Opposing effects on regulated insulin secretion of acute vs chronic stimulation of AMP-activated protein kinase.

AIMS/HYPOTHESIS: Although targeted in extrapancreatic tissues by several drugs used to treat type 2 diabetes, the role of AMP-activated protein kinase (AMPK) in the control of insulin secretion is still debatable. Previous studies have used pharmacological activators of limited selectivity and specificity, and none has examined in primary pancreatic beta cells the actions of the latest generation of highly potent and specific activators that act via the allosteric drug and metabolite (ADaM) site. METHODS: AMPK was activated acutely in islets isolated from C57BL6/J mice, and in an EndoC-ßH3 cell line, using three structurally distinct ADaM site activators (991, PF-06409577 and RA089), with varying selectivity for ß1- vs ß2-containing complexes. Mouse lines expressing a gain-of-function mutation in the γ1 AMPK subunit (D316a) were generated to examine the effects of chronic AMPK stimulation in the whole body, or selectively in the beta cell. RESULTS: Acute (1.5 h) treatment of wild-type mouse islets with 991, PF-06409577 or RA089 robustly stimulated insulin secretion at high glucose concentrations (p<0.01, p<0.05 and p<0.001, respectively), despite a lowering of glucose-induced intracellular free Ca2+ dynamics in response to 991 (AUC, p<0.05) and to RA089 at the highest dose (25 µmol/l) at 5.59 min (p<0.05). Although abolished in the absence of AMPK, the effects of 991 were observed in the absence of the upstream kinase, liver kinase B1, further implicating 'amplifying' pathways. In marked contrast, chronic activation of AMPK, either globally or selectively in the beta cell, achieved using a gain-of-function mutant, impaired insulin release in vivo (p<0.05 at 15 min following i.p. injection of 3 mmol/l glucose) and in vitro (p<0.01 following incubation of islets with 17 mmol/l glucose), and lowered glucose tolerance (p<0.001). CONCLUSIONS/INTERPRETATION: AMPK activation exerts complex, time-dependent effects on insulin secretion. These observations should inform the design and future clinical use of AMPK modulators.

Benchmarking Information Scrambling.

Information scrambling refers to the rapid spreading of initially localized information over an entire system, via the generation of global entanglement. This effect is usually detected by measuring a temporal decay of the out-of-time order correlators. However, in experiments, decays of these correlators suffer from fake positive signals from various sources, e.g., decoherence due to inevitable couplings to the environment, or errors that cause mismatches between the purported forward and backward evolutions. In this Letter, we provide a simple and robust approach to single out the effect of genuine scrambling. This allows us to benchmark the scrambling process by quantifying the degree of the scrambling from the noisy backgrounds. We also demonstrate our protocol with simulations on IBM cloud-based quantum computers.

Common factors in HIV/AIDS prevention success: lessons from Thailand.

BACKGROUND: Thailand has achieved global acclaim for its response to HIV/AIDS. However, the success of some of the country's most well-known initiatives was by no means a foregone conclusion. Policy entrepreneurs on the periphery of power had to achieve buy-in from stakeholders in state and society to scale and mainstream their ideas. This paper offers a comparative and historical understanding the process by which three of the country's most well-known initiatives came into being: a civil society campaign to promote condom usage; a Ministry of Public Health program that aimed to prevent the spread of Human Immunodeficiency Virus (HIV) by targeting high-risk populations (the 100% condom program); and a universal Prevention of Mother-To-Child Transmission (PMTCT) program. METHODS: The research relied on existing literature and interviews with high-ranking ministerial officials, representatives from international and non-governmental organizations, professors, and philanthropic organizations, in addition to a review of the existing literature. Taking a comparative and historical approach that is common within political science and sociology, we analysed the in-depth qualitative interviews in relation to the literatures and used an inductive cross-case analysis aimed to draw out critical features that the initiatives shared in common. RESULTS: Common factors in HIV/AIDS prevention that cut across the three key cases include policy entrepreneurs who championed the programs, successful demonstration projects that produced a credible evidence base for policy adoption, and a diverse set of institutional partners that played critical roles in helping to mainstream their initiatives into national HIV/AIDS policy and scale programs nationally. The findings from this comparative research project have implications not only for the building of understanding related to one single project, but for broader theoretical understanding related to the mainstreaming of health policy from peripheral spaces of power. CONCLUSIONS: This analysis draws out the role that demonstration projects played in building a credible evidence base for policy adoption and the role that a diverse set of institutional partners played in elevating the profile of policy entrepreneurs' ideas and helping to scale them nationally as state policy. Success was contingent on entrepreneurs first identifying and then taking advantage of different political opportunities that arose during each of the historical periods. Over time, these initiatives have evolved from vertical programs into an integrated program, in parallel with the evolution of the HIV/AIDS landscape at the global level.

Microscopy of Polyurea Grease.

Understanding the physical structure of greases can provide critical insight into improving the lubricating performance of a grease. Observation of the grease structure can be quite difficult depending on the type of grease and the length scale of the structure. Polyurea greases in previous reports have typically been examined by removal of the oil phase, which significantly changes the polyurea structure. This paper examines the effect of sample preparation conditions on the microstructure of polyurea greases. This study reveals new structures in the polyurea that have not been observed in the previous literature, including entangled fibers and nanotubes. Correlation is found between the observed polyurea microstructure coverage and grease stiffness.

Electroencephalography reveals a selective disruption of cognitive control processes in craving cigarette smokers.

Addiction to nicotine is extremely challenging to overcome, and the intense craving for the next cigarette often leads to relapse in smokers who wish to quit. To dampen the urges of craving and inhibit unwanted behaviour, smokers must harness cognitive control, which is itself impaired in addiction. It is likely that craving may interact with cognitive control, and the present study sought to test the specificity of such interactions. To this end, data from 24 smokers were gathered using EEG and behavioural measures in a craving session (following a three-hour nicotine abstention period) and a non-craving session (having just smoked). In both sessions, participants performed a task probing various facets of cognitive control (response inhibition, task switching and conflict processing). Results showed that craving smokers were less flexible with the implementation of cognitive control, with demands of task switching and incongruency yielding greater deficits under conditions of craving. Importantly, inhibitory control was not affected by craving, suggesting that the interactions of craving and cognitive control are selective. Together, these results provide evidence that smokers already exhibit specific control-related deficits after brief nicotine deprivation. This disruption of cognitive control while craving may help to explain why abstinence is so difficult to maintain.

Mapping the global endemicity and clinical burden of Plasmodium vivax, 2000-17: a spatial and temporal modelling study.

BACKGROUND: Plasmodium vivax exacts a significant toll on health worldwide, yet few efforts to date have quantified the extent and temporal trends of its global distribution. Given the challenges associated with the proper diagnosis and treatment of P vivax, national malaria programmes-particularly those pursuing malaria elimination strategies-require up to date assessments of P vivax endemicity and disease impact. This study presents the first global maps of P vivax clinical burden from 2000 to 2017. METHODS: In this spatial and temporal modelling study, we adjusted routine malariometric surveillance data for known biases and used socioeconomic indicators to generate time series of the clinical burden of P vivax. These data informed Bayesian geospatial models, which produced fine-scale predictions of P vivax clinical incidence and infection prevalence over time. Within sub-Saharan Africa, where routine surveillance for P vivax is not standard practice, we combined predicted surfaces of Plasmodium falciparum with country-specific ratios of P vivax to P falciparum. These results were combined with surveillance-based outputs outside of Africa to generate global maps. FINDINGS: We present the first high-resolution maps of P vivax burden. These results are combined with those for P falciparum (published separately) to form the malaria estimates for the Global Burden of Disease 2017 study. The burden of P vivax malaria decreased by 41·6%, from 24·5 million cases (95% uncertainty interval 22·5-27·0) in 2000 to 14·3 million cases (13·7-15·0) in 2017. The Americas had a reduction of 56·8% (47·6-67·0) in total cases since 2000, while South-East Asia recorded declines of 50·5% (50·3-50·6) and the Western Pacific regions recorded declines of 51·3% (48·0-55·4). Europe achieved zero P vivax cases during the study period. Nonetheless, rates of decline have stalled in the past five years for many countries, with particular increases noted in regions affected by political and economic instability. INTERPRETATION: Our study highlights important spatial and temporal patterns in the clinical burden and prevalence of P vivax. Amid substantial progress worldwide, plateauing gains and areas of increased burden signal the potential for challenges that are greater than expected on the road to malaria elimination. These results support global monitoring systems and can inform the optimisation of diagnosis and treatment where P vivax has most impact. FUNDING: Bill & Melinda Gates Foundation and the Wellcome Trust.

Mapping the global prevalence, incidence, and mortality of Plasmodium falciparum, 2000-17: a spatial and temporal modelling study.

BACKGROUND: Since 2000, the scale-up of malaria control interventions has substantially reduced morbidity and mortality caused by the disease globally, fuelling bold aims for disease elimination. In tandem with increased availability of geospatially resolved data, malaria control programmes increasingly use high-resolution maps to characterise spatially heterogeneous patterns of disease risk and thus efficiently target areas of high burden. METHODS: We updated and refined the Plasmodium falciparum parasite rate and clinical incidence models for sub-Saharan Africa, which rely on cross-sectional survey data for parasite rate and intervention coverage. For malaria endemic countries outside of sub-Saharan Africa, we produced estimates of parasite rate and incidence by applying an ecological downscaling approach to malaria incidence data acquired via routine surveillance. Mortality estimates were derived by linking incidence to systematically derived vital registration and verbal autopsy data. Informed by high-resolution covariate surfaces, we estimated P falciparum parasite rate, clinical incidence, and mortality at national, subnational, and 5 × 5 km pixel scales with corresponding uncertainty metrics. FINDINGS: We present the first global, high-resolution map of P falciparum malaria mortality and the first global prevalence and incidence maps since 2010. These results are combined with those for Plasmodium vivax (published separately) to form the malaria estimates for the Global Burden of Disease 2017 study. The P falciparum estimates span the period 2000-17, and illustrate the rapid decline in burden between 2005 and 2017, with incidence declining by 27·9% and mortality declining by 42·5%. Despite a growing population in endemic regions, P falciparum cases declined between 2005 and 2017, from 232·3 million (95% uncertainty interval 198·8-277·7) to 193·9 million (156·6-240·2) and deaths declined from 925 800 (596 900-1 341 100) to 618 700 (368 600-952 200). Despite the declines in burden, 90·1% of people within sub-Saharan Africa continue to reside in endemic areas, and this region accounted for 79·4% of cases and 87·6% of deaths in 2017. INTERPRETATION: High-resolution maps of P falciparum provide a contemporary resource for informing global policy and malaria control planning, programme implementation, and monitoring initiatives. Amid progress in reducing global malaria burden, areas where incidence trends have plateaued or increased in the past 5 years underscore the fragility of hard-won gains against malaria. Efforts towards elimination should be strengthened in such areas, and those where burden remained high throughout the study period. FUNDING: Bill & Melinda Gates Foundation.

Dissociating Reward- and Attention-driven Biasing of Global Feature-based Selection in Human Visual Cortex.

Objects that promise rewards are prioritized for visual selection. The way this prioritization shapes sensory processing in visual cortex, however, is debated. It has been suggested that rewards motivate stronger attentional focusing, resulting in a modulation of sensory selection in early visual cortex. An open question is whether those reward-driven modulations would be independent of similar modulations indexing the selection of attended features that are not associated with reward. Here, we use magnetoencephalography in human observers to investigate whether the modulations indexing global color-based selection in visual cortex are separable for target- and (monetary) reward-defining colors. To assess the underlying global color-based activity modulation, we compare the event-related magnetic field response elicited by a color probe in the unattended hemifield drawn either in the target color, the reward color, both colors, or a neutral task-irrelevant color. To test whether target and reward relevance trigger separable modulations, we manipulate attention demands on target selection while keeping reward-defining experimental parameters constant. Replicating previous observations, we find that reward and target relevance produce almost indistinguishable gain modulations in ventral extratriate cortex contralateral to the unattended color probe. Importantly, increasing attention demands on target discrimination increases the response to the target-defining color, whereas the response to the rewarded color remains largely unchanged. These observations indicate that, although task relevance and reward influence the very same feature-selective area in extrastriate visual cortex, the associated modulations are largely independent.

malariaAtlas: an R interface to global malariometric data hosted by the Malaria Atlas Project.

BACKGROUND: The Malaria Atlas Project (MAP) has worked to assemble and maintain a global open-access database of spatial malariometric data for over a decade. This data spans various formats and topics, including: geo-located surveys of malaria parasite rate; global administrative boundary shapefiles; and global and regional rasters representing the distribution of malaria and associated illnesses, blood disorders, and intervention coverage. MAP has recently released malariaAtlas, an R package providing a direct interface to MAP's routinely-updated malariometric databases and research outputs. METHODS AND RESULTS: The current paper reviews the functionality available in malariaAtlas and highlights its utility for spatial epidemiological analysis of malaria. malariaAtlas enables users to freely download, visualise and analyse global malariometric data within R. Currently available data types include: malaria parasite rate and vector occurrence point data; subnational administrative boundary shapefiles; and a large suite of rasters covering a diverse range of metrics related to malaria research. malariaAtlas is here used in two mock analyses to illustrate how this data may be incorporated into a standard R workflow for spatial analysis. CONCLUSIONS: malariaAtlas is the first open-access R-interface to malariometric data, providing a new and reproducible means of accessing such data within a freely available and commonly used statistical software environment. In this way, the malariaAtlas package aims to contribute to the environment of data-sharing within the malaria research community.

Moving towards universal health coverage: lessons from 11 country studies.

In recent years, many countries have adopted universal health coverage (UHC) as a national aspiration. In response to increasing demand for a systematic assessment of global experiences with UHC, the Government of Japan and the World Bank collaborated on a 2-year multicountry research programme to analyse the processes of moving towards UHC. The programme included 11 countries (Bangladesh, Brazil, Ethiopia, France, Ghana, Indonesia, Japan, Peru, Thailand, Turkey, and Vietnam), representing diverse geographical, economic, and historical contexts. The study identified common challenges and opportunities and useful insights for how to move towards UHC. The study showed that UHC is a complex process, fraught with challenges, many possible pathways, and various pitfalls--but is also feasible and achievable. Movement towards UHC is a long-term policy engagement that needs both technical knowledge and political know-how. Technical solutions need to be accompanied by pragmatic and innovative strategies that address the national political economy context.

Reward-associated features capture attention in the absence of awareness: Evidence from object-substitution masking.

Reward-associated visual features have been shown to capture visual attention, evidenced in faster and more accurate behavioral performance, as well as in neural responses reflecting lateralized shifts of visual attention to those features. Specifically, the contralateral N2pc event-related-potential (ERP) component that reflects attentional shifting exhibits increased amplitude in response to task-relevant targets containing a reward-associated feature. In the present study, we examined the automaticity of such reward-association effects using object-substitution masking (OSM) in conjunction with MEG measures of visual attentional shifts. In OSM, a visual-search array is presented, with the target item to be detected indicated by a surrounding mask (here, four surrounding squares). Delaying the offset of the target-surrounding four-dot mask relative to the offset of the rest of the target/distracter array disrupts the viewer's awareness of the target (masked condition), whereas simultaneous offsets do not (unmasked condition). Here we manipulated whether the color of the OSM target was or was not of a previously reward-associated color. By tracking reward-associated enhancements of behavior and the N2pc in response to masked targets containing a previously rewarded or unrewarded feature, the automaticity of attentional capture by reward could be probed. We found an enhanced N2pc response to targets containing a previously reward-associated color feature. Moreover, this enhancement of the N2pc by reward did not differ between masking conditions, nor did it differ as a function of the apparent visibility of the target within the masked condition. Overall, these results underscore the automaticity of attentional capture by reward-associated features, and demonstrate the ability of feature-based reward associations to shape attentional capture and allocation outside of perceptual awareness.

An electrophysiological marker of the desire to quit in smokers.

For many smokers, the motivational state of craving is a central feature of their dependence on nicotine, and is often at odds with a general desire to quit. How this desire to quit may influence the craving for a cigarette, however, is unclear. In the current study, we manipulated the level of craving in 24 regular smokers, and recorded EEG measures of brain activity during a rare target detection task utilizing addiction-unrelated stimuli. In response to the non-targets, we observed that smokers wanting to quit showed an enhanced late frontal activation when they were craving vs. not craving, whereas smokers not wanting to quit showed the opposite pattern of activity. A dissociation was also present in the target-related P300 response as a function of craving and desire to quit, with smokers who did not want to quit processing targets differentially between the states of craving and non-craving. The data suggest that distinct top-down control mechanisms during craving may be implemented by people who wish to quit smoking, as compared to those who do not wish to quit. This pattern of findings establishes this ERP activity as a potential biomarker that may help to differentiate people who want to quit their addiction from those who wish to continue to use their substance of choice.

An electrophysiological dissociation of craving and stimulus-dependent attentional capture in smokers.

It has been suggested that over the course of an addiction, addiction-related stimuli become highly salient in the environment, thereby capturing an addict's attention. To assess these effects neurally in smokers, and how they interact with craving, we recorded electroencephalography (EEG) in two sessions: one in which participants had just smoked (non-craving), and one in which they had abstained from smoking for 3 h (craving). In both sessions, participants performed a visual-search task in which two colored squares were presented to the left and right of fixation, with one color being the target to which they should shift attention and discriminate the locations of two missing corners. Task-irrelevant images, both smoking-related and non-smoking-related, were embedded in both squares, enabling the shift of spatial attention to the target to be examined as a function of the addiction-related image being present or absent in the target, the distractor, or both. Behaviorally, participants were slower to respond to targets containing a smoking-related image. Furthermore, when the target contained a smoking-related image, the neural responses indicated that attention had been shifted less strongly to the target; when the distractor contained a smoking-related image, the shift of attention to the contralateral target was stronger. These effects occurred independently of craving and suggest that participants were actively avoiding the smoking-related images. Together, these results provide an electrophysiological dissociation between addiction-related visual-stimulus processing and the neural activity associated with craving.

"Developmental capture" of the state: explaining Thailand's universal coverage policy.

The notion of "regulatory capture" is typically used to describe the takeover of state agencies by outside interest groups that seek to weaken regulation and advance the agendas of interest groups through control over state policy levers. This concept can be contrasted with that of "developmental capture" of state agencies by networks of reformist bureaucrats within the state who seek to promote inclusive state social and developmental policies of benefit to the broader populace. Building on work that has pointed to instances in which state bureaucrats act autonomously from societal and political pressures, this article argues that existing explanations are insufficient for explaining Thailand's universal health care policy. It points to the critical role played by a network of bureaucrats within the state who strategically mobilized resources in the bureaucracy, political parties, civil society, and international organizations to institutionalize universal health care in the face of broader professional dissent, political uncertainty, and international pressure.

Tracing the paths: a systematic review of mediators of complex trauma and complex post-traumatic stress disorder.

Complex trauma is associated with complex-posttraumatic stress disorder (CPTSD). While dissociative processes, developmental factors and systemic factors are implicated in the development of CPTSD, there are no existing systematic reviews examining the underlying pathways linking complex trauma and CPTSD. This study aims to systematically review evidence of mediating factors linking complex trauma exposure in childhood (birth to eighteen years of age) and subsequent development of CPTSD (via self-reports and diagnostic assessments). All clinical, at-risk and community-sampled articles on three online databases (PsycINFO, MedLine and Embase) were systematically searched, along with grey literature from ProQuest. Fifteen articles were eligible for inclusion according to pre-determined eligibility criteria and a search strategy. Five categories of mediating processes were identified: 1) dissociative processes; 2) relationship with self; 3) emotional developmental processes; 4) social developmental processes; and 5) systemic and contextual factors. Further research is required to examine the extent to which targeting these mediators may act as mechanisms for change in supporting individuals to heal from complex trauma. Systematic review registration: https://www.crd.york.ac.uk/PROSPERO/, identifier CRD42022346152.

Disruption of visual awareness during the attentional blink is reflected by selective disruption of late-stage neural processing.

Any information represented in the brain holds the potential to influence behavior. It is therefore of broad interest to determine the extent and quality of neural processing of stimulus input that occurs with and without awareness. The attentional blink is a useful tool for dissociating neural and behavioral measures of perceptual visual processing across conditions of awareness. The extent of higher-order visual information beyond basic sensory signaling that is processed during the attentional blink remains controversial. To determine what neural processing at the level of visual-object categorization occurs in the absence of awareness, electrophysiological responses to images of faces and houses were recorded both within and outside the attentional blink period during a rapid serial visual presentation stream. Electrophysiological results were sorted according to behavioral performance (correctly identified targets vs. missed targets) within these blink and nonblink periods. An early index of face-specific processing (the N170, 140- to 220-msec poststimulus) was observed regardless of whether the participant demonstrated awareness of the stimulus, whereas a later face-specific effect with the same topographic distribution (500- to 700-msec poststimulus) was only seen for accurate behavioral discrimination of the stimulus content. The present findings suggest a multistage process of object-category processing, with only the later phase being associated with explicit visual awareness.

Evaluating COVID-19-Related Disruptions to Effective Malaria Case Management in 2020-2021 and Its Potential Effects on Malaria Burden in Sub-Saharan Africa.

The COVID-19 pandemic has led to far-reaching disruptions to health systems, including preventative and curative services for malaria. The aim of this study was to estimate the magnitude of disruptions in malaria case management in sub-Saharan Africa and their impact on malaria burden during the COVID-19 pandemic. We used survey data collected by the World Health Organization, in which individual country stakeholders reported on the extent of disruptions to malaria diagnosis and treatment. The relative disruption values were then applied to estimates of antimalarial treatment rates and used as inputs to an established spatiotemporal Bayesian geostatistical framework to generate annual malaria burden estimates with case management disruptions. This enabled an estimation of the additional malaria burden attributable to pandemic-related impacts on treatment rates in 2020 and 2021. Our analysis found that disruptions in access to antimalarial treatment in sub-Saharan Africa likely resulted in approximately 5.9 (4.4-7.2 95% CI) million more malaria cases and 76 (20-132) thousand additional deaths in the 2020-2021 period within the study region, equivalent to approximately 1.2% (0.3-2.1 95% CI) greater clinical incidence of malaria and 8.1% (2.1-14.1 95% CI) greater malaria mortality than expected in the absence of the disruptions to malaria case management. The available evidence suggests that access to antimalarials was disrupted to a significant degree and should be considered an area of focus to avoid further escalations in malaria morbidity and mortality. The results from this analysis were used to estimate cases and deaths in the World Malaria Report 2022 during the pandemic years.

Trends in treatment-seeking for fever in children under five years old in 151 countries from 1990 to 2020.

Access to medical treatment for fever is essential to prevent morbidity and mortality in individuals and to prevent transmission of communicable febrile illness in communities. Quantification of the rates at which treatment is accessed is critical for health system planning and a prerequisite for disease burden estimates. In this study, national data on the proportion of children under five years old with fever who were taken for medical treatment were collected from all available countries in Africa, Latin America, and Asia (n = 91). We used generalised additive mixed models to estimate 30-year trends in the treatment-seeking rates across the majority of countries in these regions (n = 151). Our results show that the proportions of febrile children brought for medical treatment increased steadily over the last 30 years, with the greatest increases occurring in areas where rates had originally been lowest, which includes Latin America and Caribbean, North Africa and the Middle East (51 and 50% increase, respectively), and Sub-Saharan Africa (23% increase). Overall, the aggregated and population-weighted estimate of children with fever taken for treatment at any type of facility rose from 61% (59-64 95% CI) in 1990 to 71% (69-72 95% CI) in 2020. The overall population-weighted average for fraction of treatment in the public sector was largely unchanged during the study period: 49% (42-58 95% CI) sought care at public facilities in 1990 and 47% (44-52 95% CI) in 2020. Overall, the findings indicate that improvements in access to care have been made where they were most needed, but that despite rapid initial gains, progress can plateau without substantial investment. In 2020 there remained significant gaps in care utilisation that must be factored in when developing control strategies and deriving disease burden estimates.

Experience of an NIHR Clinical Lectureship (medical/dental) and the determining factors for a clinical academic career post lectureship: a mixed-method evaluation.

OBJECTIVES: The objective of this study is to investigate early-to-late postdoctoral clinical academic progression and the experiences of NIHR Clinical Lectureship (CL) fellows, considering enablers and barriers to success, and identifying the factors associated with immediate progression to a clinical academic role following completion of the award. SETTING: Datasets of CL awardees across the UK. PARTICIPANTS: For semistructured interviews, n=40 CL awardees that had finished their award within the previous 5 years. For quantitative analysis, n=1226 completed or currently active CL awardees. OUTCOME MEASURES: The responses from the semistructured interviews to the defined questions on experiences during the award, postaward progression, and enablers and barriers to academic progression. Other primary outcome measures were quantitative data on first destinations postaward, demographic data, and whether an awardee had previously held an NIHR Academic Clinical Fellowship (ACF) or was a recipient of the Academy of Medical Sciences (AMS) Starter Grant. RESULTS: CL awardees identified numerous benefits to the award, with the majority achieving their aims. Most awardees progressed to a clinical academic role; however, some returned to a clinical only position, citing concerns around the time pressure associated with balancing clinical and academic responsibilities, and the competition to attain further postdoctoral awards. The region of the award partnership, year of award end and success in applying for an AMS Starter Grant were associated with progression to a clinical academic role. Gender, holding an ACF and having a craft or non-craft specialty had no independent statistical association with clinical academic progression. CONCLUSIONS: The CL is a valued element of the Integrated Academic Pathway. By addressing issues around later postdoctoral progression opportunities, responding to challenges experienced by CLs, and by understanding the factors identified in this study associated with clinical academic progression, it should be possible to increase the proportion of CLs that become fully independent clinical academic research leaders. PARTICIPANTS: 1226 NIHR CLs active or completed on the award between 2006 and 2020.