Treatment Targets and Strategies for Eating Disorders Recovery: A Delphi Consensus With Lived Experience, Carers, Researchers, and Clinicians.

OBJECTIVE: Long-term recovery rates following eating disorders (EDs) treatment remain low. This might be partly due to a lack of agreement between key stakeholder groups, including people with lived experience, carers, clinicians, and researchers, regarding optimal therapeutic targets and strategies. We aimed to reach a consensus across these diverse groups on the most valued treatment targets and strategies for fostering ED recovery. METHOD: We used the Delphi method with two phases: (i) Survey development and (ii) Expert rating. The survey development phase included the design of an initial set of items through scoping review and feedback from a committee of 14 experts. During the survey rating, we engaged a larger panel of 185 experts who comprised the stakeholder groups: Individuals with lived ED experience (n = 49), carers (n = 44), researchers (n = 46), and clinicians (n = 46). RESULTS: Thirty-one targets and 29 strategies reached consensus (> 70% agreement over three rounds). Psychological-emotional-social targets including quality of life, sense of purpose, and emotion regulation, along with ED behaviors, reached the highest agreement (> 90%). Strategies reflecting an individualized approach to treatment (i.e., considering diversity, assessing comorbidities, and enhancing rapport) achieved the highest agreement (> 90%). Responses across groups were similar, except researchers leaning more towards consideration of weight- and eating-related targets. DISCUSSION: Holistic targets and individualized therapeutic strategies have consistent support from the different stakeholder groups involved in ED treatment. The agreed set of targets/strategies may be used, in triangulation with other sources of evidence, to design and evaluate coproduced and personalized interventions.

Reclassification of Botryococcus braunii chemical races into separate species based on a comparative genomics analysis.

The colonial green microalga Botryococcus braunii is well known for producing liquid hydrocarbons that can be utilized as biofuel feedstocks. B. braunii is taxonomically classified as a single species made up of three chemical races, A, B, and L, that are mainly distinguished by the hydrocarbons produced. We previously reported a B race draft nuclear genome, and here we report the draft nuclear genomes for the A and L races. A comparative genomic study of the three B. braunii races and 14 other algal species within Chlorophyta revealed significant differences in the genomes of each race of B. braunii. Phylogenomically, there was a clear divergence of the three races with the A race diverging earlier than both the B and L races, and the B and L races diverging from a later common ancestor not shared by the A race. DNA repeat content analysis suggested the B race had more repeat content than the A or L races. Orthogroup analysis revealed the B. braunii races displayed more gene orthogroup diversity than three closely related Chlamydomonas species, with nearly 24-36% of all genes in each B. braunii race being specific to each race. This analysis suggests the three races are distinct species based on sufficient differences in their respective genomes. We propose reclassification of the three chemical races to the following species names: Botryococcus alkenealis (A race), Botryococcus braunii (B race), and Botryococcus lycopadienor (L race).

Perspectives on the role of nutrition in influencing academy soccer player development and performance: A qualitative case study of key stakeholders from an English category one soccer academy.

This study aimed to explore player and stakeholder perceptions of the role of nutrition in influencing the development of male academy soccer players. Semi-structured interviews (28 ± 13 mins in length) were conducted with 31 participants from an English category one academy, including players (Youth Development Phase, YDP: n = 6; Professional Development Phase, PDP: n = 4), parents/guardians (n = 10), coaches (n = 3), sport scientists (n = 3), physiotherapists (n = 3), and catering (n = 2). Via reflexive thematic analysis, data demonstrate an apparent lack of understanding and awareness on the role of nutrition in influencing player development, especially in relation to growth, maturation and reducing injury risk. Players highlighted the influence of their parents on their dietary behaviours, whilst parents also called for education to better support their sons. Notably, players and stakeholders perceived that the daily schedule of an academy soccer player presents as "too busy to eat", especially in relation to before school, and before and after training. The results demonstrate the necessity for the co-creation of player and stakeholder specific nutrition education programmes as an initial step towards positively impacting the nutrition culture associated with the academy soccer environment.

Assessing clinician competence in the delivery of cognitive-behavioural therapy for eating disorders: development of the Cognitive-Behavioural Therapy Scale for Eating Disorders (CBTS-ED).

Evidence-based cognitive-behaviour therapy for eating disorders (CBT-ED) differs from other forms of CBT for psychological disorders, making existing generic CBT measures of therapist competence inadequate for evaluating CBT-ED. This study developed and piloted the reliability of a novel measure of therapist competence in this domain-the Cognitive Behaviour Therapy Scale for Eating Disorders (CBTS-ED). Initially, a team of CBT-ED experts developed a 26-item measure, with general (i.e. present in every session) and specific (context- or case-dependent) items. To determine statistical properties of the measure, nine CBT-ED experts and eight non-experts independently observed six role-played mock CBT-ED therapy sessions, rating the therapists' performance using the CBTS-ED. The inter-item consistency (Cronbach's alpha and McDonald's omega) and inter-rater reliability (ICC) were assessed, as appropriate to the clustering of the items. The CBTS-ED demonstrated good internal consistency and moderate/good inter-rater reliability for the general items, at least comparable to existing generic CBT scales in other domains. An updated version is proposed, where five of the 16 "specific" items are reallocated to the general group. These preliminary results suggest that the CBTS-ED can be used effectively across both expert and non-expert raters, though less experienced raters might benefit from additional training in its use.

An exploration of mental distress in transgender people in Ireland with reference to minority stress and dissonance theory.

Introduction: Internationally mental distress is more prominent in the LGBTI community than the general population. The LGBTIreland study was set up to take stock of this in the Republic of Ireland. This paper reports on the analysis of the transgender group with reference to minority stress theory and cognitive dissonance theory. Method: An online survey was conducted addressing several aspects of mental health and distress that received responses from all groupings (n = 2,264) among which 12.3% (n = 279) identified as transgender. The survey consisted of several validated tools to measure depression, anxiety, stress (DASS-21), coping (CSES), self-esteem (RSES), alcohol and drugs misuse (AUDIT) and a variety of questions addressing demographics, experiential aspects, coping and self-related factors. Data analysis focused on predicting mental distress using DASS-general (composite of depression, anxiety and stress). Results: Transgender participants reported higher levels of mental distress, self-harm, suicidal ideation and attempts, and lower levels of self-esteem in comparison with the LGB groups, as well as the general population. Hierarchical multiple regression showed that 53% of variance in mental distress could be predicted from reduced self-esteem, the experience of harassment and not belonging in school. Furthermore, mental distress was highest among younger participants, those who were 'not out', those who had self-harmed and used avoidant coping. There was no significant difference in distress levels among those who had sought mental health support and those who had not. Conclusions: To understand mental distress in transgender people, the minority stress model is useful when taking into account both adverse external (environmental) and internal (cognitive/emotional) factors. The cognitive dissonance mechanism is essential in outlining the mechanism whereby gender incongruence is associated with psychological discomfort, low self-esteem and high mental distress.

Improving programme-led and focused interventions for eating disorders: An experts' consensus statement-A UK perspective.

OBJECTIVE: Eating disorders are associated with significant illness burden and costs, yet access to evidence-based care is limited. Greater use of programme-led and focused interventions that are less resource-intensive might be part of the solution to this demand-capacity mismatch. METHOD: In October 2022, a group of predominantly UK-based clinical and academic researchers, charity representatives and people with lived experience convened to consider ways to improve access to, and efficacy of, programme-led and focused interventions for eating disorders in an attempt to bridge the demand-capacity gap. RESULTS: Several key recommendations were made across areas of research, policy, and practice. Of particular importance is the view that programme-led and focused interventions are suitable for a range of different eating disorder presentations across all ages, providing medical and psychiatric risk are closely monitored. The terminology used for these interventions should be carefully considered, so as not to imply that the treatment is suboptimal. CONCLUSIONS: Programme-led and focused interventions are a viable option to close the demand-capacity gap for eating disorder treatment and are particularly needed for children and young people. Work is urgently needed across sectors to evaluate and implement such interventions as a clinical and research priority.

Rise of Ruppia in Chesapeake Bay: Climate change-driven turnover of foundation species creates new threats and management opportunities.

Global change has converted many structurally complex and ecologically and economically valuable coastlines to bare substrate. In the structural habitats that remain, climate-tolerant and opportunistic species are increasing in response to environmental extremes and variability. The shifting of dominant foundation species identity with climate change poses a unique conservation challenge because species vary in their responses to environmental stressors and to management. Here, we combine 35 y of watershed modeling and biogeochemical water quality data with species comprehensive aerial surveys to describe causes and consequences of turnover in seagrass foundation species across 26,000 ha of habitat in the Chesapeake Bay. Repeated marine heatwaves have caused 54% retraction of the formerly dominant eelgrass (Zostera marina) since 1991, allowing 171% expansion of the temperature-tolerant widgeongrass (Ruppia maritima) that has likewise benefited from large-scale nutrient reductions. However, this phase shift in dominant seagrass identity now presents two significant shifts for management: Widgeongrass meadows are not only responsible for rapid, extensive recoveries but also for the largest crashes over the last four decades; and, while adapted to high temperatures, are much more susceptible than eelgrass to nutrient pulses driven by springtime runoff. Thus, by selecting for rapid post-disturbance recolonization but low resistance to punctuated freshwater flow disturbance, climate change could threaten the Chesapeake Bay seagrass' ability to provide consistent fishery habitat and sustain functioning over time. We demonstrate that understanding the dynamics of the next generation of foundation species is a critical management priority, because shifts from relatively stable habitat to high interannual variability can have far-reaching consequences across marine and terrestrial ecosystems.

Reduction of phenolics in faba bean meal using recombinantly produced and purified Bacillus ligniniphilus catechol 2,3-dioxygenase.

Pulse meal should be a valuable product in the animal feed industry based on its strong nutritional and protein profiles. However, it contains anti-nutritional compounds including phenolics (large and small molecular weight), which must be addressed to increase uptake by the industry. Microbial fermentation is currently used as a strategy to decrease larger molecular weight poly-phenolics, but results in the undesirable accumulation of small mono-phenolics. Here, we investigate cell-free biocatalytic reduction of phenolic content in faba bean (Vicia faba L.) meal. A representative phenolic ring-breaking catechol dioxygenase, Bacillus ligniniphilus L1 catechol 2,3-dioxygenase (BLC23O) was used in this proof-of concept based on its known stability and broad substrate specificity. Initially, large-scale fermentative recombinant production and purification of BLC23O was carried out, with functionality validated by in vitro kinetic analysis. When applied to faba bean meal, BLC23O yielded greatest reductions in phenolic content in a coarse air classified fraction (high carbohydrate), compared to either a fine fraction (high protein) or the original unfractionated meal. However, the upstream hydrolytic release of phenolics from higher molecular weight species (e.g. tannins, or complexes with proteins and carbohydrates) likely remains a rate limiting step, in the absence of other enzymes or microbial fermentation. Consistent with this, when applied to a selection of commercially available purified phenolic compounds, known to occur in faba bean, BLC23O was found to have high activity against monophenolic acids and little if any detectable activity against larger molecular weight compounds. Overall, this study highlights the potential viability of the biocatalytic processing of pulse meals, for optimization of their nutritional and economical value in the animal feed industry. Supplementary Information: The online version contains supplementary material available at 10.1186/s40643-023-00633-8.

An audit of performance nutrition services in English soccer academies: implications for optimising player development.

To audit the current provision of performance nutrition services provided to male adolescent players within academies from the English soccer leagues. Practitioners from all 89 academies (status categorised as one-four according to the Elite Player Performance Plan, EPPP) completed an online survey to audit: a) job role/professional accreditation status of persons delivering nutrition support, b) activities inherent to service provision, c) topics of education, d) on-site food, fluid and supplement provision and e) nutritional related data collected for objective monitoring. More full-time accredited nutritionists are employed within category one (14/26) versus category two (0/18), three (1/41) and four (0/4). Respondents from category one clubs report more hours of monthly service delivery (62 ± 57 h) than category two (12 ± 9 h), three (14 ± 26 h) and four (12 ± 14 h), inclusive of one-to-one player support and stakeholder education programmes. Category one practitioners reported a greater prevalence of on-site food, fluid and supplement provision on training and match days. Across all categories, players from the professional development phase receive more frequent support than players from the youth development phase, despite the latter corresponding to the most rapid phase of growth and maturation. We report distinct differences in the extent of service provision provided between categories. Additionally, players from all categories receive nutrition support from non-specialist staff. Data demonstrate that performance nutrition appears an under-resourced component of academy sport science and medicine programmes in England, despite being an integral component of player development.

Nutrient limitation of phytoplankton in three tributaries of Chesapeake Bay: Detecting responses following nutrient reductions.

Many coastal ecosystems suffer from eutrophication, algal blooms, and dead zones due to excessive anthropogenic inputs of nitrogen (N) and phosphorus (P). This has led to regional restoration efforts that focus on managing watershed loads of N and P. In Chesapeake Bay, the largest estuary in the United States, dual nutrient reductions of N and P have been pursued since the 1980s. However, it remains unclear whether nutrient limitation - an indicator of restriction of algal growth by supplies of N and P - has changed in the tributaries of Chesapeake Bay following decades of reduction efforts. Toward that end, we analyzed historical data from nutrient-addition bioassay experiments and data from the Chesapeake Bay long-term water-quality monitoring program for six stations in three tidal tributaries (i.e., Patuxent, Potomac, and Choptank Rivers). Classification and regression tree (CART) models were developed using concurrent collections of water-quality parameters for each bioassay monitoring location during 1990-2003, which satisfactorily predicted the bioassay-based measures of nutrient limitation (classification accuracy = 96%). Predictions from the CART models using water-quality monitoring data showed enhanced nutrient limitation over the period of 1985-2020 at four of the six stations, including the downstream station in each of these three tributaries. These results indicate detectable, long-term water-quality improvements in the tidal tributaries. Overall, this research provides a new analytical tool for detecting signs of ecosystem recovery following nutrient reductions. More broadly, the approach can be adapted to other waterbodies with long-term bioassays and water-quality data sets to detect ecosystem recovery.

Athlete experiences of communication strategies in applied sports nutrition and future considerations for mobile app supportive solutions.

Aim: This study aimed to explore athletes' experiences and opinions of communication strategies in applied sports nutrition, as well as capture suggestions for future mobile app supportive solutions. Methods: A qualitative approach was used for this research. Data was generated from semi-structured focus groups (n = 9) with a purposive sample of 41 (male = 24, female = 17) full time professional athletes (mean age 24 ± 4.59) from five sports (football, rugby union, athletics, cycling, and boxing). Data was analyzed using reflexive thematic analysis. Results: The analysis identified four higher order themes and five sub themes. Athletes appear dissatisfied with the levels of personalization in the nutrition support they receive. Limited practitioner contact time was suggested as a contributing factor to this problem. Athletes acknowledged the usefulness of online remote nutrition support and reported a desire for more personalized technology that can tailor support to their individual needs. Conclusion: Athletes experienced a hybrid human-computer approach that combines in-person and remote digital methods to communicate with and receive information from practitioners. Mobile technology may now afford sports nutritionists with new opportunities to develop scalable solutions to support practice.

Data synthesis for environmental management: A case study of Chesapeake Bay.

Synthesizing large, complex data sets to inform resource managers towards effective environmental stewardship is a universal challenge. In Chesapeake Bay, a well-studied and intensively monitored estuary in North America, the challenge of synthesizing data on water quality and land use as factors related to a key habitat, submerged aquatic vegetation, was tackled by a team of scientists and resource managers operating at multiple levels of governance (state, federal). The synthesis effort took place over a two-year period (2016-2018), and the results were communicated widely to a) scientists via peer review publications and conference presentations; b) resource managers via web materials and workshop presentations; and c) the public through newspaper articles, radio interviews, and podcasts. The synthesis effort was initiated by resource managers at the United States Environmental Protection Agencys' Chesapeake Bay Program and 16 scientist participants were recruited from a diversity of organizations. Multiple short, immersive workshops were conducted regularly to conceptualize the problem, followed by data analysis and interpretation that supported the preparation of the synthetic products that were communicated widely. Reflections on the process indicate that there are a variety of structural and functional requirements, as well as enabling conditions, that need to be considered to achieve successful outcomes from synthesis efforts.

Using a theory of change in monitoring, evaluating and steering scale-up of a district-level health management strengthening intervention in Ghana, Malawi, and Uganda - lessons from the PERFORM2Scale consortium.

BACKGROUND: Since 2017, PERFORM2Scale, a research consortium with partners from seven countries in Africa and Europe, has steered the implementation and scale-up of a district-level health management strengthening intervention in Ghana, Malawi and Uganda. This article presents PERFORM2Scale's theory of change (ToC) and reflections upon and adaptations of the ToC over time. The article aims to contribute to understanding the benefits and challenges of using a ToC-based approach for monitoring and evaluating the scale-up of health system strengthening interventions, because there is limited documentation of this in the literature. METHODS: The consortium held annual ToC reflections that entailed multiple participatory methods, including individual scoring exercises, country and consortium-wide group discussions and visualizations. The reflections were captured in detailed annual reports, on which this article is based. RESULTS: The PERFORM2Scale ToC describes how the management strengthening intervention, which targets district health management teams, was expected to improve health workforce performance and service delivery at scale, and which assumptions were instrumental to track over time. The annual ToC reflections proved valuable in gaining a nuanced understanding of how change did (and did not) happen. This helped in strategizing on actions to further steer the scale-up the intervention. It also led to adaptations of the ToC over time. Based on the annual reflections, these actions and adaptations related to: assessing the scalability of the intervention, documentation and dissemination of evidence about the effects of the intervention, understanding power relationships between key stakeholders, the importance of developing and monitoring a scale-up strategy and identification of opportunities to integrate (parts of) the intervention into existing structures and strategies. CONCLUSIONS: PERFORM2Scale's experience provides lessons for using ToCs to monitor and evaluate the scale-up of health system strengthening interventions. ToCs can help in establishing a common vision on intervention scale-up. ToC-based approaches should include a variety of stakeholders and require their continued commitment to reflection and learning on intervention implementation and scale-up. ToC-based approaches can help in adapting interventions as well as scale-up processes to be in tune with contextual changes and stakeholders involved, to potentially increase chances for successful scale-up.

Experience of discrimination during COVID-19 pandemic: the impact of public health measures and psychological distress among refugees and other migrants in Europe.

BACKGROUND: The COVID-19 pandemic has had a disproportionately hard impact on refugees and other migrants who are often exposed to the virus with limited means to protect themselves. We tested the hypothesis that during the COVID-19 pandemic, refugees and other migrants have suffered a negative impact on mental health and have been unjustly discriminated for spreading the disease in Europe (data collection from April to November 2020). METHODS: Participants in the ApartTogether Survey (N = 8297, after listwise deletion of missing items final N = 3940) provided data regarding to their difficulties to adhere to preventive recommendations against COVID-19 infection (CARE), self-perceived stigmatization (SS), and psychological distress (PD). Structural Equation Modeling was used to investigate PD as a mediator in the pathway linking CARE to SS, while adjusting for the housing and residence status. To improve confidence in the findings, single hold-out sample cross-validation was performed using a train/test split ratio of 0.8/0.2. RESULTS: In the exploratory set (N = 3159) SS was associated with both CARE (B = 0.200, p < 0.001) and PD (B = 0.455, p < 0.001). Moreover, PD was also associated with CARE (B = 0.094, p = 0.001) and mediated the effect of CARE on SS (proportion mediated = 17.7%, p = 0.001). The results were successfully replicated in the confirmation set (N = 781; total effect = 0.417, p < 0.001; proportion mediated = 29.7%, p < 0.001). Follow-up analyses also found evidence for an opposite effect (i.e., from SS to CARE, B = 0.132; p < 0.001), suggesting that there might be a vicious circle between the self-perceived stigmatization and the access to health care and the use of preventive measures against COVID-19 infection. CONCLUSIONS: Refugees and other migrants who had more difficulties in accessing health care and preventive measures against COVID-19 infection experienced worse mental health and increased discrimination. These negative effects appeared to be stronger for those with more insecure housing and residence status, highlighting from one side the specific risk of insecure housing in the impact of COVID-19 upon mental health and infection protection, and for another side the need to proper housing as a strategy to prevent both COVID-19 and mental distress.

A pilot sequential multiple assignment randomized trial (SMART) protocol for developing an adaptive coaching intervention around a mobile application for athletes to improve carbohydrate periodization behavior.

BACKGROUND: It has recently been identified that manipulating carbohydrate availability around exercise activity can enhance training-induced metabolic adaptations. Despite this approach being accepted in the athletic populations, athletes do not systematically follow the guidelines. Digital environments appear to allow nutritionists to deliver this intervention at scale, reducing expensive human coaching time. Yet, digitally delivered dietary behavior change interventions for athletes and the coaching strategy to support them are still novel concepts within sports nutrition. METHODS/DESIGN: We aim to recruit 900 athletes across the UK. 500 athletes will be recruited to test the feasibility of a novel menu planner mobile application with coaching for 6 weeks. 250 athletes with pre-existing nutritionist support will also be recruited as control. We will then conduct a 4-week pilot sequential multiple assignment randomized trial (SMART) with an additional 150 athletes. In the SMART, athletes will be given the application and additional coaching according to their engagement responses. The primary outcomes are the mobile application and coach uptake, retention, engagement, and success in attaining carbohydrate periodization behavior. Secondary outcomes are changes in goal, weight, carbohydrate periodization self-efficacy, and beliefs about consequences. Due to the high attrition nature of digital interventions, all quantitative analyses will be carried out based on both the intention-to-treat and per-protocol principles. DISCUSSION: This study will be the first to investigate improving carbohydrate periodization using a digital approach and tailored coaching strategies under this context. Foundational evidence from this study will provide insights into the feasibility of the digital approach.

The associations of use of social network sites with perceived social support and loneliness.

Research shows that use of social network sites is associated with loneliness and this may be amplified in tertiary students by their transition from home life, especially if they struggle to integrate with peers. The buffering effects of social support may offer a solution and the online dimension may offer a suitable outlet for lonely and isolated students. In this study, N = 111 university students, aged 18-40, completed a frequency assessment of Instagram and WhatsApp, the Spanish version of the UCLA loneliness scale and the Multidimensional Scale of Social Support in an online survey. The statistical analysis was completed by Structural Equation Modeling using AMOS 25.0. The construct validity of social network sites was established by good factor loadings for WhatsApp and Instagram, but Facebook was excluded as it did not load adequately on to the latent measurement model, in keeping with the diminishing trend for Facebook use in young students. Loneliness emerged as pivotal in a mediation model, and online social support from friends/significant others, emerged as salient in the predictive model in contrast to family. However, these associations may not have the same advantageous weight for mature students given the observed negative associations with age. Results may have implications for policy and planning through highlighting the psychological variables that are operative in the dynamics of integration, retention, and adjustment to tertiary level experience.

Factors Influencing Attendees' Engagement with Group Psychoeducation: A Multi-stakeholder Perspective.

Few studies have explored the problem of engagement in relation to group psychoeducation from a multi-site and multi-stakeholder perspective. The aim of the study was to explore the factors influencing service user and family engagement with group psychoeducation programmes. The study design was qualitative descriptive. Data were collected through individual and focus group interviews with key stakeholders (n = 75) involved with the programme within 14 mental health sites in the Republic of Ireland. Enablers and barriers to engagement were identified at participant, provider, programme and organization level. Motivated participants and engaged clinicians, peer co-facilitation and support, and skilled and responsive facilitators were some of the factors which enhanced engagement. Barriers to engagement included readiness among participants, concerns related to stigma and confidentiality, desire to distance oneself from mental health services, a lack of support for programme participation within families, group discomfort, the time and length of the programme, issues with transport, visibility of the programme, and structural supports for clinicians. Findings from the study illustrate the multifaceted nature of engagement as well as provide a greater understanding of the multifactorial influences on engagement. Strategies to enhance engagement should therefore reflect a multipronged approach. At the outset of programme implementation, organizations should address their readiness to engage, conduct local needs assessments to anticipate individuals' needs and plan accordingly in order to maximize engagement, and bolster facilitators' engagement skills through the provision of training and mentoring opportunities.

"Do what you can with a happy heart": a longitudinal study of patient and family members' lived experiences of physical activity post-myocardial infarction.

PURPOSE: Physical activity (PA) post-myocardial infarction (MI) can reduce risk of reoccurrence and mortality. Yet uptake of PA through cardiac rehabilitation (CR) is poor, and little is known about the long-term PA behaviour of cardiac patients. This study aimed to explore the lived experiences of patients' engagement with PA post-MI, together with the experiences of their family. METHODS: Longitudinal interviews with six family-dyads were conducted which drew on interpretative phenomenology to understand the lived experiences of PA for post-MI patients and family members. RESULTS: Participants described a journey that involved leaving "normality" (doing what PA they wanted and when) and transitioning to a new "normality" (being active within post-MI parameters). This journey was expressed through feelings of "I can't do what I was doing before," "finding my way," and "accepting this way". CONCLUSION: The role of family within the patient's journey was complex, with PA identity, beliefs, and fear of MI re-occurrence influencing PA support both positively and negatively. PA engagement post-MI is a dynamic and interactive process within which the family can have an important influence.IMPLICATIONS FOR REHABILITATIONThe process of (re-)engaging in physical activity post-myocardial infarction involves a complex journey towards acceptance of a new "normality".Family play an important role in regulating and supporting patients' physical activity during the rehabilitation process.Promoting positive health beliefs and helping families understand what, how and when patients should be physically active may optimise the rehabilitation journey for post-myocardial infarction patients.

Multi-scale trend analysis of water quality using error propagation of generalized additive models.

Effective stewardship of ecosystems to sustain current ecological status or mitigate impacts requires nuanced understanding of how conditions have changed over time in response to anthropogenic pressures and natural variability. Detecting and appropriately characterizing changes requires accurate and flexible trend assessment methods that can be readily applied to environmental monitoring datasets. A key requirement is complete propagation of uncertainty through the analysis. However, this is difficult when there are mismatches between sampling frequency, period of record, and trends of interest. Here, we propose a novel application of generalized additive models (GAMs) for characterizing multi-decadal changes in water quality indicators and demonstrate its utility by analyzing a 30-year record of biweekly-to-monthly chlorophyll-a concentrations in the San Francisco Estuary. GAMs have shown promise in water quality trend analysis to separate long-term (i.e., annual or decadal) trends from seasonal variation. Our proposed methods estimate seasonal averages in a response variable with GAMs, extract uncertainty measures for the seasonal estimates, and then use the uncertainty measures with mixed-effects meta-analysis regression to quantify inter-annual trends that account for full propagation of error across methods. We first demonstrate that nearly identical descriptions of temporal changes can be obtained using different smoothing spline formulations of the original time series. We then extract seasonal averages and their standard errors for an a priori time period within each year from the GAM results. Finally, we demonstrate how across-year trends in seasonal averages can be modeled with mixed-effects meta-analysis regression that propagates uncertainties from the GAM fits to the across-year analysis. Overall, this approach leverages GAMs to smooth data with missing observations or varying sample effort across years to estimate seasonal averages and meta-analysis to estimate trends across years. Methods are provided in the wqtrends R package.