Genome sequence and genetic diversity of European ash trees.

Ash trees (genus Fraxinus, family Oleaceae) are widespread throughout the Northern Hemisphere, but are being devastated in Europe by the fungus Hymenoscyphus fraxineus, causing ash dieback, and in North America by the herbivorous beetle Agrilus planipennis. Here we sequence the genome of a low-heterozygosity Fraxinus excelsior tree from Gloucestershire, UK, annotating 38,852 protein-coding genes of which 25% appear ash specific when compared with the genomes of ten other plant species. Analyses of paralogous genes suggest a whole-genome duplication shared with olive (Olea europaea, Oleaceae). We also re-sequence 37 F. excelsior trees from Europe, finding evidence for apparent long-term decline in effective population size. Using our reference sequence, we re-analyse association transcriptomic data, yielding improved markers for reduced susceptibility to ash dieback. Surveys of these markers in British populations suggest that reduced susceptibility to ash dieback may be more widespread in Great Britain than in Denmark. We also present evidence that susceptibility of trees to H. fraxineus is associated with their iridoid glycoside levels. This rapid, integrated, multidisciplinary research response to an emerging health threat in a non-model organism opens the way for mitigation of the epidemic.

Differential attainment: how can we close the gap in paediatrics?

Differential attainment is the gap in attainment between different demographic groups undertaking the same assessment. Across the UK, we see differences in outcome in undergraduate and postgraduate medical education on the basis of gender, age, ethnicity and country of primary medical qualification which cannot be explained by a difference in ability. The largest gaps appear when we look at the variation in outcome between UK and international medical graduates (IMGs) and between white British and black, Asian and minority ethnic (BAME) doctors in postgraduate medical education. If we look to postgraduate medical examinations, the differences in attainment are stark and occur across all medical specialties, with paediatrics being no exception. The differences are also seen in the rates of relative success in recruitment to training posts and in a trainee's likelihood of getting a satisfactory outcome at the Annual Review of Competence Progression. Ensuring all doctors reach their full potential is undoubtedly an issue of fairness that is of particular significance to paediatrics as IMGs make up 47% of our medical workforce and 36% of the paediatric workforce identifies as being from a BAME group. It is clear that if we fail to close the gap in differential attainment, there will be both a personal cost to affected individuals, but also a cost to the wider paediatric profession and the children they serve. This paper hopes to summarise the background and causes to differential attainment and look towards possible interventions that might tackle this issue.

'Please help me, I am so miserable!': sexual health, emotions and counselling in teen and young adult problem pages in late 1980s Ireland.

In 1984, the Irish Family Planning Association (IFPA) established a youth group comprised of young volunteers aged between 16 years and 20 years. The IFPA was responding to a perceived need for sexual health advice for young people in the absence of any formal sex education in Irish schools. The group established a telephone helpline and, from late 1987, was commissioned to provide advice columns for two Irish magazines for young people called Hot Press and Fresh The advice columns run by the IFPA youth group provided an important educational and counselling service for young people on matters relating to sexual health and relationships. Letters to the two magazines also attest to a significant degree of ignorance around sexual and reproductive health among young people and the prevalence of risk taking with regard to contraception. Moreover, the letters were often frank and deeply honest about the feelings and emotions experienced by the letter writer. Replies to the letter writers from the IFPA group were sensitive and empathetic, but clear and unambiguous, highlighting the team's approaches to sexual health counselling and 'risk' which were modelled on approaches by British groups such as the Samaritans, Grapevine and Brook. Drawing on the uncatalogued letters received by the youth group, as well as the published replies in the magazine advice columns, this article will shed light on the key sexual health concerns of young Irish people in the late 1980s. Ultimately, it will examine what these queries reveal about the impact of Ireland's social and moral climate on teenagers' emotional health. More broadly, the letters to these magazines illuminate the stigma, shame and silences around these issues in 1980s' Ireland, and highlight the importance of magazines as a source of communication and an outlet for young people to express their emotions relating to sexuality, relationships and sexual health.

Using a weight of evidence approach to identify sources of microbiological contamination in a shellfish-growing area with "Restricted" classification.

Shellfish-growing areas in rural catchments are occasionally affected by elevated faecal contamination from diffuse sources and may be subject to frequent harvest closures/classification downgrades. We combined traditional risk management methods based on sanitary surveys and monitoring of Escherichia coli in seawater and shellfish with faecal source tracking, bacterial source apportionment, and hydrometeorological modelling to determine the causes of elevated E. coli concentrations contributing to harvest closures in Papanui Inlet (Aotearoa New Zealand). These multiple lines of evidence were used to inform a weight of evidence assessment of bacterial contamination in the inlet. Ruminant livestock was estimated to contribute 80% of the faecal coliform loading. Concentrations of E. coli in seawater were low (≤ 87 MPN 100 ml-1) whilst concentrations in tuaki/cockles/little neck clams (Austrovenus stutchburyi) occasionally exceeded the "Approved" classification limit (230 MPN 100 g-1). The most frequent positive genetic markers in seawater were the seagull (Catellicoccus marimammalium) (54% of seawater samples), and in shellfish, the bovine and seagull markers (both 12.5% of shellfish samples). Solar radiation was negatively correlated with E. coli in tuaki. We found that the growing area is affected by faecal inputs from animal and, to a lesser extent, human (septic tank discharges) sources which elevate contamination to levels detectable in tuaki but not in seawater, particularly in the summer months. The innovative approach can enhance the management of shellfish-growing areas affected by intermittent contamination and enables more targeted action to reduce pollution to improve shellfish water quality.

Refinement of the Well-being in Pregnancy (WiP) questionnaire: cognitive interviews with women and healthcare professionals and a validation survey.

BACKGROUND: Measuring positive and negative aspects of well-being during pregnancy and childbirth is important for both healthy women and women who are living with long-term health conditions (LTCs). This study aimed to further refine the Well-being in Pregnancy (WiP) questionnaire and to incorporate LTC specific items where appropriate. METHODS: A multi-method study. Cognitive interviews with pregnant or postpartum women (n = 11) and consultations with healthcare professionals (n = 11) and public representatives (n = 4) were conducted to explore the acceptability of existing WiP items and content. Items were refined and subsequently administered on an online survey (n = 768). Item reduction steps and exploratory factor analysis were performed on survey data. Convergent validity was examined using Pearson correlation coefficients to compare relationships with other included validated assessments. RESULTS: Following amendments to three items, the addition of eight core WiP items and five LTC specific items, a total of 25 items were considered relevant and appropriate for use with pregnant women. Analysis of survey data reduced the questionnaire to 12 items measuring three core WiP scales; 1) Concerns over support after birth, 2) Positive pregnancy and, 3) Confidence about motherhood, and a five item standalone LTC specific scale. All scales demonstrated good validity and internal reliability. Scores for the three core scales moderately correlated with established well-being measures indicating that they were measuring similar, yet distinct concepts. CONCLUSIONS: Analyses confirmed good psychometric properties of the refined WiP questionnaire. The use of pregnancy specific well-being measures, such as the WiP, provide a route into asking women in more detail about how their care may be tailored to support them and also facilitates positive conversations with women about how care and experience of pregnancy and childbirth may be enhanced further.

Evaluating a psychological support service focused on the needs of critical care and theatres staff in the first wave of COVID-19.

BACKGROUND: In response to COVID-19, the authors used clinical psychology resources from their hospital's Pain Medicine Department to provide direct support to critical areas. AIMS: The degree to which the service met the needs of staff and managers between March and August 2020 was evaluated. METHODS: A total of 51 staff were referred. Most were nurses (43%), followed by theatre practitioners (36%), healthcare assistants (9%), consultants (8%), administrative (2%) and support staff (2%). Working status, reason for referral and presenting difficulties at first appointment and outcome were recorded. Staff were sent an anonymous survey following intervention. FINDINGS: Staff reported high rates of burnout, anxiety and low mood, with 22% experiencing exacerbation of pre-existing mental health problems. All staff reported benefit from the intervention and managers provided positive feedback. CONCLUSION: Establishing a supportive service that included psychology benefited both staff and managers at the peak of the pandemic. Recommendations are provided.

Resolving phylogeny and polyploid parentage using genus-wide genome-wide sequence data from birch trees.

Numerous plant genera have a history including frequent hybridisation and polyploidisation (allopolyploidisation), which means that their phylogeny is a network of reticulate evolution that cannot be accurately depicted as a bifurcating tree with a single tip per species. The genus Betula, which contains many ecologically important tree species, is a case in point. We generated genome-wide sequence reads for 27 diploid and 36 polyploid Betula species or subspecies using restriction site associated DNA (RAD) sequences. These reads were assembled into contigs with a mean length of 675 bp. We reconstructed the evolutionary relationships among diploid Betula species using both supermatrix (concatenation) and species tree methods. We identified the closest diploid relatives of the polyploids according to the relative rates at which reads from polyploids mapped to contigs from different diploid species within a concatenated reference sequence. By mapping reads from allopolyploids to their different putative diploid relatives we assembled contigs from the putative sub-genomes of allopolyploid taxa. We used these to build new phylogenies that included allopolyploid sub-genomes as separate tips. This approach yielded a highly evidenced phylogenetic hypothesis for the genus Betula, including the complex reticulate origins of the majority of its polyploid taxa. Our phylogeny divides the genus into two well supported clades, which, interestingly, differ in their seed-wing morphology. We therefore propose to split Betula into two subgenera.

Utility of Whole Genome Sequencing in Assessing and Enhancing Partner Notification of Neisseria gonorrhoeae Infection.

BACKGROUND: Gonorrhea is a sexually transmitted infection of global concern. We investigated whole-genome sequencing (WGS) as a tool to measure and enhance partner notification (PN) in gonorrhea management. METHODS: Between May and November 2018, all N. gonorrhoeae isolated from patients attending Leeds Sexual Health, United Kingdom, underwent WGS. Reports listing sequences within 20 single-nucleotide polymorphisms (SNPs) of study isolates within a database containing select isolates from April 1, 2016, to November 15, 2018, were issued to clinicians. The proportion of cases with a potential transmission partner identified by PN was determined from patient and PN data. The WGS reports were reviewed to identify additional cases within 6 SNPs or less and verified for PN concordance. RESULTS: Three hundred eighty isolates from 377 cases were successfully sequenced; 292 had traceable/contactable partners and 69 (18%) had a potential transmission partner identified by PN. Concordant PN and WGS links were identified in 47 partner pairs. Of 308 cases with no transmission partner by PN, 185 (60%) had a case within 6 SNPs or less; examination of these cases' PN data identified 7 partner pairs with previously unrecognized PN link, giving a total of 54 pairs; all had 4 or less SNP differences. The WGS clusters confirmed gaps in partner finding, at individual and group levels. Despite the clinic providing sexual health services to the whole city, 35 cases with multiple partners had no genetically related case, suggesting multiple undiagnosed infections. CONCLUSIONS: Whole-genome sequencing could improve gonorrhea PN and control by identifying new links and clusters with significant gaps in partner finding.

Development of an Exercise-Specific Parkinson's Disease Questionnaire: The PDQ-Exercise.

BACKGROUND: Exercise is now a significant and key component in the management of Parkinson's disease. However, no self-report, Parkinson's-specific measure of exercise currently exists. OBJECTIVE: To develop a patient-reported outcome measure (PROM) for use in studies and clinical trials that aim to assess the efficacy of exercise therapy for people with Parkinson's (PwP). METHODS: Participants were recruited via Parkinson's UK. To generate meaningful items, PwP participated in exploratory cognitive interviews. To pretest the items generated, PwP took part in two rounds of cognitive debrief interviews. Items were subsequently tested through an online survey that also included the eight-item Parkinson's Disease Questionnaire (PDQ-8) and Oxford Participation and Activities Questionnaire (Ox-PAQ). RESULTS: Twenty PwP were interviewed for item generation. Analyses identified issues related to adopting and maintaining exercise, resulting in the generation of 10 items. Fourteen PwP took part in subsequent cognitive debrief interviews. Following the first 10 interviews, one item was removed, and minor adjustments were made to the wording of two items. Four final interviews verified that no further adjustments were required. Consequently, nine items were included in the validation survey, which was fully completed by 398 PwP. Inspection of floor and ceiling effects resulted in the removal of two further items. A principal component analysis identified a single seven-item factor explaining 61.6% of variance. Further analyses indicated that the measure demonstrates sound reliability and validity. CONCLUSIONS: Results indicate that the PDQ-Exercise is an acceptable, reliable, and valid PROM. Further assessment of its psychometric properties is in progress. © 2021 The Authors. Movement Disorders published by Wiley Periodicals LLC on behalf of International Parkinson and Movement Disorder Society.

Exploring the use of health and wellbeing measures during pregnancy and the first year following birth in women living with pre-existing long-term conditions: qualitative interviews with women and healthcare professionals.

BACKGROUND: One way in which care for pregnant and postpartum women living with long-term health conditions (LTCs) may be improved is through the adoption of standardised measures to provide evidence of health outcomes and wellbeing from the woman's perspective. AIM: The study explores the views of pregnant and postpartum women living with LTCs, and healthcare professionals to better understand the potential value of using standardised health and wellbeing measures within this patient population. METHODS: Qualitative semi-structured telephone interviews were conducted to explore the perceived value of using measures with pregnant and postpartum women living with LTCs within maternity services. Participants were asked to provide feedback on three exemplar measures: the Long Term Conditions Questionnaire, the Wellbeing in Pregnancy Questionnaire and the EuroQol EQ-5D-5L instrument. Thematic analysis was used in the analysis of the transcripts. RESULTS: Eleven women and 11 healthcare professionals took part in semi-structured interviews. Analysis identified five themes as relevant to the use of measures within maternity services: 1) Improving care, 2) Assessing outcomes, 3) Interpretation and application of data, 4) Engagement challenges and implementation and, 5) Women and healthcare professionals alignment. CONCLUSIONS: Despite varying prior experience and expressing some questions about implementation, respondents were cautiously positive about the use of standardised health and wellbeing measures. Their use offers the opportunity for both affected women and healthcare professionals caring for them to collectively identify and assess important areas of unmet needs and improve outcomes. Incorporating the perspectives of women with LTC's will help bring awareness to elements of women centred care which health services may seek to address.

Investigating the Effects of Error Management Training versus Error Avoidance Training on the Performance of Veterinary Students Learning Blood Smear Analysis.

Conventional veterinary training emphasizes correct methodologies, potentially failing to exploit learning opportunities that arise as a result of errors. Error management training (EMT) encourages mistakes during low-stakes training, with the intention of modifying perceptions toward errors and using them to improve performance in unfamiliar scenarios (adaptive transfer). Herein, we aimed to determine the efficacy of EMT, supplemented by a metacognitive module, for veterinary students learning blood smear preparation and interpretation. Our hypothesis was that EMT and metacognition are associated with improved adaptive transfer performance, as compared with error avoidance training (EAT). A total of 26 students were prospectively enrolled in this double-blind study. Performance was evaluated according to monolayer area, smear quality, cell identification, calculated white blood cell differential counts, and overall application/interpretation. Students were trained with normal canine blood and static photomicrographs. Participants tested 72 hours after training demonstrated improved performance in a test that directly recapitulated training (Wilcoxon matched-pairs signed-rank test; two-tailed p all ≤ .001). There were no significant differences between EAT and EMT in this test (Mann-Whitney U test and Welch's t-test; two-tailed p ≥ .26) or in short- and long-term adaptive transfer tests (p ≥ .22). Survey data indicate that participants found errors to be a valuable element of training, and that many felt capable of accurately reflecting on their own performance. These data suggest that EMT might produce outcomes comparable to EAT as it relates to blood smear analysis.

Investigating the Effects of Error Management Training versus Error Avoidance Training on the Performance of Veterinary Students Learning to Tie Surgical Knots.

Although errors can be a powerful impetus for learning, conventional pedagogy often emphasizes error-avoidance strategies that reward correct answers and disfavor mistakes. Error management training (EMT) takes an explicitly positive approach to errors, using them to create an active and self-directed learning environment. Using a surgical knot-tying model, we aimed to determine the efficacy of EMT among veterinary students with no prior surgical experience. We hypothesized that EMT would result in improved performance in unfamiliar scenarios (adaptive transfer) compared with an error-avoidance method. In this prospective double-blinded study, 42 students were equally divided between error avoidance training (EAT) and EMT groups. Performance in instrument- and hand-tied knots was evaluated for technique, time, number of attempts, and, when applicable, knot-leaking pressure. All participants demonstrated significant improvement between a pre-test and an analogous test 48 hours after training for all six outcomes (Wilcoxon matched pairs; two-tailed ps ≤ .013). An adaptive transfer test found no significant differences between EMT and EAT at 48 hours (ps ≥ .053). All participants demonstrated a significant performance decline in six of eight outcomes at 7 weeks post-training (ps ≤ .021). This decline was not significant for four of six EMT outcomes yet significant for five of six EAT outcomes. These data suggest that students trained in both EMT and EAT experience comparable gains in short-term performance, including adaptive transfer. Compared with EAT, EMT may help attenuate performance decline after a sustained period of quiescence. Educators may consider actively incorporating EMT into veterinary curricula.

Reasoning about Durations.

A set of assertions is consistent provided they can all be true at the same time. Naive individuals could prove consistency using the formal rules of a logical calculus, but it calls for them to fail to prove the negation of one assertion from the remainder in the set. An alternative procedure is for them to use an intuitive system (System 1) to construct a mental model of all the assertions. The task should be easy in this case. However, some sets of consistent assertions have no intuitive models and call for a deliberative system (System 2) to construct an alternative model. Formal rules and mental models therefore make different predictions. We report three experiments that tested their respective merits. The participants assessed the consistency of temporal descriptions based on statements using "during" and "before." They were more accurate for consistent problems with intuitive models than for those that called for deliberative models. There was no robust difference in accuracy between consistent and inconsistent problems. The results therefore corroborated the model theory.

Measures for the integration of health and social care services for long-term health conditions: a systematic review of reviews.

BACKGROUND: As people are living longer with higher incidences of long-term health conditions, there is a move towards greater integration of care, including integration of health and social care services. Integrated care needs to be comprehensively and systematically evaluated if it is to be implemented widely. We performed a systematic review of reviews to identify measures which have been used to assess integrated care across health and social care services for people living with long-term health conditions. METHODS: Four electronic databases (PUBMED; MEDLINE; EMBASE; Cochrane library of systematic reviews) were searched in August 2018 for relevant reviews evaluating the integration of health and social care between 1998 and 2018. Articles were assessed according to apriori eligibility criteria. A data extraction form was utilised to collate the identified measures into five categories. RESULTS: Of the 18 articles included, system outcomes and process measures were most frequently identified (15 articles each). Patient or carer reported outcomes were identified in 13 articles while health outcomes were reported in 12 articles. Structural measures were reported in nine articles. Challenges to measuring integration included the identification of a wide range of potential impacts of integration, difficulties in comparing findings due to differences in study design and heterogeneity of types of outcomes, and a need for appropriate, robust measurement tools. CONCLUSIONS: Our review revealed no shortage of measures for assessing the structures, processes and outcomes of integrated care. The very large number of available measures and infrequent use of any common set make comparisons between schemes more difficult. The promotion of core measurement sets and stakeholder consultation would advance measurement in this area.

Measuring the benefits of the integration of health and social care: qualitative interviews with professional stakeholders and patient representatives.

BACKGROUND: Integrated care has the potential to ease the increasing pressures faced by health and social care systems, however, challenges around measuring the benefits for providers, patients, and service users remain. This paper explores stakeholders' views on the benefits of integrated care and approaches to measuring the integration of health and social care. METHODS: Twenty-five semi-structured qualitative interviews were conducted with professional stakeholders (n = 19) and patient representatives (n = 6). Interviews focused on the benefits of integrated care and how it should be evaluated. Data was analysed using framework analysis. RESULTS: Three overarching themes emerged from the data: (1) integrated care and its benefits, with stakeholders defining it primarily from the patient's perspective; (2) potential measures for assessing the benefits of integration in terms of system effects, patient experiences, and patient outcomes; and (3) broader considerations around the assessment of integrated care, including the use of qualitative methods. CONCLUSIONS: There was consensus among stakeholders that patient experiences and outcomes are the best measures of integration, and that the main measures currently used to assess integration do not directly assess patient benefits. Validated health status measures are readily available, however, a substantial shift in practices is required before their use becomes commonplace.

Do modals identify better models? A comparison of signal detection and probabilistic models of inductive reasoning.

The nature of the relationship between deductive and inductive reasoning is a hotly debated topic. A key question is whether there is a single dimension of evidence underlying both deductive and inductive judgments. Following Rips (2001), Rotello and Heit (2009) and Heit and Rotello (2010) implemented one- and two-dimensional models grounded in signal detection theory to assess predictions for receiver operating characteristic data (ROCs), and concluded in favor of the two-dimensional model. Recently, Lassiter and Goodman (2015) proposed a different type of one-dimensional model, the Probability Threshold Model (PTM), that they concluded offered a good account of data collected over a range of decision modals (e.g., How likely, possible, or necessary is the argument conclusion?). Here, we apply the PTM and the signal detection models to ROCs from 3 large experiments in which participants made judgments about arguments varying in terms of modals introduced by Lassiter and Goodman (2015). Two independent variables that are theoretically important for the study of inductive reasoning, namely premise-conclusion similarity (as utilized in Heit & Rotello, 2010) and number of premises (as utilized in Rotello & Heit, 2009), are also varied in Experiments 1 and 2, respectively. In all cases, the PTM provides the poorest fit both quantitatively and qualitatively; the two-dimensional signal detection model is preferred.

Self-efficacy and health-related quality of life: a cross-sectional study of primary care patients with multi-morbidity.

BACKGROUND: Multi-morbidity in chronic long-term conditions is a major concern for health services. Self-management in concert with clinical care forms part of the effective management of multi-morbidity. Self-efficacy is a mechanism through which self-management can be achieved. Quality of life is adversely impacted by multi-morbidity but could be improved by effective self-management. This study examines the relationship between self-efficacy and quality of life in primary care patients with multi-morbidity. METHODS: A cross-sectional survey was conducted with primary care patients in England. Potential participants were mailed a questionnaire containing quality of life measures (the EQ-5D-5L and the Long-Term Conditions Questionnaire (LTCQ)), the Disease Burden Impact Scale (DBIS) and the Self-efficacy for Managing Chronic Disease Scale. Descriptive statistics, analysis of variance and linear regression analyses were conducted to examine the relationship between quality of life (dependent variable), self-efficacy, and demographic and disease-related variables. RESULTS: The 848 participants living with multi-morbidity reported a mean of 6.46 (SD 3.49) chronic long-term conditions, with the mean number of physical conditions 5.99 (SD 3.34) and mental health conditions 0.47 (SD 0.66). The mean scores were 15.45 (SD 12.00) for disease burden, 0.69 (SD 0.28) for the EQ-5D-5L, 65.44 (SD 23.66) for the EQ-VAS, and 69.31 (SD 21.77) for the LTCQ. The mean self-efficacy score was 6.69 (SD 2.53). The regression models were all significant at p < 0.001 (adjusted R2 > 0.70). Significant factors in all models were self-efficacy, disease burden and being permanently sick or disabled. Other factors varied between models, with the most notable being the presence of a mental health condition in the LTCQ model. CONCLUSIONS: Multi-morbid primary care patients with lower self-efficacy and higher disease burden have lower quality of life. Awareness of self-efficacy levels among patients with multi-morbidity may help health professionals identify patients who are in need of enhanced self-management support. Providing self-management support for chronic disease has been hailed as a hallmark of good care. Higher self-efficacy may lead to enhanced quality of life in multi-morbidity.

Updating and reasoning: Different processes, different models, different functions.

Two issues should be addressed to refine and extend the distinction between temporal updating and reasoning advocated by Hoerl & McCormack. First, do the mental representations constructed during updating differ from those used for reasoning? Second, are updating and reasoning the only two processes relevant to temporal thinking? If not, is a dual-systems framework sensible? We address both issues below.

Health Care Professionals' Perceptions of the Arthroplasty Patient Experience: Planning Phase in the Development of a Patient-Reported Outcome Measure.

PURPOSE: The aim of this study was to explore health care professionals' perceptions and perspectives of surgery and early recovery for patients undergoing lower limb arthroplasty. DESIGN: Thematic analysis with semi-structured qualitative interviews. METHODS: Following ethical approval, interviews were performed with recovery room nurses (n=3), ward nurses (n=2), surgeons (n=5), anesthesiologists (n=5), physiotherapists (n=5), and occupational therapists (n=2). Data were analyzed using an in-depth narrative thematic analysis method. NVivo qualitative data analysis software was used. FINDINGS: Three main themes evolved from the interviews: immediate patient recovery issues, discharge criteria, and priorities during hospitalization from health care providers' perspectives. CONCLUSIONS: The early postoperative recovery period can be a challenging time for health care providers and patients alike. However, identifying key areas of importance can provide insight and guide focus in clinical practice, thus improving patient recovery.