the solutions. Equitable access to housing through sufficient and sustained investment in an integrated approach, engaging all stakeholders, is needed. This is essential to address persisting inequities between Aboriginal and non-Aboriginal Australians in health and other outcomes.

Inherited Thrombophilia.

Thrombophilia alters normal hemostasis, shifting the balance in favor of thrombus formation. Inherited conditions include factor V Leiden (FVL), prothrombin G20210A mutation, deficiencies in natural anticoagulants (antithrombin [AT], protein C, and protein S), hyperhomocysteinemia, and elevations in clotting factors (factors VIII and XI). Although FVL and prothrombin mutation are common disorders, deficiencies in the natural anticoagulants are rare. The risk of initial thrombosis conferred by inherited thrombophilia varies with the highest risk in those homozygous for either FVL or prothrombin mutation, or with AT deficiency. In the nonpregnant patient, the presence of a thrombophilia does not affect treatment of an acute event. Although vitamin B supplementation has been shown to decrease the levels of homocysteine, the treatment has failed to show a benefit in thrombus prevention and is therefore not recommended.

Thrombophilia Screening.

Although controversial, screening for thrombophilia has become common. Testing for antiphospholipid antibodies is indicated in order to guide treatment decisions if there is clinical suspicion for antiphospholipid syndrome. The utility of identifying other thrombophilias in symptomatic venous thromboembolism (VTE) is questionable, as the risk of recurrence does not appear to be increased by an appreciable degree with the most common disorders (heterozygosity for factor V Leiden or prothrombin mutation). Although recurrence appears to be increased in those with homozygous or multiple abnormalities and potentially deficiencies in natural anticoagulants, screening to detect these conditions is difficult to justify based on their rarity. The American College of Chest Physicians' current guidelines note the increased risk of recurrence with idiopathic, proximal events regardless of thrombophilia status. They suggest duration of anticoagulation therapy be based on location and provoking factors rather than whether or not the individual has a thrombophilia. Because routine prophylaxis in asymptomatic individuals with thrombophilia is not recommended, screening of asymptomatic family members is difficult to justify. Screening prior to prescribing combination oral contraceptives is not cost effective, may result in unwanted pregnancies, and may have little effect on the overall rate of VTE.

Acquired Thrombophilia.

Acquired thrombophilia is associated with an increased risk of venous thromboembolism (VTE). Antiphospholipid syndrome (APS) is the most prevalent acquired thrombophilia and is associated with both venous and arterial thromboses. Human immunodeficiency virus (HIV) is another form of acquired thrombophilia. Risk factors associated with VTE in this population include those related to the disease itself, host factors, and the pharmacotherapy for HIV. A significant proportion of VTE events occur in patients with malignancies. There is an increase in mortality associated with patients having cancer who experience VTE when compared to patients having cancer without VTE. Combination oral contraceptive (COC) use infers risk of thromboembolic events. The risk is dependent upon the presence of an underlying inherited thrombophilia, the estrogen dose, and generation of progestin. Patients at highest risk of VTE include those receiving high-dose estrogen and fourth-generation, progesterone-containing contraceptives. With the exception of APS, thrombophilia status does not alter the acute treatment of an initial VTE in nonpregnant patients.

Pregnancy-Related Venous Thromboembolism.

Pregnancy is associated with an increased risk of venous thromboembolism (VTE), with a reported incidence ranging from 0.49 to 2 events per 1000 deliveries. Risk factors include advanced maternal age, obesity, smoking, and cesarian section. Women with a history of previous VTE are at a 4-fold higher risk of recurrent thromboembolic events during subsequent pregnancies. Additionally, the presence of concomitant thrombophilia, particularly factor V Leiden (homozygosity), prothrombin gene mutation (homozygosity), or antiphospholipid syndrome (APS), increases the risk of pregnancy-related VTE. Low-molecular-weight heparin (LMWH) and unfractionated heparin (UFH) are the drugs of choice for anticoagulation during pregnancy. LMWH is preferred due to ease of use and lower rates of adverse events. Women with high thromboembolic risk particularly those with a family history of VTE should receive antepartum thromboprophylaxis. Women with low thromboembolic risk or previous VTE caused by a transient risk factor (ie, provoked), who have no family history of VTE, may undergo antepartum surveillance. Postpartum anticoagulation can be considered in women with both high and low thromboembolic risk.

"If They Help Us, We Can Help Them": First Nations Peoples Identify Intercultural Health Communication Problems and Solutions in Hospital in Northern Australia.

Effective intercultural communication between First Nations peoples and healthcare providers in colonised countries is required to deliver equitable healthcare and improve patient experiences and health outcomes. This paper presents First Nations peoples' perspectives and proposed solutions to problematic communication experiences at Royal Darwin Hospital in northern Australia. The study's methodological foundations comprise decolonising principles rooted in Critical Race Theory, Freirean pedagogy, and cultural safety. Eleven individuals from diverse First Nations backgrounds receiving treatment at the largest hospital in the Northern Territory, participated in in-depth interviews conducted in their preferred languages. Data were inductively analysed, adapted from a constructivist grounded theory approach and guided by First Nations knowledges. First Nations patients at Royal Darwin Hospital described a culturally unsafe hospital due to ineffective intercultural communication. Patient "counterstories" recounted instances of confusion, aggression, healthcare provider resistance to shared decision-making opportunities, pressure to abandon cultural protocols, and institutional neglect. Poor communication incited anger among staff and patients, and contributed to experiences of racism, missed appointments, clinical mistakes, patients prematurely discharging before completing treatment, and patients experiencing financial troubles and homelessness. In a spirit of generosity, patients proposed solutions focused on relationship building and mutual understanding so that new decolonised systems, which draw on First Nations and Western knowledges, can be codesigned. This study serves as a call to action for policymakers, administrators, and healthcare providers to prioritise improving intercultural communication by addressing the behaviour of staff and changing systemically racist policies in the pursuit of health equity and cultural safety for First Nations peoples.

Can freshwater plants and algae act as an effective feed supplement to reduce methane emissions from ruminant livestock?

Methane production by livestock is a substantial component of greenhouse gas emissions worldwide. The marine red algae, Asparagopsis taxiformis, has been identified as a possible supplement in livestock feeds due to its potent inhibition of methane production but currently is unable to be produced at scale. Finding additional taxa that inhibit methane production is therefore desirable. Here we provide foundational evidence of methanogenesis-inhibiting properties in Australian freshwater plants and algae, reviewing candidate species and testing species' chemical composition and efficacy in vitro. Candidate plant species and naturally-occurring algal mixes were collected and assessed for ability to reduce methane in batch testing and characterised for biochemical composition, lipids and fatty acids, minerals and DNA. We identified three algal mixes and one plant (Montia australasica) with potential to reduce methane yield in in vitro batch assay trials. All three algal mixes contained Spirogyra, although additional testing would be needed to confirm this alga was responsible for the observed activity. For the two samples that underwent multiple dose testing, Algal mix 1 (predominantly Spirogyra maxima) and M. australasica, there seems to be an optimum dose but sources, harvesting and storage conditions potentially determine their methanogenesis-inhibiting activity. Based on their compositions, fatty acids are likely to be acting to reduce methane in Algal mix 1 while M. australasica likely contains substantial amounts of the flavonoids apigenin and kaempferol, which are associated with methane reduction. Based on their mineral composition, the samples tested would be safe for livestock consumption at an inclusion rate of 20%. Thus, we identified multiple Australian species that have potential to be used as a feed supplement to reduce methane yield in livestock which may be suitable for individual farmers to grow and feed, reducing complexities of supply associated with marine alternatives and suggesting avenues for investigation for similar species elsewhere.

Development of Pressure Sensors to Help Support Community Lymphedema Monitoring: A Scoping Review.

Breast cancer-related lymphedema is a condition occurring after a partial or full mastectomy, where there is a buildup of interstitial fluid in the body, particularly in the upper limb. There is a lack of at-home sensors that can help monitor the progression of lymphedema. The purpose of this scoping review is to gather relevant information on sensors for remote lymphedema monitoring. A literature search of Medline, PubMed, Scopus, Web of Science, and BMC databases yielded 96 studies. A total of six studies were selected for data extraction. Data were extracted from each study and organized into tables for analysis. A total of six different devices were mentioned in the six studies included in the scoping review, divided into wearable and nonwearable sensors. Nonwearable sensors were more likely to be adaptable for remote sensing as they were further along in development and commercially available on the market. Nonwearable sensors are more developed than wearable sensors for the purpose of remote lymphedema monitoring. This review advocates further development and validation of sensors for lymphedema management, particularly for remote monitoring and health assessments.

Improving outcomes for hospitalised First Nations peoples though greater cultural safety and better communication: the Communicate Study Partnership study protocol.

BACKGROUND: The Communicate Study is a partnership project which aims to transform the culture of healthcare systems to achieve excellence in culturally safe care for First Nations people. It responds to the ongoing impact of colonisation which results in First Nations peoples experiencing adverse outcomes of hospitalisation in Australia's Northern Territory. In this setting, the majority of healthcare users are First Nations peoples, but the majority of healthcare providers are not. Our hypotheses are that strategies to ensure cultural safety can be effectively taught, systems can become culturally safe and that the provision of culturally safe healthcare in first languages will improve experiences and outcomes of hospitalisation. METHODS: We will implement a multicomponent intervention at three hospitals over 4 years. The main intervention components are as follows: cultural safety training called 'Ask the Specialist Plus' which incorporates a locally developed, purpose-built podcast, developing a community of practice in cultural safety and improving access to and uptake of Aboriginal language interpreters. Intervention components are informed by the 'behaviour change wheel' and address a supply-demand model for interpreters. The philosophical underpinnings are critical race theory, Freirean pedagogy and cultural safety. There are co-primary qualitative and quantitative outcome measures: cultural safety, as experienced by First Nations peoples at participating hospitals, and proportion of admitted First Nations patients who self-discharge. Qualitative measures of patient and provider experience, and patient-provider interactions, will be examined through interviews and observational data. Quantitative outcomes (documentation of language, uptake of interpreters (booked and completed), proportion of admissions ending in self-discharge, unplanned readmission, hospital length of stay, costs and cost benefits of interpreter use) will be measured using time-series analysis. Continuous quality improvement will use data in a participatory way to motivate change. Programme evaluation will assess Reach, Effectiveness, Adoption, Implementation and Maintenance ('RE-AIM'). DISCUSSION: The intervention components are innovative, sustainable and have been successfully piloted. Refinement and scale-up through this project have the potential to transform First Nations patients' experiences of care and health outcomes. TRIAL REGISTRATION: Registered with ClinicalTrials.gov Protocol Record 2008644.

Refeeding Syndrome in Emergency Department Boarders: How COVID-19 Can Reshape Patient Care in the Emergency Department.

Emergency departments (EDs) in the United States are the primary drivers of hospital admissions. As the nation continues to experience unrestrained spread of the severe acute respiratory syndrome coronavirus 2, causing coronavirus disease 2019 (COVID-19), EDs, hospitals, and testing centers are overwhelmed with patients. The consequence of "boarding" admitted patients in EDs leads not only to longer ED wait times for all patients but also delays the medical practice of intensivists and internists while patients await an inpatient bed. Here, we describe the case of an ED boarder with severe COVID-19 who developed refeeding syndrome while boarding in the ED, ultimately requiring in-depth electrolyte and renal management by the ED team before intensive care unit admission.

Technologies measuring manual wheelchair propulsion metrics: a scoping review.

The aim of this review is to investigate existing and developing technologies assessing metrics of manual wheelchair propulsion. A scoping review of scientific and gray literature was performed. Five databases were searched - Medline, Scopus, CINAHL, Institute of Electrical and Electronics Engineers (IEEE), and Embase. The 38 retained articles identified 27 devices categorized into accelerometers, wheelchair-mounted devices, instrumented wheels, and wearables. The devices included in this review can be used by manual wheelchair users to monitor propulsion effort and activity goals, by clinicians to assess rehabilitation programs, and to inform and guide future research. The findings support a need for further research into the development of custom algorithms for manual wheelchair user populations as well as further validation in broader free-living environments with equitable participant populations.