A Randomized Trial of E-Cigarettes versus Nicotine-Replacement Therapy.

BACKGROUND: E-cigarettes are commonly used in attempts to stop smoking, but evidence is limited regarding their effectiveness as compared with that of nicotine products approved as smoking-cessation treatments. METHODS: We randomly assigned adults attending U.K. National Health Service stop-smoking services to either nicotine-replacement products of their choice, including product combinations, provided for up to 3 months, or an e-cigarette starter pack (a second-generation refillable e-cigarette with one bottle of nicotine e-liquid [18 mg per milliliter]), with a recommendation to purchase further e-liquids of the flavor and strength of their choice. Treatment included weekly behavioral support for at least 4 weeks. The primary outcome was sustained abstinence for 1 year, which was validated biochemically at the final visit. Participants who were lost to follow-up or did not provide biochemical validation were considered to not be abstinent. Secondary outcomes included participant-reported treatment usage and respiratory symptoms. RESULTS: A total of 886 participants underwent randomization. The 1-year abstinence rate was 18.0% in the e-cigarette group, as compared with 9.9% in the nicotine-replacement group (relative risk, 1.83; 95% confidence interval [CI], 1.30 to 2.58; P<0.001). Among participants with 1-year abstinence, those in the e-cigarette group were more likely than those in the nicotine-replacement group to use their assigned product at 52 weeks (80% [63 of 79 participants] vs. 9% [4 of 44 participants]). Overall, throat or mouth irritation was reported more frequently in the e-cigarette group (65.3%, vs. 51.2% in the nicotine-replacement group) and nausea more frequently in the nicotine-replacement group (37.9%, vs. 31.3% in the e-cigarette group). The e-cigarette group reported greater declines in the incidence of cough and phlegm production from baseline to 52 weeks than did the nicotine-replacement group (relative risk for cough, 0.8; 95% CI, 0.6 to 0.9; relative risk for phlegm, 0.7; 95% CI, 0.6 to 0.9). There were no significant between-group differences in the incidence of wheezing or shortness of breath. CONCLUSIONS: E-cigarettes were more effective for smoking cessation than nicotine-replacement therapy, when both products were accompanied by behavioral support. (Funded by the National Institute for Health Research and Cancer Research UK; Current Controlled Trials number, ISRCTN60477608 .).

How a sample of English stop smoking services and vape shops adapted during the early COVID-19 pandemic: a mixed-methods cross-sectional survey.

BACKGROUND: The COVID-19 pandemic in England led to major changes in the delivery of support via stop smoking services (SSS) and to the widespread temporary closure of bricks and mortar e-cigarette retailers (vape shops herein). The impact of disruptions across the smoking cessation support landscape has not been fully documented. The purpose of this study was to capture how SSS and vape shops in England were affected and adapted their 'business as usual' during the early months of the COVID-19 pandemic. METHOD: An online cross-sectional survey was conducted between March and July 2020. Surveys were disseminated through online networks, professional forums and contacts. Open-ended qualitative responses were coded using thematic analysis. RESULTS: Responses from 46 SSS and 59 vape shops were included. SSS were able to adapt during this period, e.g. offering a remote service. A high percentage (74.6%) of vape shops had to close and were unable to make changes; 71.2% reported business declining. For both vape shops and SSS qualitative data revealed practical challenges to adapting, but also new pathways to support and co-working. CONCLUSION: The closure of vape shops appears to have most impacted smaller bricks and mortar shops affecting businesses by decline in customers and impacting staff (furlough). For those services that could stay open there may be lessons learned in how to support vulnerable and disadvantaged people who smoke by considering new pathways to support.

Neointimal hyperplasia and calcification in medium sized arteries in adult patients with chronic kidney disease.

The nature of arterial changes resulting in cardiovascular events and dialysis vascular access failures in adult predialysis patients is not well known. This study examined intimal changes, calcium deposition, and consequent stiffness in brachial and radial arteries of adult CKD patients. Ten brachial-artery and seven radial-artery specimens were obtained during fistula creation from nine predialysis and eight dialysis-dependent, nondiabetic patients; and age-gender matched controls undergoing coronary bypass grafts (6 radial) or kidney donation (6 renal). Arterial stiffness was measured at baseline. Vessel histology, morphometric analysis of intima-media, and direct quantification of calcium load was performed using standard techniques. Both predialysis and dialysis patients demonstrated significant arterial intimal hyperplasia with intima:media ratio higher than controls (0.13 ± 0.12 vs. 0.02 ± 0.05, p = 0.01). Calcium deposition was demonstrated on histology and the calcium content in patients was higher than controls (34.68 ± 26.86 vs. 10.95 ± 9.18 µg/µg, p = 0.003). The blood vessel calcium content correlated with arterial stiffness (r = 0.64, p = 0.018). This study for the first time describes, and suggests mechanistic linkage between, intimal hyperplasia, pathological calcium deposition, and increased functional arterial stiffness in dialysis and predialysis patients. Our research could serve as a unique window into the in vivo status of the uremic vasculature impacting fistula maturation and cardiovascular disease.

Factors affecting severity of wildfires in Scottish heathlands and blanket bogs.

Temperate heathlands and blanket bogs are globally rare and face growing wildfire threats. Ecosystem impacts differ between low and high severity fires, where severity reflects immediate fuel consumption. This study assessed factors influencing fire severity in Scottish heathlands and blanket bogs, including the efficacy of the Canadian Fire Weather Index System (CFWIS). Using remote sensing, we measured the differenced Normalised Burn Ratio at 92 wildfire sites from 2015 to 2021. We used Generalised Additive Mixed Models to investigate the impact of topography, habitat wetness, CFWIS components and 30-day weather on severity. Dry heath exhibited higher severity than wet heath and blanket bog, and slope, elevation and south facing aspect were positively correlated to severity. Weather effects were less clear due to data scale differences, yet still indicated weather's significant role in severity. Rainfall had an increasingly negative effect from approximately 15 days before the fire, whilst temperature had an increasingly positive effect. Vapour Pressure Deficit (VPD) was the weather variable with highest explanatory value, and predicted severity better than any CFWIS component. The best-explained fire severity model (R2 = 0.25) incorporated topography, habitat wetness wind and VPD on the day of the fire. The Drought Code (DC), predicting organic matter flammability at ≥10 cm soil depth, was the CFWIS component with the highest predictive effect across habitats. Our findings suggest that wildfires in wet heath and blanket bogs are typically characterised by low severity, but that warmer, drier weather may increase the risk of severe, smouldering fires which threaten peatland carbon stores.

User evaluation and feasibility test of an app designed for smoking cessation in Italian people who smoke: preliminary findings from an uncontrolled pre-test post-test open study.

BACKGROUND: mHealth is a public health practice that exploits the use of mobile devices, including smartphone applications. We will describe an uncontrolled pre-test post-test open pilot study concerning the feasibility evaluation of a smartphone App designed to help in smoking cessation. The aim of this study is to evaluate the feasibility of a smartphone app as a tool for smoking cessation. This study is necessary to the literature because smoking is a major public health concern and has been linked to various health issues such as cardiovascular disease, respiratory disease, and cancer. While there are several smoking cessation interventions available, the use of mobile devices to aid in smoking cessation is a relatively new and innovative approach that requires further investigation. METHODS: The App "Smoke Free" was configured on the devices of N = 30 participants who smoked combustible cigarette, 13 males and 17 females aged 18 to 55 years, with the indications to use it for 90 days, describe their experience, suggest new features, and report any critical aspect. The study consisted of an initial screening visit to select participants that reflected the inclusion criteria and 4 study visits: a baseline visit, two follow-up visits, and one final visit. We used descriptive stats to summarize results. Repeated measures ANOVA and Wilcoxon test were used to test differences in smoking consumption, self-reported craving, and measured eCO level. Statistical software Jamovi was used for analysis. Interviews were conducted via phone or in-person and analyzed using qualitative description principles. RESULTS: Participants evaluated the app as having good aesthetic appeal and user-friendliness but being moderately useful, despite some quitting or reducing their smoking behavior. To improve it, participants have proposed features such as more notifications, social network integration, and damage caused by smoking to the body over time for future app updates. CONCLUSIONS: The application was moderately useful with good feasibility, with several suggestions for future updates that could improve its effectiveness.

Calmodulin-dependent protein kinase kinase-beta is an alternative upstream kinase for AMP-activated protein kinase.

The AMP-activated protein kinase (AMPK) is a critical regulator of energy balance at both the cellular and whole-body levels. Two upstream kinases have been reported to activate AMPK in cell-free assays, i.e., the tumor suppressor LKB1 and calmodulin-dependent protein kinase kinase. However, evidence that this is physiologically relevant currently only exists for LKB1. We now report that there is a significant basal activity and phosphorylation of AMPK in LKB1-deficient cells that can be stimulated by Ca2+ ionophores, and studies using the CaMKK inhibitor STO-609 and isoform-specific siRNAs show that CaMKKbeta is required for this effect. CaMKKbeta also activates AMPK much more rapidly than CaMKKalpha in cell-free assays. K(+)-induced depolarization in rat cerebrocortical slices, which increases intracellular Ca2+ without disturbing cellular adenine nucleotide levels, activates AMPK, and this is blocked by STO-609. Our results suggest a potential Ca(2+)-dependent neuroprotective pathway involving phosphorylation and activation of AMPK by CaMKKbeta.

UK Research Priorities for Electronic Cigarettes: A James Lind Alliance Priority Setting Partnership.

This study aimed to bring together people who smoke or vape, people who do not smoke and healthcare professionals to identify and agree priorities for electronic cigarette research in the UK. We carried out a priority setting partnership, guided by the methodology developed by the James Lind Alliance involving five key stages: initiation, consultation, collation, prioritisation and dissemination. A total of 765 people submitted 1887 questions that they wanted answered by research. Questions were organised into themes, merged and rewritten as summary questions, with 52 unique questions going forward to the prioritisation survey. Participants then ranked their top 10 questions. Following this ranking exercise, the top 26 were identified by selecting the most frequently prioritised questions adjusting for representative stakeholder group. These were put forward for discussion in the final prioritisation workshop, whereby the top 10 electronic cigarette research questions were agreed. The list of priorities identified will be of interest to researchers and funders of electronic cigarette research and will hopefully direct future research and funding calls. These priorities provide insight into the questions that matter to people who are using or concerned about e-cigarettes, including frontline professionals.

Cost-effectiveness of e-cigarettes compared with nicotine replacement therapy in stop smoking services in England (TEC study): a randomized controlled trial.

AIM: To evaluate the cost-effectiveness of e-cigarettes as a smoking cessation aid used in routine stop smoking services in England. DESIGN: Cost-effectiveness analysis was performed from the National Health Service (NHS) and Personal Social Services (PSS) perspective for 12-month periods and life-time. Costs, including that of both treatments, other smoking cessation help and health-care services, and health benefits, estimated from EQ-5D-5L and measured in quality-adjusted life-years (QALYs), for the 12-month analysis, came from a randomized controlled trial. Life-time analysis was model-based with input from both trial data and published secondary data sources. Cost-effectiveness was measured by an incremental cost-effectiveness ratio (ICER). SETTING: Three stop-smoking service sites in England. PARTICIPANTS: Adult smokers (n = 886) who sought help to quit in the participating sites. INTERVENTION AND COMPARATOR: An e-cigarette (EC) starter kit versus provision of nicotine replacement therapy (NRT) for up to 3 months, both with standard behavioural support. A total of 886 participants were randomized (439 in the EC arm, 447 in the NRT arm). Excluding one death in each arm, the 1-year quit rate was 18.0 and 9.9%, respectively. MEASUREMENTS: Cost of treatments was estimated from the treatment log. Costs of other smoking cessation help and health-care services and EQ-5D-5 L were collected at baseline, 6- and 12-month follow-ups. Incremental costs and incremental QALYs were estimated using regression adjusting for baseline covariates and their respective baseline values. FINDINGS: The ICER was £1100 per QALY gained at the 12 months after quit date (87% probability below £20 000/QALY). Markov model estimated the life-time ICER of EC to be £65 per QALY (85% probability below £20 000/QALY). CONCLUSION: Using e-cigarettes as a smoking cessation aid with standard behavioural support in stop-smoking services in England is likely to be more cost-effective than using nicotine replacement therapy in the same setting.

Stop Smoking Practitioners' understanding of e-cigarettes' use and efficacy with particular reference to vapers' socioeconomic status.

Introduction: We have undertaken four online surveys of Stop Smoking Service (SSS) practitioners in England, between 2011 and 2016, in order to enhance our understanding of e-cigarettes: a fast moving new phenomenon. It is important to understand whether e-cigarettes can ameliorate or exacerbate health inequalities given that smoking is one of the most serious causes of excessive mortality and morbidity among disadvantaged groups globally. Aims: To update findings of previous surveys and examine socioeconomic status differences in e-cigarette use and efficacy. Methods: Analysis was undertaken of electronic surveys, particularly, the most recent 2016 survey (n = 514) and 2015/16 SSS client routine monitoring data. Results: SSS practitioners were becoming more positive about e-cigarettes: 42% agreed that e-cigarettes were a good thing compared with 15% in 2011. Reported use of e-cigarettes among SSS clients was low (about 3%) despite higher quit rates (63% of clients reported being quit at four week follow-up, compared with 51% overall). Where socioeconomic differences in e-cigarettes' efficacy for quitting were identified, affluent and working smokers were advantaged. Conclusions: Low use of e-cigarettes by clients and practitioner opinions suggest that further education of SSS staff is needed if they are to adopt the current service recommendations about e-cigarettes.

Can mowing restore boreal rich-fen vegetation in the face of climate change?

Low-frequency mowing has been proposed to be an effective strategy for the restoration and management of boreal fens after abandonment of traditional haymaking. This study investigates how mowing affects long-term vegetation change in both oceanic and continental boreal rich-fen vegetation. This will allow evaluation of the effectiveness of mowing as a management and restoration tool in this ecosystem in the face of climate change. At two nature reserves in Central Norway (Tågdalen, 63° 03' N, 9° 05 E, oceanic climate and Sølendet, 62° 40' N, 11° 50' E, continental climate), we used permanent plot data from the two sites to compare plant species composition from the late 1960s to the early 1980s with that recorded in 2012-2015 in abandoned and mown fens. Changes in species composition and frequency were analysed by multivariate and univariate methods in relation to environmental variables and modelled climate and groundwater data. Mowing resulted in a decline in shrub and Molinia caerulea cover at the continental and oceanic sites respectively, and the total cover of specialist fen species had increased to a significantly greater extent in the mown plots than the unmown at the continental site. However, mowing did not have an effect on the cover of specialist bryophyte species, and some specialist species declined regardless of mowing treatment. Temperature sums had increased at both sites, but precipitation had not changed significantly. Mowing was shown to be the most important determinant of plant community composition at both sites, with local environmental conditions being of secondary importance. In conclusion, the abandonment of traditional management practices results in the loss of characteristic fen species. In order to encourage the restoration of typical rich-fen vegetation, particularly in oceanic areas, additional management measures, such as more intensive mowing, may be required.

E-cigarettes compared with nicotine replacement therapy within the UK Stop Smoking Services: the TEC RCT.

BACKGROUND: Over the past few years, a large number of smokers in the UK have stopped smoking with the help of e-cigarettes. So far, UK Stop Smoking Services (SSSs) have been reluctant to include e-cigarettes among their treatment options because data on their efficacy compared with the licensed medications are lacking. OBJECTIVE: The objective was to compare the efficacy of refillable e-cigarettes and nicotine replacement therapy (NRT) products, when accompanied by weekly behavioural support. DESIGN: A randomised controlled trial comparing e-cigarettes and NRT. SETTING: Three sites that provide local SSSs. PARTICIPANTS: The participants were 886 smokers seeking help to quit smoking, aged ≥ 18 years, not pregnant or breastfeeding, with no strong preference to use or not to use NRT or e-cigarettes in their quit attempt, and currently not using NRT or e-cigarettes. A total of 886 participants were randomised but two died during the study (one in each study arm) and were not included in the analysis. INTERVENTIONS: The NRT arm (n = 446) received NRT of their choice (single or combination), provided for up to 12 weeks. The e-cigarette arm (n = 438) received an e-cigarette starter pack and were encouraged to buy addtional e-liquids and e-cigarette products of their choice. Both arms received the same standard behavioural support. Participants attended weekly sessions at their SSS and provided outcome data at 4 weeks. They were then followed up by telephone at 6 and 12 months. Participants reporting abstinence or at least 50% reduction in cigarette consumption at 12 months were invited to attend for carbon monoxide (CO) validation. Participants/researchers could not be blinded to the intervention. MAIN OUTCOME MEASURES: The primary outcome was CO-validated sustained abstinence rates at 52 weeks. Participants lost to follow-up or not providing biochemical validation were included as non-abstainers. Secondary outcomes included abstinence at other time points, reduction in smoke intake, treatment adherence and ratings, elicited adverse reactions, and changes in self-reported respiratory health. A cost-efficacy analysis of the intervention was also conducted. RESULTS: The 1-year quit rate was 9.9% in the NRT arm and 18.0% in the e-cigarette arm (risk ratio 1.83, 95% confidence interval 1.30 to 2.58; p < 0.001). The e-cigarette arm had significantly higher validated quit rates at all time points. Participants in the e-cigarette arm showed significantly better adherence and experienced fewer urges to smoke throughout the initial 4 weeks of their quit attempt than those in the NRT arm, and gave their allocated product more favourable ratings. They were also more likely to be still using their allocated product at 1 year (39.5% vs. 4.3%, χ2 = 161.4; p < 0.001). Participants assigned to e-cigarettes reported significantly less coughing and phlegm at 1 year than those assigned to NRT (controlling for smoking status). A detailed economic analysis confirmed that, because e-cigarettes incur lower NHS costs than NRT and generate a higher quit rate, e-cigarette use is more cost-effective. LIMITATIONS: The results may not be generalisable to other types of smokers or settings, or to cartridge-based e-cigarettes. CONCLUSIONS: Within the context of multisession treatment for smokers seeking help, e-cigarettes were significantly more effective than NRT. If SSSs provide e-cigarette starter packs, it is likely to boost their success rates and improve their cost-efficacy. FUTURE WORK: The efficacy of e-cigarettes provided with different levels of support will show whether smokers should be encouraged to switch to vaping within support services or whether e-cigarettes can be recommended with less intensive or no support. TRIAL REGISTRATION: Current Controlled Trials ISRCTN60477608. 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. 23, No. 43. See the NIHR Journals Library website for further project information. The trial was supported by the Cancer Research UK Prevention Trials Unit (grant A16893).

Alarge number of smokers in the UK have stopped smoking with the help of e-cigarettes, but it is not known if e-cigarettes are as helpful as stop smoking medications that are provided by the UK Stop Smoking Services (SSSs). This information is needed to decide whether or not SSSs should include e-cigarettes among their treatment options. A total of 886 smokers who were seeking help with quitting and did not mind whether they would use nicotine replacement therapy (NRT), such as nicotine patches, or e-cigarettes were recruited at three SSSs. The smokers were randomly allocated (by chance) to receive weekly behavioural support and either a NRT of their choice (a single NRT product or product combinations) (n = 447) or a starter pack of e-cigarettes (n = 439). The trial ran from May 2015 to February 2018. The participants were followed up for 1 year to see how many stopped smoking in each group. Smokers using e-cigarettes suffered less cigarette withdrawal discomfort early on and had higher quit rates at all time points. At 1 year, 10% of participants in the NRT trial arm had been abstinent for the whole year, compared with 18% in the e-cigarette arm; regarding abstinence for at least 6 months, the figures were 12% in the NRT arm and 21% in the e-cigarette arm. Of interest, coughs and phlegm production also reduced more in people quitting with e-cigarettes than those quitting with NRT. This supports previous reports suggesting that an ingredient in e-cigarettes (i.e. propylene glycol) may protect vapers from airborne infections. E-cigarette starter packs cost much less than NRT and so, if SSSs provide them, their use is likely to boost the success rates and reduce the costs of SSSs.

The potential for modelling peatland habitat condition in Scotland using long-term MODIS data.

Globally, peatlands provide an important sink of carbon in their near natural state but potentially act as a source of gaseous and dissolved carbon emission if not in good condition. There is a pressing need to remotely identify peatland sites requiring improvement and to monitor progress following restoration. A medium resolution model was developed based on a training dataset of peatland habitat condition and environmental covariates, such as morphological features, against information derived from the Moderate Resolution Imaging Spectroradiometer (MODIS), covering Scotland (UK). The initial, unrestricted, model provided the probability of a site being in favourable condition. Receiver operator characteristics (ROC) curves for restricted training data, limited to those located on a peat soil map, resulted in an accuracy of 0.915. The kappa statistic was 0.8151, suggesting good model fit. The derived map of predicted peatland condition at the suggested 0.56 threshold was corroborated by data from other sources, including known restoration sites, areas under known non-peatland land cover and previous vegetation survey data mapped onto inferred condition categories. The resulting locations of the areas of peatland modelled to be in favourable ecological condition were largely confined to the North and West of the country, which not only coincides with prior land use intensity but with published predictions of future retraction of the bioclimatic space for peatlands. The model is limited by a lack of spatially appropriate ground observations, and a lack of verification of peat depth at training site locations, hence future efforts to remotely assess peatland condition will require more appropriate ground-based monitoring. If appropriate ground-based observations could be collected, using remote sensing could be considered a cost-efficient means to provide data on changes in peatland habitat condition.

What is the most ecologically-meaningful metric of nitrogen deposition?

Nitrogen (N) deposition poses a severe risk to global terrestrial ecosystems, and managing this threat is an important focus for air pollution science and policy. To understand and manage the impacts of N deposition, we need metrics which accurately reflect N deposition pressure on the environment, and are responsive to changes in both N deposition and its impacts over time. In the UK, the metric typically used is a measure of total N deposition over 1-3 years, despite evidence that N accumulates in many ecosystems and impacts from low-level exposure can take considerable time to develop. Improvements in N deposition modelling now allow the development of metrics which incorporate the long-term history of pollution, as well as current exposure. Here we test the potential of alternative N deposition metrics to explain vegetation compositional variability in British semi-natural habitats. We assembled 36 individual datasets representing 48,332 occurrence records in 5479 quadrats from 1683 sites, and used redundancy analyses to test the explanatory power of 33 alternative N metrics based on national pollutant deposition models. We find convincing evidence for N deposition impacts across datasets and habitats, even when accounting for other large-scale drivers of vegetation change. Metrics that incorporate long-term N deposition trajectories consistently explain greater compositional variance than 1-3 year N deposition. There is considerable variability in results across habitats and between similar metrics, but overall we propose that a thirty-year moving window of cumulative deposition is optimal to represent impacts on plant communities for application in science, policy and management.

Effects of singing groups on staff well-being: a feasibility study.

AIMS: To determine the feasibility of recruiting and retaining staff 'singing for well-being' groups over three months and the acceptability of the proposed intervention and data collection methods, and to explore the potential effects of singing groups on staff well-being. METHOD: This was a feasibility study that used a two-group wait-list crossover design. Standardised measures of well-being, engagement, burnout and organisational commitment were used, alongside participant feedback. Questionnaires were given to participants at baseline, three months and six months, with the mean group scores for the measures used calculated at each point. FINDINGS: Participant recruitment did not meet the target set, and only half of the participants returned pre-intervention and post-intervention questionnaires. Acceptability of the programme was high and, despite limited data, positive effects emerged in relation to emotional and work-related well-being. Participant comments about the singing programme and facilitator were universally favourable. CONCLUSION: This feasibility study suggests there may be several benefits of staff singing groups, in terms of improving the well-being of participants. However, proceeding to a full research trial would require additional time and resources to maximise recruitment.

Proceedings From the Symposium on Kidney Disease in Older People: Royal Society of Medicine, London, January 19, 2017.

People are living longer. On the whole, they have healthier lives and many of the problems previously seen at a younger age now appear in their later years. Kidneys, like other organs, age, and kidney disease in the aged is a prime example. In the United Kingdom, as in other developed countries, the prevalence of end stage kidney disease is highest in the 70- to 79-year-old age group. There are many older people who require renal replacement and are now considered for dialysis. While older patients with end-stage renal disease invariably aspire for a better quality of life, this needs a specialized approach and management. In January 2017, the Royal Society of Medicine held a seminar in London on "Kidney Disease in Older People" with presentations from a multidisciplinary body of experts speaking on various aspects of kidney problems in this age group and its management. The objectives were to increase awareness and improve the understanding of nephrology in the context of geriatric medicine but also geriatrics in its interface with nephrology, especially in the area of chronic kidney disease.

An Alternative Approach to Delivering Intensive Dialysis in Pregnancy.

Pregnancy outcomes in patients with end-stage renal disease (ESRD) on dialysis are improving. Recent literature supports intensive hemodialysis (HD) as the modality of choice during pregnancy in ESRD. We report the successful delivery of a healthy infant at full term in a patient with ESRD by supplementing peritoneal dialysis (PD) with intermittent HD to achieve adequate dialysis intensity.

Sheep grazing in the North Atlantic region: A long-term perspective on environmental sustainability.

Sheep grazing is an important part of agriculture in the North Atlantic region, defined here as the Faroe Islands, Greenland, Iceland, Norway and Scotland. This process has played a key role in shaping the landscape and biodiversity of the region, sometimes with major environmental consequences, and has also been instrumental in the development of its rural economy and culture. In this review, we present results of the first interdisciplinary study taking a long-term perspective on sheep management, resource economy and the ecological impacts of sheep grazing, showing that sustainability boundaries are most likely to be exceeded in fragile environments where financial support is linked to the number of sheep produced. The sustainability of sheep grazing can be enhanced by a management regime that promotes grazing densities appropriate to the site and supported by area-based subsidy systems, thus minimizing environmental degradation, encouraging biodiversity and preserving the integrity of ecosystem processes.

Views from the Coalface: What Do English Stop Smoking Service Personnel Think about E-Cigarettes?

The UK Stop Smoking Services (SSS) are a source of information and advice on e-cigarettes for smokers and thus it is important to understand the knowledge of, and attitudes towards, e-cigarettes held by stop smoking practitioners. The datasets were English SSS quarterly monitoring returns (n = 207,883) and an online survey of English SSS practitioners, managers, and commissioners between 26th November and 15th December 2014 (n = 1801). SSS monitoring data suggested 2% of clients were using e-cigarettes to quit with SSS and that clients using e-cigarettes had similar quit rates to clients using Varenicline. Most SSS personnel are waiting for licenced e-cigarettes to become available before they will recommend them to clients. However, less than a quarter view e-cigarettes as "a good thing". Managers and commissioners were more positive than practitioners. SSS personnel working for the NHS (hospitals and GP surgeries) were less positive about e-cigarettes than those employed elsewhere. E-cigarettes were cited as the most important reason for the recent decline in service footfall. Thus dissemination of information about e-cigarettes needs to be examined and services should address their stance on e-cigarettes with some urgency.