Nitrofurantoin: what is the evidence for current UK guidance?

Three days of nitrofurantoin at 100 mg twice daily is recommended as first-line treatment for uncomplicated urinary tract infection (UTI) in evidence-based guidelines across the UK. A review of international guidelines shows that the evidence base has been interpreted in very different ways. UK guidelines are unusual in promoting short (3 day) courses, and we find little direct evidence to support this. Although 'short' courses of antibiotics for other agents may provide optimum balance between providing effective treatment whilst reducing selective pressure driving resistance amongst colonizing microbial flora, it remains unclear that course lengths can be extrapolated to nitrofurantoin. Three days of nitrofurantoin may indeed be a useful intervention in a large group of patients. However, without supporting evidence and because clinical response should be expected to vary widely, it is unclear that establishing and promoting an antibiotic duration for UTI is the best approach to optimizing prescribing in this important area.

Preanalytical quality improvement - an interdisciplinary journey, on behalf of the European Federation for Clinical Chemistry and Laboratory Medicine (EFLM) Working Group for Preanalytical Phase (WG-PRE).

Since the beginning of laboratory medicine, the main focus was to provide high quality analytics. Over time the importance of the extra-analytical phases and their contribution to the overall quality became evident. However, as the initial preanalytical processes take place outside of the laboratory and mostly without its supervision, all professions participating in these process steps, from test selection to sample collection and transport, need to engage accordingly. Focusing solely on intra-laboratory processes will not be sufficient to achieve the best possible preanalytical quality. The Working Group for the Preanalytical Phase (WG-PRE) of the European Federation of Clinical Chemistry and Laboratory Medicine (EFLM) has provided several recommendations, opinion papers and scientific evidence over the past years, aiming to standardize the preanalytical phase across Europe. One of its strategies to reach this goal are educational efforts. As such, the WG-PRE has organized five conferences in the past decade with the sole focus on preanalytical quality. This year's conference mainly aims to depict the views of different professions on preanalytical processes in order to acquire common ground as basis for further improvements. This article summarizes the content of this 6th preanalytical conference.

Drone-Based Environmental Monitoring and Image Processing Approaches for Resource Estimates of Private Native Forest.

This paper investigated the utility of drone-based environmental monitoring to assist with forest inventory in Queensland private native forests (PNF). The research aimed to build capabilities to carry out forest inventory more efficiently without the need to rely on laborious field assessments. The use of drone-derived images and the subsequent application of digital photogrammetry to obtain information about PNFs are underinvestigated in southeast Queensland vegetation types. In this study, we used image processing to separate individual trees and digital photogrammetry to derive a canopy height model (CHM). The study was supported with tree height data collected in the field for one site. The paper addressed the research question "How well do drone-derived point clouds estimate the height of trees in PNF ecosystems?" The study indicated that a drone with a basic RGB camera can estimate tree height with good confidence. The results can potentially be applied across multiple land tenures and similar forest types. This informs the development of drone-based and remote-sensing image-processing methods, which will lead to improved forest inventories, thereby providing forest managers with recent, accurate, and efficient information on forest resources.

Tropical Rainforest Restoration Plantations Are Slow to Restore the Soil Biological and Organic Carbon Characteristics of Old Growth Rainforest.

Widespread and continuing losses of tropical old-growth forests imperil global biodiversity and alter global carbon (C) cycling. Soil organic carbon (SOC) typically declines with land use change from old-growth forest, but the underlying mechanisms are poorly understood. Ecological restoration plantations offer an established means of restoring aboveground biomass, structure and diversity of forests, but their capacity to recover the soil microbial community and SOC is unknown due to limited empirical data and consensus on the mechanisms of SOC formation. Here, we examine soil microbial community response and SOC in tropical rainforest restoration plantings, comparing them with the original old-growth forest and the previous land use (pasture). Two decades post-reforestation, we found a statistically significant but small increase in SOC in the fast-turnover particulate C fraction. Although the δ13C signature of the more stable humic organic C (HOC) fraction indicated a significant compositional turnover in reforested soils, from C4 pasture-derived C to C3 forest-derived C, this did not translate to HOC gains compared with the pasture baseline. Matched old-growth rainforest soils had significantly higher concentrations of HOC than pasture and reforested soils, and soil microbial enzyme efficiency and the ratio of gram-positive to gram-negative bacteria followed the same pattern. Restoration plantings had unique soil microbial composition and function, distinct from baseline pasture but not converging on target old growth rainforest within the examined timeframe. Our results suggest that tropical reforestation efforts could benefit from management interventions beyond re-establishing tree cover to realize the ambition of early recovery of soil microbial communities and stable SOC.

The phosphorus-rich signature of fire in the soil-plant system: a global meta-analysis.

The biogeochemical and stoichiometric signature of vegetation fire may influence post-fire ecosystem characteristics and the evolution of plant 'fire traits'. Phosphorus (P), a potentially limiting nutrient in many fire-prone environments, might be particularly important in this context; however, the effects of fire on P cycling often vary widely. We conducted a global-scale meta-analysis using data from 174 soil studies and 39 litter studies, and found that fire led to significantly higher concentrations of soil mineral P as well as significantly lower soil and litter carbon:P and nitrogen:P ratios. These results demonstrate that fire has a P-rich signature in the soil-plant system that varies with vegetation type. Further, they suggest that burning can ease P limitation and decouple the biogeochemical cycling of P, carbon and nitrogen. These effects resemble a transient reversion to an earlier stage of ecosystem development, and likely underpin at least some of fire's impacts on ecosystems and organisms.

Temporal Changes Rather than Long-Term Repeated Burning Predominately Control the Shift in the Abundance of Soil Denitrifying Community in an Australian Sclerophyll Forest.

To understand the temporal dynamics of soil bacterial denitrifying community in response to long-term prescribed burning and its resilience and recovery following a fire, a wet sclerophyll forest study site under two treatments (2 yearly burning (2YB) and no burning (NB)) and with 40-year-old burning history was used. Similar temporal patterns in the abundance of total (16S rRNA) and denitrifying (narG, nirK, nirS, nosZ) bacteria between two burning treatments revealed strong temporal influences. The magnitude of burning impacts on the abundance of 16S rRNA and denitrification genes was smaller compared with the impact of sampling time, but significant burning and temporal impacts were recorded for all (P < 0.001)-except for the nirS gene. Impacts of prescribed fire on the abundance of soil denitrifying community could be observed immediately after fire, and this impact diminished over a 24-month period prior to the next prescribed burning event. In conclusion, temporal changes govern the fluctuations of the abundance of soil denitrifying genes over the sampling period and the denitrifying community can recover after fire, suggesting that this community is resilient to the effects of prescribed burning. A combination of biotic and abiotic factors may account for the different temporal dynamics of denitrification gene abundance.

OH production from the photolysis of isoprene-derived peroxy radicals: cross-sections, quantum yields and atmospheric implications.

In environments with high concentrations of biogenic volatile organic compounds and low concentrations of nitrogen oxides (NOx = NO + NO2), significant discrepancies have been found between measured and modeled concentrations of hydroxyl radical (OH). The photolysis of peroxy radicals from isoprene (HO-Iso-O2) in the near ultraviolet represents a potential source of OH in these environments, yet has not been considered in atmospheric models. This paper presents measurements of the absorption cross-sections for OH formation (σRO2,OH) from the photolysis of HO-Iso-O2 at wavelengths from 310-362.5 nm, via direct observation by laser-induced fluorescence of the additional OH produced following laser photolysis of HO-Iso-O2. Values of σRO2,OH for HO-Iso-O2 ranged from (6.0 ± 1.6) × 10-20 cm2 molecule-1 at 310 nm to (0.50 ± 0.15) × 10-20 cm2 molecule-1 at 362.5 nm. OH photodissociation yields from HO-Iso-O2 photolysis, ϕOH,RO2, were determined via comparison of the measured values of σRO2,OH to the total absorption cross-sections for HO-Iso-O2 (σRO2), which were obtained using a newly-constructed spectrometer. ϕOH,RO2 was determined to be 0.13 ± 0.04 at wavelengths from 310-362.5 nm. To determine the impact of HO-Iso-O2 photolysis on atmospheric OH concentrations, a modeling case-study for a high-isoprene, low-NOx environment (namely, the 2008 Oxidant and Particle Photochemical Processes above a South-East Asian Tropical Rainforest (OP-3) field campaign, conducted in Borneo) was undertaken using the detailed Master Chemical Mechanism. The model calculated that the inclusion of HO-Iso-O2 photolysis in the model had increased the OH concentration by only 1% on average from 10:00-16:00 local time. Thus, HO-Iso-O2 photolysis alone is insufficient to resolve the discrepancy seen between measured OH concentrations and those predicted by atmospheric chemistry models in such environments.

Rapid prediction of particulate, humus and resistant fractions of soil organic carbon in reforested lands using infrared spectroscopy.

Reforestation of agricultural lands with mixed-species environmental plantings can effectively sequester C. While accurate and efficient methods for predicting soil organic C content and composition have recently been developed for soils under agricultural land uses, such methods under forested land uses are currently lacking. This study aimed to develop a method using infrared spectroscopy for accurately predicting total organic C (TOC) and its fractions (particulate, POC; humus, HOC; and resistant, ROC organic C) in soils under environmental plantings. Soils were collected from 117 paired agricultural-reforestation sites across Australia. TOC fractions were determined in a subset of 38 reforested soils using physical fractionation by automated wet-sieving and 13C nuclear magnetic resonance (NMR) spectroscopy. Mid- and near-infrared spectra (MNIRS, 6000-450 cm-1) were acquired from finely-ground soils from environmental plantings and agricultural land. Satisfactory prediction models based on MNIRS and partial least squares regression (PLSR) were developed for TOC and its fractions. Leave-one-out cross-validations of MNIRS-PLSR models indicated accurate predictions (R2 > 0.90, negligible bias, ratio of performance to deviation > 3) and fraction-specific functional group contributions to beta coefficients in the models. TOC and its fractions were predicted using the cross-validated models and soil spectra for 3109 reforested and agricultural soils. The reliability of predictions determined using k-nearest neighbour score distance indicated that >80% of predictions were within the satisfactory inlier limit. The study demonstrated the utility of infrared spectroscopy (MNIRS-PLSR) to rapidly and economically determine TOC and its fractions and thereby accurately describe the effects of land use change such as reforestation on agricultural soils.

Testing the generality of above-ground biomass allometry across plant functional types at the continent scale.

Accurate ground-based estimation of the carbon stored in terrestrial ecosystems is critical to quantifying the global carbon budget. Allometric models provide cost-effective methods for biomass prediction. But do such models vary with ecoregion or plant functional type? We compiled 15 054 measurements of individual tree or shrub biomass from across Australia to examine the generality of allometric models for above-ground biomass prediction. This provided a robust case study because Australia includes ecoregions ranging from arid shrublands to tropical rainforests, and has a rich history of biomass research, particularly in planted forests. Regardless of ecoregion, for five broad categories of plant functional type (shrubs; multistemmed trees; trees of the genus Eucalyptus and closely related genera; other trees of high wood density; and other trees of low wood density), relationships between biomass and stem diameter were generic. Simple power-law models explained 84-95% of the variation in biomass, with little improvement in model performance when other plant variables (height, bole wood density), or site characteristics (climate, age, management) were included. Predictions of stand-based biomass from allometric models of varying levels of generalization (species-specific, plant functional type) were validated using whole-plot harvest data from 17 contrasting stands (range: 9-356 Mg ha(-1) ). Losses in efficiency of prediction were <1% if generalized models were used in place of species-specific models. Furthermore, application of generalized multispecies models did not introduce significant bias in biomass prediction in 92% of the 53 species tested. Further, overall efficiency of stand-level biomass prediction was 99%, with a mean absolute prediction error of only 13%. Hence, for cost-effective prediction of biomass across a wide range of stands, we recommend use of generic allometric models based on plant functional types. Development of new species-specific models is only warranted when gains in accuracy of stand-based predictions are relatively high (e.g. high-value monocultures).

In situ monitoring of corrosion mechanisms and phosphate inhibitor surface deposition during corrosion of zinc-magnesium-aluminium (ZMA) alloys using novel time-lapse microscopy.

In situ time-lapse optical microscopy was used to examine the microstructural corrosion mechanisms in three zinc-magnesium-aluminium (ZMA) alloy coated steels immersed in 1% NaCl pH 7. Preferential corrosion of MgZn(2) lamellae within the eutectic phases was observed in all the ZMA alloys followed by subsequent dissolution of Zn rich phases. The total extent and rate of corrosion, measured using time-lapse image analysis and scanning vibrating electrode technique (SVET) estimated mass loss, decreased as Mg and Al alloying additions were increased up to a level of 3 wt% Mg and 3.7 wt% Al. This was probably due to the increased presence of MgO and Al(2)O(3) at the alloy surface retarding the kinetics of cathodic oxygen reduction. The addition of 1 × 10(-2) mol dm(-3) Na(3)PO(4) to 1% NaCl pH 7 had a dramatic influence on the corrosion mechanism for a ZMA with passivation of anodic sites through phosphate precipitation observed using time-lapse image analysis. Intriguing rapid precipitation of filamentous phosphate was also observed and it is postulated that these filaments nucleate and grow due to super saturation effects. Polarisation experiments showed that the addition of 1 × 10(-2) mol dm(-3) Na(3)PO(4) to the 1% NaCl electrolyte promoted an anodic shift of 50 mV in open circuit potential for the ZMA alloy with a reduction in anodic current of 2.5 orders of magnitude suggesting that it was acting primarily as an anodic inhibitor supporting the inferences from the time-lapse investigations. These phosphate additions resulted in a 98% reduction in estimated mass loss as measured by SVET demonstrating the effectiveness of phosphate inhibitors for this alloy system.

Vertical Distribution of Soil Denitrifying Communities in a Wet Sclerophyll Forest under Long-Term Repeated Burning.

Soil biogeochemical cycles are largely mediated by microorganisms, while fire significantly modifies biogeochemical cycles mainly via altering microbial community and substrate availability. Majority of studies on fire effects have focused on the surface soil; therefore, our understanding of the vertical distribution of microbial communities and the impacts of fire on nitrogen (N) dynamics in the soil profile is limited. Here, we examined the changes of soil denitrification capacity (DNC) and denitrifying communities with depth under different burning regimes, and their interaction with environmental gradients along the soil profile. Results showed that soil depth had a more pronounced impact than the burning treatment on the bacterial community size. The abundance of 16S rRNA and denitrification genes (narG, nirK, and nirS) declined exponentially with soil depth. Surprisingly, the nosZ-harboring denitrifiers were enriched in the deeper soil layers, which was likely to indicate that the nosZ-harboring denitrifiers could better adapt to the stress conditions (i.e., oxygen deficiency, nutrient limitation, etc.) than other denitrifiers. Soil nutrients, including dissolved organic carbon (DOC), total soluble N (TSN), ammonium (NH(4)(+)), and nitrate (NO(3)(-)), declined significantly with soil depth, which probably contributed to the vertical distribution of denitrifying communities. Soil DNC decreased significantly with soil depth, which was negligible in the depths below 20 cm. These findings have provided new insights into niche separation of the N-cycling functional guilds along the soil profile, under a varied fire disturbance regime.

Direct evidence for a substantive reaction between the Criegee intermediate, CH2OO, and the water vapour dimer.

The C1 Criegee intermediate, CH2OO, reaction with water vapour has been studied. The removal rate constant shows a quadratic dependence on [H2O], implying reaction with the water dimer, (H2O)2. The rate constant, kCH2OO+(H2O)2 = (4.0 ± 1.2) × 10(-12) cm(3) molecule(-1) s(-1), is such that this is the major atmospheric sink for CH2OO.

High-frequency fire alters C : N : P stoichiometry in forest litter.

Fire is a major driver of ecosystem change and can disproportionately affect the cycling of different nutrients. Thus, a stoichiometric approach to investigate the relationships between nutrient availability and microbial resource use during decomposition is likely to provide insight into the effects of fire on ecosystem functioning. We conducted a field litter bag experiment to investigate the long-term impact of repeated fire on the stoichiometry of leaf litter C, N and P pools, and nutrient-acquiring enzyme activities during decomposition in a wet sclerophyll eucalypt forest in Queensland, Australia. Fire frequency treatments have been maintained since 1972, including burning every 2 years (2yrB), burning every 4 years (4 yrB) and no burning (NB). C : N ratios in freshly fallen litter were 29-42% higher and C : P ratios were 6-25% lower for 2 yrB than NB during decomposition, with correspondingly lower 2yrB N : P ratios (27-32) than for NB (34-49). Trends in litter soluble and microbial N : P ratios were similar to the overall litter N : P ratios across fire treatments. Consistent with these, the ratio of activities for N-acquiring to P-acquiring enzymes in litter was higher for 2 yrB than NB, whereas 4 yrB was generally intermediate between 2 yrB and NB. Decomposition rates of freshly fallen litter were significantly lower for 2 yrB (72 ± 2% mass remaining at the end of experiment) than for 4 yrB (59 ± 3%) and NB (62 ± 3%), a difference that may be related to effects of N limitation, lower moisture content, and/or litter C quality. Results for older mixed-age litter were similar to those for freshly fallen litter although treatment differences were less pronounced. Overall, these findings show that frequent fire (2 yrB) decoupled N and P cycling, as manifested in litter C : N : P stoichiometry and in microbial biomass N : P ratio and enzymatic activities. Furthermore, these data indicate that fire induced a transient shift to N-limited ecosystem conditions during the postfire recovery phase.

Infectious bronchitis virus: an overview of the "chicken coronavirus".

Infectious bronchitis virus (IBV) is a highly contagious avian Gammacoronavirus that affects mainly chickens (Gallus gallus) but can circulate in other avian species. IBV constitutes a significant threat to the poultry industry, causing reduced egg yield, growth and mortality levels that can vary in impact. The virus can be transmitted horizontally by inhalation or direct/indirect contact with infected birds or contaminated fomites, vehicles, farm personnel and litter (Figure 1). The error-prone viral polymerase and recombination mechanisms mean diverse viral population results, with multiple genotypes, serotypes, pathotypes and protectotypes. This significantly complicates control and mitigation strategies based on vigilance in biosecurity and the deployment of vaccination.

A systematic review of psychosocial functioning changes after gender-affirming hormone therapy among transgender people.

This systematic review assessed the state and quality of evidence for effects of gender-affirming hormone therapy on psychosocial functioning. Forty-six relevant journal articles (six qualitative, 21 cross-sectional, 19 prospective cohort) were identified. Gender-affirming hormone therapy was consistently found to reduce depressive symptoms and psychological distress. Evidence for quality of life was inconsistent, with some trends suggesting improvements. There was some evidence of affective changes differing for those on masculinizing versus feminizing hormone therapy. Results for self-mastery effects were ambiguous, with some studies suggesting greater anger expression, particularly among those on masculinizing hormone therapy, but no increase in anger intensity. There were some trends toward positive change in interpersonal functioning. Overall, risk of bias was highly variable between studies. Small samples and lack of adjustment for key confounders limited causal inferences. More high-quality evidence for psychosocial effects of gender-affirming hormone therapy is vital for ensuring health equity for transgender people.

OpenSAFELY NHS Service Restoration Observatory 2: changes in primary care clinical activity in England during the COVID-19 pandemic.

BACKGROUND: The COVID-19 pandemic has disrupted healthcare activity across a broad range of clinical services. The NHS stopped non-urgent work in March 2020, later recommending services be restored to near-normal levels before winter where possible. AIM: To describe changes in the volume and variation of coded clinical activity in general practice across six clinical areas: cardiovascular disease, diabetes, mental health, female and reproductive health, screening and related procedures, and processes related to medication. DESIGN AND SETTING: With the approval of NHS England, a cohort study was conducted of 23.8 million patient records in general practice, in situ using OpenSAFELY. METHOD: Common primary care activities were analysed using Clinical Terms Version 3 codes and keyword searches from January 2019 to December 2020, presenting median and deciles of code usage across practices per month. RESULTS: Substantial and widespread changes in clinical activity in primary care were identified since the onset of the COVID-19 pandemic, with generally good recovery by December 2020. A few exceptions showed poor recovery and warrant further investigation, such as mental health (for example, for 'Depression interim review' the median occurrences across practices in December 2020 was down by 41.6% compared with December 2019). CONCLUSION: Granular NHS general practice data at population-scale can be used to monitor disruptions to healthcare services and guide the development of mitigation strategies. The authors are now developing real-time monitoring dashboards for the key measures identified in this study, as well as further studies using primary care data to monitor and mitigate the indirect health impacts of COVID-19 on the NHS.

Eleven key measures for monitoring general practice clinical activity during COVID-19: A retrospective cohort study using 48 million adults' primary care records in England through OpenSAFELY.

Background: The COVID-19 pandemic has had a significant impact on delivery of NHS care. We have developed the OpenSAFELY Service Restoration Observatory (SRO) to develop key measures of primary care activity and describe the trends in these measures throughout the COVID-19 pandemic. Methods: With the approval of NHS England, we developed an open source software framework for data management and analysis to describe trends and variation in clinical activity across primary care electronic health record (EHR) data on 48 million adults.We developed SNOMED-CT codelists for key measures of primary care clinical activity such as blood pressure monitoring and asthma reviews, selected by an expert clinical advisory group and conducted a population cohort-based study to describe trends and variation in these measures January 2019-December 2021, and pragmatically classified their level of recovery one year into the pandemic using the percentage change in the median practice level rate. Results: We produced 11 measures reflective of clinical activity in general practice. A substantial drop in activity was observed in all measures at the outset of the COVID-19 pandemic. By April 2021, the median rate had recovered to within 15% of the median rate in April 2019 in six measures. The remaining measures showed a sustained drop, ranging from a 18.5% reduction in medication reviews to a 42.0% reduction in blood pressure monitoring. Three measures continued to show a sustained drop by December 2021. Conclusions: The COVID-19 pandemic was associated with a substantial change in primary care activity across the measures we developed, with recovery in most measures. We delivered an open source software framework to describe trends and variation in clinical activity across an unprecedented scale of primary care data. We will continue to expand the set of key measures to be routinely monitored using our publicly available NHS OpenSAFELY SRO dashboards with near real-time data. Funding: This research used data assets made available as part of the Data and Connectivity National Core Study, led by Health Data Research UK in partnership with the Office for National Statistics and funded by UK Research and Innovation (grant ref MC_PC_20058).The OpenSAFELY Platform is supported by grants from the Wellcome Trust (222097/Z/20/Z); MRC (MR/V015757/1, MC_PC-20059, MR/W016729/1); NIHR (NIHR135559, COV-LT2-0073), and Health Data Research UK (HDRUK2021.000, 2021.0157).

A practical critique of antifungal treatment guidelines for haemato-oncologists.

The management of invasive fungal disease (IFD) in the haemato-oncology setting remains a challenge. This article reviews recent guidelines relating to IFD for their similarities and differences, as well as applying the Appraisal of Guidelines Research and Evaluation (AGREE) criteria. The guidelines' recommendations on antifungal prophylaxis, empirical and definitive treatment of candidiasis and aspergillosis are summarized; also, minimum standards for diagnosis and follow-up are discussed. This critique of the reviewed guidelines is a practical guide to physicians and commissioners in making local policies for IFD management.

Congenital keratoconjunctivitis sicca and ichthyosiform dermatosis in 25 Cavalier King Charles spaniel dogs. Part I: clinical signs, histopathology, and inheritance.

The clinical presentation and progression (over 9 months to 13 years) of congenital keratoconjunctivitis sicca and ichthyosiform dermatosis (CKCSID) in the Cavalier King Charles spaniel dog are described for six new cases and six previously described cases. Cases presented with a congenitally abnormal (rough/curly) coat and signs of KCS from eyelid opening. Persistent scale along the dorsal spine and flanks with a harsh frizzy and alopecic coat was evident in the first few months of life. Ventral abdominal skin was hyperpigmented and hyperkeratinized in adulthood. Footpads were hyperkeratinized from young adulthood with nail growth abnormalities and intermittent sloughing. Long-term follow-up of cases (13/25) is described. Immunomodulatory/lacrimostimulant treatment had no statistically significant effect on Schirmer tear test results, although subjectively, this treatment reduced progression of the keratitis. Histopathological analysis of samples (skin/footpads/lacrimal glands/salivary glands) for three new cases was consistent with an ichthyosiform dermatosis, with no pathology of the salivary or lacrimal glands identified histologically. Pedigree analysis suggests the syndrome is inherited by an autosomal recessive mode.

How performance targets can ingrain a culture of 'performing out': An ethnography of two Indian primary healthcare facilities.

Low- and middle-income country health systems often apply decontextualised and unrealistic performance targets to facilities. This can lead to empty compliance and 'performing out', whereby managers and providers manipulate or inflate data to create the false impression of a functional system. While this is a well-recognised pitfall of audit-style performance accountability processes, the social processes by which these practices emerge has not been well described in the literature. In this paper, with a focus on maternal and newborn care, we seek to better understand how and why the practices of 'performing out' occur, and their implications for health system functioning, organisational culture, and quality of care. We do this through a focused facility ethnography undertaken in two primary healthcare facilities in an eastern Indian state, anonymised as Esma, where practices of 'performing out' are prevalent. We draw on the understanding that health systems are complex adaptive systems encompassing both hardware and software elements, where individual behavioural practices are an outcome of the system as a whole. To unpack how the dynamic interactions between system elements and agents influence individual behaviours, we draw upon the sociological theories of practice of Bourdieu, encompassing the concepts of field, habitus, and capital. This lens helps illustrate how resource scarcity, unyielding application of unrealistic targets with punitive sanctions for non-achievement, and complex power dynamics lead system actors to manipulate data and create documentation to show the achievement of targets that were not actually met. The practices of 'performing out' are shaped by, and in turn shape, the organisational culture of the facilities, with perverse behaviour becoming part of an entrenched habitus - the 'dispositions' of agents that guide behaviour and thinking. In the longer term, the habituation of 'performing out' contributes to a systemic orientation toward sub-par performance, undermining quality of care.