Adjunctive Medication Management and Contingency Management to enhance adherence to acamprosate for alcohol dependence: the ADAM trial RCT.

Background: Acamprosate is an effective and cost-effective medication for alcohol relapse prevention but poor adherence can limit its full benefit. Effective interventions to support adherence to acamprosate are therefore needed. Objectives: To determine the effectiveness of Medication Management, with and without Contingency Management, compared to Standard Support alone in enhancing adherence to acamprosate and the impact of adherence to acamprosate on abstinence and reduced alcohol consumption. Design: Multicentre, three-arm, parallel-group, randomised controlled clinical trial. Setting: Specialist alcohol treatment services in five regions of England (South East London, Central and North West London, Wessex, Yorkshire and Humber and West Midlands). Participants: Adults (aged 18 years or more), an International Statistical Classification of Diseases and Related Health Problems, Tenth Revision, diagnosis of alcohol dependence, abstinent from alcohol at baseline assessment, in receipt of a prescription for acamprosate. Interventions: (1) Standard Support, (2) Standard Support with adjunctive Medication Management provided by pharmacists via a clinical contact centre (12 sessions over 6 months), (3) Standard Support with adjunctive Medication Management plus Contingency Management that consisted of vouchers (up to £120) to reinforce participation in Medication Management. Consenting participants were randomised in a 2 : 1 : 1 ratio to one of the three groups using a stratified random permuted block method using a remote system. Participants and researchers were not blind to treatment allocation. Main outcome measures: Primary outcome: self-reported percentage of medication taken in the previous 28 days at 6 months post randomisation. Economic outcome: EuroQol-5 Dimensions, a five-level version, used to calculate quality-adjusted life-years, with costs estimated using the Adult Service Use Schedule. Results: Of the 1459 potential participants approached, 1019 (70%) were assessed and 739 (73 consented to participate in the study, 372 (50%) were allocated to Standard Support, 182 (25%) to Standard Support with Medication Management and 185 (25%) to Standard Support and Medication Management with Contingency Management. Data were available for 518 (70%) of participants at 6-month follow-up, 255 (68.5%) allocated to Standard Support, 122 (67.0%) to Standard Support and Medication Management and 141 (76.2%) to Standard Support and Medication Management with Contingency Management. The mean difference of per cent adherence to acamprosate was higher for those who received Standard Support and Medication Management with Contingency Management (10.6%, 95% confidence interval 19.6% to 1.6%) compared to Standard Support alone, at the primary end point (6-month follow-up). There was no significant difference in per cent days adherent when comparing Standard Support and Medication Management with Standard Support alone 3.1% (95% confidence interval 12.8% to -6.5%) or comparing Standard Support and Medication Management with Standard Support and Medication Management with Contingency Management 7.9% (95% confidence interval 18.7% to -2.8%). The primary economic analysis at 6 months found that Standard Support and Medication Management with Contingency Management was cost-effective compared to Standard Support alone, achieving small gains in quality-adjusted life-years at a lower cost per participant. Cost-effectiveness was not observed for adjunctive Medication Management compared to Standard Support alone. There were no serious adverse events related to the trial interventions reported. Limitations: The trial's primary outcome measure changed substantially due to data collection difficulties and therefore relied on a measure of self-reported adherence. A lower than anticipated follow-up rate at 12 months may have lowered the statistical power to detect differences in the secondary analyses, although the primary analysis was not impacted. Conclusions: Medication Management enhanced with Contingency Management is beneficial to patients for supporting them to take acamprosate. Future work: Given our findings in relation to Contingency Management enhancing Medication Management adherence, future trials should be developed to explore its effectiveness and cost-effectiveness with other alcohol interventions where there is evidence of poor adherence. Trial registration: This trial is registered as ISRCTN17083622 https://doi.org/10.1186/ISRCTN17083622. Funding: This project was funded by the National Institute for Health and Care Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 27, No. 22. See the NIHR Journals Library website for further project information.

Many people who are trying to stop drinking alcohol can find it difficult to remain alcohol free. There is a medication called acamprosate (Campral) that can reduce cravings thereby increasing the likelihood of abstinence. However, some people have trouble taking the right amount of acamprosate tablets needed every day at the right time, preferably at mealtimes. This means the medication is not as effective. We have tested some new ways to help support people taking acamprosate. We tested three different strategies to find the best way to support people taking acamprosate. We recruited 739 people aged 18 and over who were receiving alcohol treatment to stop drinking and were taking acamprosate. We randomly allocated these people to three groups. The first was Standard Support, the usual support people receive when taking acamprosate. The second group received Standard Support plus Medication Management. This consisted of 12 telephone calls over 6 months with a trained pharmacist to discuss the importance of taking the right amount of the medication, how the medication works and strategies to help people take the medication correctly. The third group received Standard Support, Medication Management and Contingency Management. This involved giving people shopping vouchers for participating with Medication Management calls. The maximum value of vouchers per person was £120. People who were in the group receiving Medication Management and Contingency Management took a greater number of acamprosate tablets. We also found that Medication Management plus Contingency Management was more cost-effective; there were greater gains in health with a smaller cost per person compared to Standard Support alone. This shows that there is likely to be a benefit to patients of Medication Management plus Contingency Management for supporting people taking acamprosate.

Recently acquired hepatitis C: Epidemiological characteristics and treatment response in a large cohort of MSM living with HIV in Madrid.

INTRODUCTION: We analyzed epidemiological, clinical characteristics, and the response to treatment in people living with HIV (PLHIV) who recently acquired hepatitis C (RAHC) in a multicentre study in Madrid (Spain). METHODS: Multicenter, ambispective, observational study of RAHC in men who have sex with men (MSM) infected with HIV. Clinical, epidemiological, and RAHC evolution were recorded prospectively in 2019 and 2020 and retrospectively in 2017 and 2018. In patients who received HCV treatment, sustained virological response (SVR) was provided 12 weeks after the end of treatment in an intention to treat analysis (ITT): all treated patients were included; and in analysis per-protocol (PP): missing patients were excluded. RESULTS: Overall, 133 patients were included. Median (IQR) age was 40 (34.3-46.1) years, 90.9% had at least one previous sexual transmission disease (STD), and 33.6% had previously hepatitis C. More than half of the prospective sample included patients using chemsex related drugs (57.3%), 45.7% of them intravenously. The most prevalent genotype was G1a (66.2%), followed by G4 (11.3%). Ten of 90 patients evaluated for spontaneous cure (11%) cured the infection spontaneously, and 119 had treatment after a median time of 1.8 (0.7-4.6) months: sustained virological response (SVR) was achieved in 90.7% in the ITT and 94.7% in the PP analysis, with no differences regarding the direct-acting antiviral agents (DAA) combination used. CONCLUSIONS: MSM infected by HIV with a RAHC were exposed to high-risk sexual behavior. Spontaneous cure rate was low, while SVR after treatment was achieved by more than 90%.

HIDDEN2: Study protocol for the hospital deep vein thrombosis detection study in patients with cancer receiving palliative care.

INTRODUCTION: Medical patients, admitted acutely to hospital, are at risk of venous thromboembolism (VTE). Clinical guidelines advise thromboprophylaxis prophylaxis for those at high risk of VTE. VTE is a common sequela of cancer, but guidelines take little consideration of cancer as an independent risk factor and their utility in palliative care patients is unclear. The hospice inpatient deep vein thrombosis (DVT) detection study (HIDDen) reported a 28% prevalence of asymptomatic iliofemoral DVT in hospice patients of poor performance status (PS) and prognosis, calling into question the utility of thromboprophylaxis in the palliative care setting. However, the majority of cancer inpatients receiving palliative care are admitted to hospital through the acute medical setting, yet their risk factors for VTE may differ from those admitted to hospices. OBJECTIVE: To better understand the prevalence and behaviours of VTE in patients with cancer receiving palliative care who are admitted as an acute medical emergency. DESIGN: Multicentre, observational cohort study. SETTING: Secondary care acute hospitals in South Wales, UK. PATIENTS: We plan to recruit 232 patients≥18 years old with a diagnosis of incurable cancer, and/or receiving palliative or best supportive care who are admitted acutely to hospital. Patients will be followed up for a maximum of 6 months following registration. PRIMARY OUTCOME: Presence of lower extremity DVT. SECONDARY OUTCOMES: Symptom burden attributed to DVT or pulmonary embolism, patient PS, patient demographics and development of new VTE within 90 days of registration. ANALYSIS: The study statistical analysis plan will document analysis, methodology and procedures. ETHICS AND DISSEMINATION: Ethical approval was obtained from the Wales Research Ethics Committee, reference 22/WA/0037 (IRAS 306352)-the main trial results will be analysed as soon as practically possible and the publication shared with investigators and on sponsor website; applications to access trial data will be subject to sponsor review process.

'It is easier to not allow them to see your disability straight away, to see you as a person': An Interpretative Phenomenological Analysis of video gaming from the perspectives of men with Duchenne Muscular Dystrophy.

BACKGROUND: Young men with Duchenne Muscular Dystrophy benefit from palliative care that supports their psychosocial needs. Acknowledging the sub-cultures they engage with can support their wellbeing. Anecdotal reports suggest video gaming is a sub-culture engaged with by young men with Duchenne Muscular Dystrophy. AIM: To explore the lived experience of video gaming from the perspective of young men with Duchenne Muscular Dystrophy. DESIGN: Interpretative Phenomenological Analysis approach involving in-depth interviews using a topic guide that focused on social media broadly, with reference to video gaming. Sequential interviewing was undertaken to support participation regarding fatigue and tiredness, symptoms of Duchenne Muscular Dystrophy. SETTING/PARTICIPANTS: Participants were purposefully recruited from a hospice in the North of England. Twitter was used to support recruitment. Eight young men with Duchenne Muscular Dystrophy were recruited to the study. RESULTS: Five themes were developed; 'gamer as a shared and accepted identity', 'an existential and bodily escapism', 'introspection through video gaming', 'video gaming as a release' and 'when life gives you few choices-video game'. Motivations for engagement with video gaming are diverse and reflective of the situated perspectives of young men with Duchenne Muscular Dystrophy. CONCLUSIONS: An awareness of the popular sub-cultures that young men with Duchenne Muscular Dystrophy engage with is key to building a therapeutic alliance, establishing rapport and recognising personhood in interactions between professionals and persons in palliative care settings. This study highlights the value of video gaming, offering professionals valuable insight into its placement in the daily lives of young men with Duchenne Muscular Dystrophy.

Brief transdiagnostic group intervention for people living with HIV and emotional disorders: feasibility and clinical utility.

Emotional regulation-based transdiagnostic interventions provide positive but limited evidence regarding efficacy with people living with human immunodeficiency virus (HIV). In the present study, 10 participants living with HIV with emotional disorders completed a five-session transdiagnostic group intervention to improve their emotional regulation skills (Unified Protocol). Changes at pre-treatment, post-treatment and three-month follow-up were explored at the population (mean-rank) and the individual level (reliable change index). Compared to pre-treatment, participants improved significantly in anxiety, depression, negative affect and quality of life. Changes were maintained at the three-month follow-up. Emotion regulation, particularly the confusion factor, improved when comparing pre-treatment with the three-month follow-up. At the three-month follow-up, the percentage of normalized scores was the largest in maladjustment (70%), followed by depression, negative affect, and lack of control (50%). All participants indicated high treatment satisfaction and perceived benefits. These promising results suggest that brief emotion regulation interventions might be feasible and effective in the public health settings for people living with HIV suffering emotional disorders.

The Role of the JAK/STAT Signaling Pathway in the Pathogenesis of Alzheimer's Disease: New Potential Treatment Target.

Alzheimer's disease is characterized by the accumulation of amyloid plaques and neurofibrillary tangles in the brain. However, emerging evidence suggests that neuroinflammation, mediated notably by activated neuroglial cells, neutrophils, and macrophages, also plays an important role in the pathogenesis of Alzheimer's disease. Therefore, understanding the interplay between the nervous and immune systems might be the key to the prevention or delay of Alzheimer's disease progression. One of the most important mechanisms determining gliogenic cell fate is the Janus kinase/signal transducer and activator of transcription (JAK/STAT) signaling pathway that is influenced by the overactivation of microglia and astrocytes. The JAK/STAT signaling pathway is one of the critical factors that promote neuroinflammation in neurodegenerative diseases such as Alzheimer's disease by initiating innate immunity, orchestrating adaptive immune mechanisms, and finally, constraining neuroinflammatory response. Since a chronic neuroinflammatory environment in the brain is a hallmark of Alzheimer's disease, understanding the process would allow establishing the underlying role of neuroinflammation, then estimating the prognosis of Alzheimer's disease development and finding a new potential treatment target. In this review, we highlight the recent advances in the potential role of JAK/STAT signaling in neurological diseases with a focus on discussing future research directions regarding novel therapeutic approaches and predictive biomarkers for Alzheimer's disease.

Understanding Attachment, Emotional Regulation, and Childhood Adversity and Their Link to Chemsex.

Background: Although evidence shows that engaging in chemsex can be associated with poor mental health, little is known about the relationship between psychological factors and this type of drug use. We aim to explore associations between engagement in chemsex and several psychological variables (adverse life events, attachment styles, emotional regulation skills, self-care patterns) in a sample of gay, bisexual, and other men who have sex with men (GBMSM) with drug-related problems. Methods: A group of GBMSM engaged in chemsex (n = 41) and a control group of GBMSM (n = 39) completed an online survey to assess drug-related problems and the abovementioned psychological variables, in which both groups were compared. All analyses were adjusted for covariates showing significant differences between groups. Results: Compared to the control group, participants engaged in chemsex showed significantly higher frequencies of an avoidant-insecure attachment style and early adverse life events, regardless of all covariates (HIV status, job situation, and place of birth). Poorer emotional regulation and self-care patterns and a higher frequency of sexual abuse were also found in participants engaged in chemsex, though we cannot rule out the influence of HIV status on this second group of variables. Conclusions: Some people with drug-related problems engaged in chemsex might have suffered early adverse events and might have an avoidant-insecure attachment style. Moreover, those who have been diagnosed with HIV might show higher emotional dysregulation and poorer self-care patterns. These variables should be routinely evaluated in this population.

Developing a method to assess fidelity to a complex vocational rehabilitation intervention in the FRESH trial: a feasibility study.

BACKGROUND: Determining whether complex rehabilitation interventions are delivered with fidelity is important. Implementation fidelity can differ between sites, therapists delivering interventions and, over time, threatening trial outcomes and increasing the risk of type II and III errors. This study aimed to develop a method of assessing occupational therapists' fidelity to deliver a complex, individually tailored vocational rehabilitation (VR) intervention to people with traumatic brain injury (TBI) and assess the feasibility of its use in a randomised controlled trial. METHODS: Using mixed methods and drawing on the intervention logic model, we developed data collection tools to measure fidelity to early specialist TBI VR (ESTVR). Fidelity was measured quantitatively using intervention case report forms (CRF), fidelity checklists and clinical records. Qualitative data from mentoring records, interviews with intervention therapists, participants with TBI, employers and NHS staff at trial sites explored moderators of implementation fidelity. The conceptual framework of implementation fidelity (CFIF) guided measurement and analysis of and factors affecting fidelity. Data were triangulated and benchmarked against an earlier cohort study. RESULTS: Fidelity to a complex individually tailored VR intervention could be measured. Overall, OTs delivered ESTVR with fidelity. Different fidelity measures answered different questions, offering unique insights into fidelity. Fidelity was best assessed using a fidelity checklist, intervention CRFs and clinical notes. The OT clinical notes and mentoring records were best at identifying fidelity moderating factors. Interviews added little insight into fidelity moderating factors over and above mentoring or clinical records. Data triangulation offered a comprehensive assessment of fidelity, highlighting limitations of measurement methods and learning for future trials but was resource intensive. Interviews, fidelity visits and analysing clinical notes were also resource intense. Comparing fidelity data to a benchmark and using CFIF as a framework for organising the fidelity assessment helped. CONCLUSIONS: OTs delivered the VR intervention with fidelity. A fidelity checklist and benchmark plus mentoring may offer a practical and effective way of measuring fidelity and identifying fidelity moderating factors in trials of complex individually-tailored rehabilitation interventions. Mentoring provided real-time indicators of and reasons for fidelity deviations. These methods require further evaluation. TRIAL REGISTRATION: ISRCTN Registry, ISRCTN38581822 (Registered: 02/01/2014).

Critical thinking and diagnostic reasoning for advanced clinical practitioners in sexual health.

This article provides an overview of key areas within sexual health examination, diagnosis and treatment options for advanced clinical practitioners (ACPs) working outside this field of practice, who may not often encounter consultations of a sexual health nature. ACPs require an understanding of appropriate and necessary investigations, alongside specific advice or education they can offer patients. Within a sexual health context especially, the consultation and subsequent steps can be challenging and distressing for the patient, and the ACP must consider their knowledge and experience when caring for a patient in this area. Increasing knowledge and awareness of common conditions and treatments, red flags, and referral processes can allow the ACP to provide reassurance and support to the patient and improve their healthcare experience. Having answers to a patient's questions regarding processes and time frames can strengthen the relationship between the ACP and their patient and help reduce a patient's anxiety and fear of the unknown.

Arthroscopic hip surgery compared with personalised hip therapy in people over 16 years old with femoroacetabular impingement syndrome: UK FASHIoN RCT.

BACKGROUND: Femoroacetabular impingement syndrome is an important cause of hip pain in young adults. It can be treated by arthroscopic hip surgery or with physiotherapist-led conservative care. OBJECTIVE: To compare the clinical effectiveness and cost-effectiveness of hip arthroscopy with best conservative care. DESIGN: The UK FASHIoN (full trial of arthroscopic surgery for hip impingement compared with non-operative care) trial was a pragmatic, multicentre, randomised controlled trial that was carried out at 23 NHS hospitals. PARTICIPANTS: Participants were included if they had femoroacetabular impingement, were aged ≥ 16 years old, had hip pain with radiographic features of cam or pincer morphology (but no osteoarthritis) and were believed to be likely to benefit from hip arthroscopy. INTERVENTION: Participants were randomly allocated (1 : 1) to receive hip arthroscopy followed by postoperative physiotherapy, or personalised hip therapy (i.e. an individualised physiotherapist-led programme of conservative care). Randomisation was stratified by impingement type and recruiting centre using a central telephone randomisation service. Outcome assessment and analysis were masked. MAIN OUTCOME MEASURE: The primary outcome was hip-related quality of life, measured by the patient-reported International Hip Outcome Tool (iHOT-33) 12 months after randomisation, and analysed by intention to treat. RESULTS: Between July 2012 and July 2016, 648 eligible patients were identified and 348 participants were recruited. In total, 171 participants were allocated to receive hip arthroscopy and 177 participants were allocated to receive personalised hip therapy. Three further patients were excluded from the trial after randomisation because they did not meet the eligibility criteria. Follow-up at the primary outcome assessment was 92% (N = 319; hip arthroscopy, n = 157; personalised hip therapy, n = 162). At 12 months, mean International Hip Outcome Tool (iHOT-33) score had improved from 39.2 (standard deviation 20.9) points to 58.8 (standard deviation 27.2) points for participants in the hip arthroscopy group, and from 35.6 (standard deviation 18.2) points to 49.7 (standard deviation 25.5) points for participants in personalised hip therapy group. In the primary analysis, the mean difference in International Hip Outcome Tool scores, adjusted for impingement type, sex, baseline International Hip Outcome Tool score and centre, was 6.8 (95% confidence interval 1.7 to 12.0) points in favour of hip arthroscopy (p = 0.0093). This estimate of treatment effect exceeded the minimum clinically important difference (6.1 points). Five (83%) of six serious adverse events in the hip arthroscopy group were related to treatment and one serious adverse event in the personalised hip therapy group was not. Thirty-eight (24%) personalised hip therapy patients chose to have hip arthroscopy between 1 and 3 years after randomisation. Nineteen (12%) hip arthroscopy patients had a revision arthroscopy. Eleven (7%) personalised hip therapy patients and three (2%) hip arthroscopy patients had a hip replacement within 3 years. LIMITATIONS: Study participants and treating clinicians were not blinded to the intervention arm. Delays were encountered in participants accessing treatment, particularly surgery. Follow-up lasted for 3 years. CONCLUSION: Hip arthroscopy and personalised hip therapy both improved hip-related quality of life for patients with femoroacetabular impingement syndrome. Hip arthroscopy led to a greater improvement in quality of life than personalised hip therapy, and this difference was clinically significant at 12 months. This study does not demonstrate cost-effectiveness of hip arthroscopy compared with personalised hip therapy within the first 12 months. Further follow-up will reveal whether or not the clinical benefits of hip arthroscopy are maintained and whether or not it is cost-effective in the long term. TRIAL REGISTRATION: Current Controlled Trials ISRCTN64081839. FUNDING: This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 26, No. 16. See the NIHR Journals Library website for further project information.

In some people, the ball and the socket of the hip joint develop so that they do not fit together properly. This is called hip impingement, and is an important cause of hip and groin pain in young and middle-aged adults. Treatments include physiotherapy and surgery. Physiotherapy typically involves a programme of 6­10 outpatient consultations that aim to strengthen the muscles around the hip: we called this personalised hip therapy. Surgery can be carried out by a keyhole operation, called a hip arthroscopy, which aims to reshape the hip to prevent impingement. Surgery is normally followed by some physiotherapy. We performed a research study to compare the results of hip arthroscopy and personalised hip therapy in people with hip impingement. A total of 348 people with painful hip impingement in 23 hospitals in the UK agreed to take part. About half were treated with hip arthroscopy and half with personalised hip therapy. We used questionnaires to ask participants about pain in the hip and their ability to do everyday things at 6 months and 1 year after entering the study. At 2 and 3 years, we asked if patients required any additional treatments. We found that both groups improved, but those treated with hip arthroscopy improved a moderate amount more than those treated with personalised hip therapy. However, these improvements were not cost-effective compared with personalised hip therapy at 1 year. We need to see whether or not this difference continues after several years, but the results, so far, suggest that if a person has painful hip impingement, then hip arthroscopy offers greater improvements than personalised hip therapy.

Does daily wear time of Twin Block reliably predict its efficiency of class II treatment?

PURPOSE: The objective of this study was to investigate how daily wear time (DWT) influences class II malocclusion treatment efficiency. MATERIALS AND METHODS: The study group consisted of 55 patients (mean age 10.4 years) diagnosed with a class II/1 malocclusion. Twin block appliances, with built-in Theramon® microsensors (MC Technology, Hargelsberg, Austria) to monitor patients' cooperation (daily wear time assessment), were used for treatment. Cephalograms were taken and the following initial and final measurements were compared: Co-Gn, Co-Go, Co-Olp, Pg-Olp, WITS, SNA, SNB, ANB, Co-Go-Me, overjet, molar and canine relationships. The Shapiro-Wilk test, Wilcoxon signed-rank test, Student's t-test, Levene's test, Mann-Whitney U test, Kruskal-Wallis test, χ2 test, and Spearman's rank correlation coefficient with p < 0.05 set as the statistical significance level were used to determine the correlation of the outcomes with DWT; a ROC (receiver operating characteristic) curve was calculated to illustrate diagnostic ability of the binary classifier system. RESULTS: DWT was very highly positively correlated with change of the Pg-Olp parameter and highly with an improvement in the ANB, SNA, and SNB angles, an increase in the WITS parameter and an increase in Co-Gn distance. DWTs < 7.5 h correlated with significantly less improvement of the investigated variables. However, DWT > 7.5 h did not significantly correlate with the improvement of the overjet and most of the linear parameters in the mandible. The ROC curve and its AUC (area under curve) allowed the determination of a DWT of 7 h and 48 min to be capable of establishing a class I relationship with 83% probability. CONCLUSIONS: Class II treatment efficiency was influenced by DWT; an 8 h threshold value had an 83% probability of establishing a class I relationship.

Contrasting selection pressure on body and weapon size in a polygynous megaherbivore.

Sexual size dimorphism (SSD) is a common morphological trait in ungulates, with polygyny considered the leading driver of larger male body mass and weapon size. However, not all polygynous species exhibit SSD, while molecular evidence has revealed a more complex relationship between paternity and mating system than originally predicted. SSD is, therefore, likely to be shaped by a range of social, ecological and physiological factors. We present the first definitive analysis of SSD in the common hippopotamus (Hippopotamus amphibius) using a unique morphological dataset collected from 2994 aged individuals. The results confirm that hippos exhibit SSD, but the mean body mass differed by only 5% between the sexes, which is rather limited compared with many other polygynous ungulates. However, jaw and canine mass are significantly greater in males than females (44% and 81% heavier, respectively), highlighting the considerable selection pressure for acquiring larger weapons. A predominantly aquatic lifestyle coupled with the physiological limitations of their foregut fermenting morphology likely restricts body size differences between the sexes. Indeed, hippos appear to be a rare example among ungulates whereby sexual selection favours increased weapon size over body mass, underlining the important role that species-specific ecology and physiology have in shaping SSD.

Exploring Problematic Substance Use during Reentry from Prison to the Community: A Thematic Analysis.

The reentry process from prison to the community is rife with obstacles. Substance use problems, in particular, can present significant barriers to successful reentry. However, little research has examined the various roles that substance use plays during reentry from the perspective of those reentering the community. The current study explores reentry experiences of people who have been recently released from prison with a specific focus on their experiences with substance use during the reentry process. Using thematic analysis, the present study explored substance use experiences from 26 semi-structured interviews. Seven main themes emerged: recovery and sobriety, substance use programs, relapse, substance use exposure, triggers and other challenges, impact of incarceration on substance use, and reflections about substance use. Within each of these broad themes, additional subthemes emerged. Findings suggest complex histories of substance use spanning ecological contexts, including family, neighborhood, and corrections facilities as well as provide support for the pervasive and persistent nature of substance use among previously incarcerated individuals. Implications for practice and policy are discussed as well as potential future directions for research.

Beyond the binary: sexual health outcomes of transgender and non-binary service users of an online sexual health service.

Sexual health data on transgender and non-binary (TNB) people in the United Kingdom are limited. TNB individuals experience significant socioeconomic and stigma-related disadvantages. Sexual health morbidity and unmet need is likely to be significant. We compared the sexual health outcomes of TNB and cisgender users of London's online sexual health service. Of 119329 users that registered with the e-service between 30.4.19 and 31.12.19, 504 (0.42%) identified as TNB: 302 TNB users requested 463 kits. 78.4% (363/463) of kits were returned. 99.4% of dispatched kits included throat and rectal swabs for gonorrhoea and chlamydia testing. STI/HIV test positivity was: 5.5% syphilis, 4.8% chlamydia, 3.4% gonorrhoea and 0.7% HIV positive. HIV prevalence amongst TNB individuals was: 4.3%. 19.9% of TNB individuals engaged in chemsex, group sex, or fisting and were more likely to engage in sex work. 97.7% gave the service 4/5 or 5/5 star rating. We observed high positivity rates of HIV/STIs amongst TNB individuals and significant levels of high-risk sexual activity. Service users rated the service highly. Given TNB often have complex healthcare needs, some of which cannot be met entirely online, physical clinics must work collaboratively with e-services to support and protect this marginalised population.

Factors influencing an eruption of teeth associated with a dentigerous cyst: a systematic review and meta-analysis.

BACKGROUND: A dentigerous cyst (DC) is a pathology embracing the crown of an unerupted tooth at risk of malignant transformation. The causal tooth is usually removed together with the cyst. However, if there are orthodontic contraindications for extraction, two questions arise. (1) Which factors favor spontaneous eruption? (2) Which factors imply the necessity of applying orthodontic traction? This systematic review aimed to identify factors conducive/inconducive to the spontaneous eruption of teeth after dentigerous cyst marsupialization. METHODS: In accordance with the PRISMA guidelines, the main research question was defined in the PICO format (P: patients with dentigerous cysts; I: spontaneous tooth eruption after surgical DC treatment; C: lack of a spontaneous tooth eruption after surgical DC treatment; O: determining factors potentially influencing spontaneous tooth eruption). The MEDLINE, EMBASE, and Cochrane Central Register of Controlled Trials databases were searched for keywords combining dentigerous/odontogenic/follicular cysts with teeth and/or orthodontics, as well as human teeth and eruption patterns/intervals/periods/durations. The following data were extracted from the qualified articles (4 out of 3005 found initially): the rate of tooth eruption after surgical treatment of the cyst, the age and sex of the patients, the perpendicular projection distance between the top of the tooth cusp and the edge of the alveolar process, tooth angulation, the root formation stage, the cyst area, and the eruption space. The articles were subjected to risk of bias and quality analyses with the ROBINS-I protocol and the modified Newcastle-Ottawa QAS, respectively. Meta-analyses were performed with both fixed and random effects models. The GRADE approach was used to evaluate the quality of the evidence. The systematic review was registered in PROSPERO under ID CRD42020189044. RESULTS: Nearly 62% of DC-associated premolars erupted spontaneously after cyst marsupialization/decompression. Young age (mean = 10 years) and root formation not exceeding 1/2 of its fully developed length were the factors likely to favor spontaneous eruption. CONCLUSION: The small number of published studies, as well as their heterogeneity and the critical risk of bias, did not allow the creation of evidence-based protocols for managing teeth with DC after marsupialization. More high-quality research is needed to draw more reliable conclusions.

Modelling entanglement rates to estimate mortality of marine birds in British Columbia commercial salmon gillnet fisheries.

Incidental mortality of marine birds in fisheries is an international conservation concern, including in Canada where globally significant populations of vulnerable diving species overlap with coastal gillnet fisheries. In British Columbia (BC), commercial salmon gillnet fishing effort was historically very high (>200,000 days fished annually in the early 1950's), and although this fishery has declined, over 6,400 days were fished annually in the 2006-2016 decade. Observations of seabird bycatch within the commercial fishery, however, are limited in both scope (comprising <2% of cumulative effort 2001-2016) and in time (being available only from 1995 onwards and only for a small number of areas). Using onboard fishery observer data from commercial, test and experimental fisheries (1995-2016), we developed two models to estimate the number of marine birds captured per set in sockeye (Oncorhynchus nerka) and chum (O. keta) salmon gillnet fisheries employing a Generalized Linear Mixed Modeling (GLMM) approach in a hierarchical Bayesian framework, with observer data post-stratified by fisheries management area and year. Using estimates of total commercial fishing effort (estimated number of sets, 2001-2016) we applied the models to extrapolate annual take for the main bird species (or groups) of interest. Multinomial probability estimates of species composition were calculated based upon a sample of 852 birds identified to species that were associated with sockeye or chum fisheries, enabling estimates (with CIs) of potential numbers of the mostly commonly observed species (common murres (Uria aalge), rhinoceros auklets (Cerorhinca monocerata), and marbled murrelets (Brachyramphus marmoratus)) entangled annually in commercial sockeye and chum salmon gillnet fisheries throughout BC. Conservative estimates of annual losses to entanglement were greatest for common murres (2,846, 95% CI: 2,628-3,047), followed by rhinoceros auklets (641, CI: 549-770) and marbled murrelets (228 CI: 156-346). Populations of all three of these alcids species are currently in decline in BC and entanglement mortality is a conservation concern. Gillnet mortality has been identified as a longstanding threat to marbled murrelet populations, which are recognized as Threatened in the Canada and the United States of America (USA). In addition, 622 (CI: 458-827) birds from 12 other species were estimated to be entangled annually. We conclude that cumulative mortality from incidental take in salmon gillnet fisheries is one of the largest sources of human-induced mortality for marine birds in BC waters, a conservation concern impacting both breeders and visiting migrants.