Community based complex interventions to sustain independence in older people: systematic review and network meta-analysis.

OBJECTIVE: To synthesise evidence of the effectiveness of community based complex interventions, grouped according to their intervention components, to sustain independence for older people. DESIGN: Systematic review and network meta-analysis. DATA SOURCES: Medline, Embase, CINAHL, PsycINFO, CENTRAL, clinicaltrials.gov, and International Clinical Trials Registry Platform from inception to 9 August 2021 and reference lists of included studies. ELIGIBILITY CRITERIA: Randomised controlled trials or cluster randomised controlled trials with ≥24 weeks' follow-up studying community based complex interventions for sustaining independence in older people (mean age ≥65 years) living at home, with usual care, placebo, or another complex intervention as comparators. MAIN OUTCOMES: Living at home, activities of daily living (personal/instrumental), care home placement, and service/economic outcomes at 12 months. DATA SYNTHESIS: Interventions were grouped according to a specifically developed typology. Random effects network meta-analysis estimated comparative effects; Cochrane's revised tool (RoB 2) structured risk of bias assessment. Grading of recommendations assessment, development and evaluation (GRADE) network meta-analysis structured certainty assessment. RESULTS: The review included 129 studies (74 946 participants). Nineteen intervention components, including "multifactorial action from individualised care planning" (a process of multidomain assessment and management leading to tailored actions), were identified in 63 combinations. For living at home, compared with no intervention/placebo, evidence favoured multifactorial action from individualised care planning including medication review and regular follow-ups (routine review) (odds ratio 1.22, 95% confidence interval 0.93 to 1.59; moderate certainty); multifactorial action from individualised care planning including medication review without regular follow-ups (2.55, 0.61 to 10.60; low certainty); combined cognitive training, medication review, nutritional support, and exercise (1.93, 0.79 to 4.77; low certainty); and combined activities of daily living training, nutritional support, and exercise (1.79, 0.67 to 4.76; low certainty). Risk screening or the addition of education and self-management strategies to multifactorial action from individualised care planning and routine review with medication review may reduce odds of living at home. For instrumental activities of daily living, evidence favoured multifactorial action from individualised care planning and routine review with medication review (standardised mean difference 0.11, 95% confidence interval 0.00 to 0.21; moderate certainty). Two interventions may reduce instrumental activities of daily living: combined activities of daily living training, aids, and exercise; and combined activities of daily living training, aids, education, exercise, and multifactorial action from individualised care planning and routine review with medication review and self-management strategies. For personal activities of daily living, evidence favoured combined exercise, multifactorial action from individualised care planning, and routine review with medication review and self-management strategies (0.16, -0.51 to 0.82; low certainty). For homecare recipients, evidence favoured addition of multifactorial action from individualised care planning and routine review with medication review (0.60, 0.32 to 0.88; low certainty). High risk of bias and imprecise estimates meant that most evidence was low or very low certainty. Few studies contributed to each comparison, impeding evaluation of inconsistency and frailty. CONCLUSIONS: The intervention most likely to sustain independence is individualised care planning including medicines optimisation and regular follow-up reviews resulting in multifactorial action. Homecare recipients may particularly benefit from this intervention. Unexpectedly, some combinations may reduce independence. Further research is needed to investigate which combinations of interventions work best for different participants and contexts. REGISTRATION: PROSPERO CRD42019162195.

A sensitive method to determine 210Po and 210Pb in environmental samples by alpha spectrometry using CuS micro-precipitation.

A new sensitive method to determine polonium-210 (210Po) and lead-210 (210Pb) in a diversity of environmental samples was developed. For fresh and marine waters, Po was pre-concentrated using a titanium (III) hydroxide (Ti(OH)3) co-precipitation. Solid environmental samples were digested with nitric acid (HNO3) and hydrogen peroxide (H2O2). The alpha thin layer source was prepared using CuS micro-precipitation and 210Po was measured by alpha spectrometry. Lead-210 was left to decay for up to a year and indirectly measured via its progeny, 210Po. The chemical recoveries for 210Po and 210Pb were high, 90% and 97%, respectively, for a large variety of samples and a very low minimum detectable activity (MDA) was obtained. The method was validated using standardized solutions and certified reference materials.

What works in advocating for food advertising policy change across an english region - a realist evaluation.

BACKGROUND: With increasing recognition of the role of commercial determinants of health, local areas in England have sought to restrict the advertising of products high in fat, salt and sugar (HFSS) on council-owned spaces, as part of wider strategies to reduce obesity. While there is some evidence of the impact of such policy change on behaviour, little is known about what works in the process of implementing this policy change. METHODS: Guided by a realist evaluation framework that explores the interaction between context, mechanism and outcomes, this study aims to investigate the factors that influence the restriction of outdoor advertising of HFSS products in one region in England. It refines a programme theory co-produced with stakeholders from 14 local authorities within a region and uses multiple data sources from each area with an in-depth examination of four case study sites. Data sources include longitudinal realist interviews, focus groups and surveys with policy advocates and policy stakeholders. Data were analysed retroductively to understand the causal link between context, mechanism and outcomes. RESULTS: Outcomes were driven by five dominant mechanisms: a strategic and staggered approach to stakeholder engagement, gathering intelligence, identifying policy champions, building relationships, reframing the issue; and two secondary mechanisms of amplifying the issue and increasing public will. These led to varied outcomes with no changes in formal policy position within the evaluation period but draft policy guidance in place and changes in political will demonstrated. Dominant context factors influencing change included having a named and resourced policy advocate in place supported by an external Community of Improvement and having existing aligned local objectives. Organisational complexity and change, financial concerns, lack of local examples, ideological positions and the pandemic were also influencing contextual factors. CONCLUSION: Effecting policy change in this area requires the commitment of an extended period and the valuing of short-term policy outcomes, such as increasing political will. The importance of a resourced and well-supported policy advocate to lead this work is fundamental and the commercially sensitive nature of this policy change means that a complex interplay of mechanisms is required which may be dominated by a strategically staggered approach to stakeholder engagement.

Plasticity is a locally adapted trait with consequences for ecological dynamics in novel environments.

Phenotypic plasticity is predicted to evolve in more variable environments, conferring an advantage on individual lifetime fitness. It is less clear what the potential consequences of that plasticity will have on ecological population dynamics. Here, we use an invertebrate model system to examine the effects of environmental variation (resource availability) on the evolution of phenotypic plasticity in two life history traits-age and size at maturation-in long-running, experimental density-dependent environments. Specifically, we then explore the feedback from evolution of life history plasticity to subsequent ecological dynamics in novel conditions. Plasticity in both traits initially declined in all microcosm environments, but then evolved increased plasticity for age-at-maturation, significantly so in more environmentally variable environments. We also demonstrate how plasticity affects ecological dynamics by creating founder populations of different plastic phenotypes into new microcosms that had either familiar or novel environments. Populations originating from periodically variable environments that had evolved greatest plasticity had lowest variability in population size when introduced to novel environments than those from constant or random environments. This suggests that while plasticity may be costly it can confer benefits by reducing the likelihood that offspring will experience low survival through competitive bottlenecks in variable environments. In this study, we demonstrate how plasticity evolves in response to environmental variation and can alter population dynamics-demonstrating an eco-evolutionary feedback loop in a complex animal moderated by plasticity in growth.

Matrix-trapped viruses can prevent invasion of bacterial biofilms by colonizing cells.

Bacteriophages can be trapped in the matrix of bacterial biofilms, such that the cells inside them are protected. It is not known whether these phages are still infectious and whether they pose a threat to newly arriving bacteria. Here, we address these questions using Escherichia coli and its lytic phage T7. Prior work has demonstrated that T7 phages are bound in the outermost curli polymer layers of the E. coli biofilm matrix. We show that these phages do remain viable and can kill colonizing cells that are T7-susceptible. If cells colonize a resident biofilm before phages do, we find that they can still be killed by phage exposure if it occurs soon thereafter. However, if colonizing cells are present on the biofilm long enough before phage exposure, they gain phage protection via envelopment within curli-producing clusters of the resident biofilm cells.

Methodological advances for hypothesis-driven ethnobiology.

Ethnobiology as a discipline has evolved increasingly to embrace theory-inspired and hypothesis-driven approaches to study why and how local people choose plants and animals they interact with and use for their livelihood. However, testing complex hypotheses or a network of ethnobiological hypotheses is challenging, particularly for data sets with non-independent observations due to species phylogenetic relatedness or socio-relational links between participants. Further, to account fully for the dynamics of local ecological knowledge, it is important to include the spatially explicit distribution of knowledge, changes in knowledge, and knowledge transmission and use. To promote the use of advanced statistical modelling approaches that address these limitations, we synthesize methodological advances for hypothesis-driven research in ethnobiology while highlighting the need for more figures than tables and more tables than text in ethnobiological literature. We present the ethnobiological motivations for conducting generalized linear mixed-effect modelling, structural equation modelling, phylogenetic generalized least squares, social network analysis, species distribution modelling, and predictive modelling. For each element of the proposed ethnobiologists quantitative toolbox, we present practical applications along with scripts for a widespread implementation. Because these statistical modelling approaches are rarely taught in most ethnobiological programs but are essential for careers in academia or industry, it is critical to promote workshops and short courses focused on these advanced methods. By embracing these quantitative modelling techniques without sacrificing qualitative approaches which provide essential context, ethnobiology will progress further towards an expansive interaction with other disciplines.

Prestige and homophily predict network structure for social learning of medicinal plant knowledge.

Human subsistence societies have thrived in environmental extremes while maintaining biodiversity through social learning of ecological knowledge, such as techniques to prepare food and medicine from local resources. However, there is limited understanding of which processes shape social learning patterns and configuration in ecological knowledge networks, or how these processes apply to resource management and biological conservation. In this study, we test the hypothesis that the prestige (rarity or exclusivity) of knowledge shapes social learning networks. In addition, we test whether people tend to select who to learn from based on prestige (knowledge or reputation), and homophily (e.g., people of the same age or gender). We used interviews to assess five types of medicinal plant knowledge and how 303 people share this knowledge across four villages in Solomon Islands. We developed exponential random graph models (ERGMs) to test whether hypothesized patterns of knowledge sharing based on prestige and homophily are more common in the observed network than in randomly simulated networks of the same size. We found that prestige predicts five hypothesized network configurations and all three hypothesized learning patterns, while homophily predicts one of three hypothesized network configurations and five of the seven hypothesized learning patterns. These results compare the strength of different prestige and homophily effects on social learning and show how cultural practices such as intermarriage can affect certain aspects of prestige and homophily. By advancing our understanding of how prestige and homophily affect ecological knowledge networks, we identify which social learning patterns have the largest effects on biocultural conservation of ecological knowledge.

Biofilm Structure Promotes Coexistence of Phage-Resistant and Phage-Susceptible Bacteria.

Encounters among bacteria and their viral predators (bacteriophages) are among the most common ecological interactions on Earth. These encounters are likely to occur with regularity inside surface-bound communities that microbes most often occupy in natural environments. Such communities, termed biofilms, are spatially constrained: interactions become limited to near neighbors, diffusion of solutes and particulates can be reduced, and there is pronounced heterogeneity in nutrient access and physiological state. It is appreciated from prior theoretical work that phage-bacteria interactions are fundamentally different in spatially structured contexts, as opposed to well-mixed liquid culture. Spatially structured communities are predicted to promote the protection of susceptible host cells from phage exposure, and thus weaken selection for phage resistance. The details and generality of this prediction in realistic biofilm environments, however, are not known. Here, we explore phage-host interactions using experiments and simulations that are tuned to represent the essential elements of biofilm communities. Our simulations show that in biofilms, phage-resistant cells-as their relative abundance increases-can protect clusters of susceptible cells from phage exposure, promoting the coexistence of susceptible and phage-resistant bacteria under a large array of conditions. We characterize the population dynamics underlying this coexistence, and we show that coexistence is recapitulated in an experimental model of biofilm growth measured with confocal microscopy. Our results provide a clear view into the dynamics of phage resistance in biofilms with single-cell resolution of the underlying cell-virion interactions, linking the predictions of canonical theory to realistic models and in vitro experiments of biofilm growth.IMPORTANCE In the natural environment, bacteria most often live in communities bound to one another by secreted adhesives. These communities, or biofilms, play a central role in biogeochemical cycling, microbiome functioning, wastewater treatment, and disease. Wherever there are bacteria, there are also viruses that attack them, called phages. Interactions between bacteria and phages are likely to occur ubiquitously in biofilms. We show here, using simulations and experiments, that biofilms will in most conditions allow phage-susceptible bacteria to be protected from phage exposure, if they are growing alongside other cells that are phage resistant. This result has implications for the fundamental ecology of phage-bacteria interactions, as well as the development of phage-based antimicrobial therapeutics.

Sr-90 soil to plant transfer factor reduction using calcium and polymer soil amendments.

Introducing calcium into soils can inhibit Sr-90 uptake by plants. To test the efficacy of calcium amendments on the inhibition of Sr-90 uptake by edible plants, a number of different calcium applications, including calcium nitrate, calcium thiosulfate and a mixture of both liquid solutions, were used in this study. Pea plants (Pisum sativum 'Sabre') grown in Sr-90 contaminated soil from seeds to maturity were watered with these calcium solutions. Two different polymers, one inert and one nutrient enriched, were incorporated into the contaminated soil where pea seeds were sowed to ascertain a continuous supply of calcium and essential nutrients. Results show that the heterogeneity of Sr-90 distribution in soil translated to disparate Sr-90 contents in plant tissues. However, on average, irrigation with calcium solutions in conjunction with the usage of polymers consistently yielded a reduction in Sr-90 uptake by the plants. The lowest soil-to-plant transfer factor (TF) values were measured in the edible pea part of the plant, followed by the flowers, roots, stems, pea shells and then leaves. TF values for pea shells were between 4.9 and 20.9, and between 0.3 and 2.8 for the peas. Results do not allow the identification of one particular chemical solution that would systematically be the best choice to minimize Sr-90 uptake.

Topical Delivery of Lactobacillus Culture Supernatant Increases Survival and Wound Resolution in Traumatic Acinetobacter baumannii Infections.

Species of Lactobacillus have been proposed as potential candidates for treating wound infections due to their ability to lower pH, decrease inflammation, and release antimicrobial compounds. This study investigated the impact of lactobacilli (Lactobacillus acidophilus ATCC 4356, Lactobacillus casei ATCC 393, Lactobacillus reuteri ATCC 23272) secreted products on wound pathogens in vitro and in a murine wound infection model. Evaluation of 1-5 day lactobacilli conditioned media (CM) revealed maximal inhibition against wound pathogens using the 5-day CM. The minimum inhibitory concentration (MIC) of 5-day Lactobacillus CMs was tested by diluting CM in Mueller-Hinton (MH) broth from 0 to 25% and was found to be 12.5% for A. baumannii. Concentrating the CM to 10× with a 3 kDa centrifuge filter decreased the CM MIC to 6.25-12.5% for A. baumannii planktonic cells. Minimal impact of 5-day CMs was observed against bacterial biofilms. No toxicity was observed when these Lactobacillus CMs were injected into Galleria melonella waxworms. For the murine A. baumannii wound infection studies, improved survival was observed following topical treatment with L. acidophilus ATCC 4356 or L. reuteri ATCC 23272, while L. reuteri ATCC 23272 treatment alone improved wound resolution. Overall, this study suggests that the topical application of certain Lactobacillus species byproducts could be effective against gram-negative multi-drug resistant (MDR) wound pathogens, such as A. baumannii.

Intergenerational effects of CO2-induced stream acidification in the Trinidadian guppy (Poecilia reticulata).

Rising atmospheric carbon dioxide levels are driving decreases in aquatic pH. As a result, there has been a surge in the number of studies examining the impact of acidification on aquatic fauna over the past decade. Thus far, both positive and negative impacts on the growth of fish have been reported, creating a disparity in results. Food availability and single-generation exposure have been proposed as some of the reasons for these variable results, where unrealistically high food treatments lead to fish overcoming the energetic costs associated with acclimating to decreased pH. Likewise, exposure of fish to lower pH for only one generation may not capture the likely ecological response to acidification that wild populations might experience over two or more generations. Here we compare somatic growth rates of laboratory populations of the Trinidadian guppy (Poecilia reticulata) exposed to pH levels that represent the average and lowest levels observed in streams in its native range. Specifically, we test the role of maternal acclimation and resource availability on the response of freshwater fishes to acidification. Acidification had a negative impact on growth at more natural, low food treatments. With high food availability, fish whose mothers were acclimated to the acidified treatment showed no reduction in growth, compared to controls. Compensatory growth was observed in both control-acidified (maternal-natal environment) and acidified-control groups, where fish that did not experience intergenerational effects achieved the same size in response to acidification as those that did, after an initial period of stunted growth. These results suggest that future studies on the effects of shifting mean of aquatic pH on fishes should take account of intergenerational effects and compensatory growth, as otherwise effects of acidification may be overestimated.

Fungal biofilm morphology impacts hypoxia fitness and disease progression.

Microbial populations form intricate macroscopic colonies with diverse morphologies whose functions remain to be fully understood. Despite fungal colonies isolated from environmental and clinical samples revealing abundant intraspecies morphological diversity, it is unclear how this diversity affects fungal fitness and disease progression. Here we observe a notable effect of oxygen tension on the macroscopic and biofilm morphotypes of the human fungal pathogen Aspergillus fumigatus. A hypoxia-typic morphotype is generated through the expression of a subtelomeric gene cluster containing genes that alter the hyphal surface and perturb interhyphal interactions to disrupt in vivo biofilm and infection site morphologies. Consequently, this morphotype leads to increased host inflammation, rapid disease progression and mortality in a murine model of invasive aspergillosis. Taken together, these data suggest that filamentous fungal biofilm morphology affects fungal-host interactions and should be taken into consideration when assessing virulence and host disease progression of an isolated strain.

Permafrost thaw and implications for the fate and transport of tritium in the Canadian north.

Layers of permafrost developed during the 1950s and 1960s incorporated tritium from the atmosphere that originated from global nuclear weapons testing. In regions underlain by substantial permafrost, this tritium has been effectively trapped in ice since it was deposited and subject to radioactive decay alone, which has substantially lengthened its environmental half-life compared to areas with little or no permafrost where the weapons-test era precipitation has been subject to both decay and hydrodynamic dispersion. The Arctic is warming three times faster than other parts of the world, with northern regions incurring some of the most pronounced effects of climate change, resulting in permafrost degradation. A series of 23 waterbodies across the Canadian sub-Arctic spanning the continuous, discontinuous and isolated patches permafrost zones in northern Manitoba, Northwest Territories and Labrador were sampled. Surface water and groundwater seepage samples were collected from each lake and analyzed for tritium, stable isotopes (δ18O and δ2H) and general water chemistry characteristics. Measured tritium was significantly higher in surface waters (SW) and groundwater seepage (GW) in water bodies located in the sporadic discontinuous (64 ±â€¯15 T U. in SW and 52 ±â€¯9 T U. in GW) and extensive discontinuous (53 ±â€¯7 T U. in SW and 61 ±â€¯7 T U. in GW) permafrost regions of the Northwest Territories than in regions underlain by continuous permafrost in northern Manitoba (<12 T U. in both SW and GW) or those within isolated patches of permafrost in Labrador (16 ±â€¯2 T U. in SW and 21 ±â€¯4 T U. in GW). The greatest tritium enrichment (up to 128 T U.) was observed in lakes near Jean Marie River in the Mackenzie River valley, a region known to be experiencing extensive permafrost degradation. These results demonstrate significant permafrost degradation in the central Mackenzie River basin and show that tritium is becoming increasingly mobile in the sub-Arctic environment-at concentrations higher than expected-as a result of a warming climate. A better understanding of the cycling of tritium in the environment will improve our understanding of Arctic radioecology under changing environmental conditions.

The political mobilization of corporate directors: socio-economic correlates of affiliation to European pressure groups.

Business has played a central role in the debate over Britain's place in the European Union. This paper examines the socio-economic characteristics of directors of Britain's largest corporations who affiliated either to Business for Sterling or Britain in Europe. It reports associations between directors' social backgrounds and their probabilities of affiliation. Elite university education, club membership, wealth and multiple directorships were all associated with higher propensities to affiliate. The associations are consistent with the idea that directors' social resources allow them to overcome collective action problems as well as supplying them with the motivations to affiliate. They also indicated that directors form a privileged group in that they have a number of very powerful actors who can take unilateral political actions.

Social influences on corporate political donations in Britain.

It is argued that institutional features of the British state create collective action problems for the mobilization of corporations as donors to the Conservative Party. Social factors are necessary for overcoming these problems. Using social network analyses, the effect that interlocking directorates have on 250 large British corporations' decisions to donate are analysed. Instead of the central mobilizing factor being diffuse inner circle mechanisms positively influencing the decision to make a donation, the results show that more particularistic mechanisms such as information bias and control are equally important.

Foundation trusts. Hitting the big time.

Foundation trusts offer the potential for substantial local autonomy. Their governance arrangements raise concerns. Lay non-executives in primary care trusts will face difficulties holding hospitals to account.

Does ageism affect the management of ischaemic heart disease?

OBJECTIVES: To analyse access by age to exercise testing, coronary angiography, revascularisation (percutaneous transluminal coronary angioplasty/stent insertion and coronary artery bypass graft surgery) and receipt of thrombolysis, where indicated, for hospital patients with diagnosed cardiovascular disease. METHOD: Retrospective case note analysis, tracking each case backwards and forwards by 12 months from the patient's date of entry to the study. The setting was a district hospital in the eastern part of outer London. The case notes eligible for inclusion were those of elective and emergency in-patients with an in-patient ICD-10 code of ischaemic heart disease, angina pectoris or acute myocardial infarction and a consecutive 20% sample of new cardiac outpatients with these diagnoses. RESULTS: Analysis of 712 case notes showed that older hospital patients with ischaemic heart disease, and with indications for further investigation, were less likely than younger people to be referred for exercise tolerance tests and cardiac catheterisation and angiography. This was independent of both gender and severity of condition. Older patients did not appear to be discriminated against in relation to receipt of indicated treatments (revascularisation or thrombolysis), although, in the case of revascularisation, older patients were more likely to have been filtered out at the investigation stage (catheterisation and angiography), so selection bias partly explains this finding. CONCLUSIONS: The current findings from a single hospital are comparable with the results from a broader study of equity of access by age to cardiological interventions in another district hospital in the same region. Although only two hospitals were analysed, the similarity of findings enhances the generalisability of the results presented here. It appears that age per se causes older cardiac hospital patients to be treated differently.

Primary care trusts. Nurture not nature.

Primary care groups had few precedents in the NHS, but their introduction was met with little political hostility. It is difficult to discern PCG/Ts' achievements. The record on commissioning and health improvement is poor. They have not exploited their potential to change the whole NHS.

Age- and sex-related bias in the management of heart disease in a district general hospital.

OBJECTIVE: To investigate the clinical management of heart disease and determine whether there was age- and sex-related bias in the use of investigations and interventions. DESIGN: Retrospective analysis of individual patient records against criteria of appropriateness based on published guidelines, clinical practice and literature relevant to the 1996-7 study period. SETTING: A single, district general hospital in London, serving a population of 185,000 people. SUBJECTS: General medical, elderly medical, and cardiology inpatients and patients attending elderly medical and cardiology outpatient clinics as new referrals between 1 April 1996 and 31 March 1997. RESULTS: We located case notes of 1790 of the 1975 subjects eligible for the study: 911 (51%) were outpatients and 51% were men. Patients aged <75 were significantly more likely than patients aged >or=75 years to be given thrombolysis after an acute myocardial infarction, to be given secondary prevention with aspirin and beta-blockers, to undergo exercise testing and coronary angiography, and to receive an echocardiogram. Men were also significantly more likely than women to have these investigations and interventions as well as to receive an angiotensin-converting enzyme inhibitor when left ventricular dysfunction was identified. Investigations and interventions were underused at all ages. CONCLUSION: As well as identifying age and sex bias, we found the underuse of investigations and interventions in all age groups in this district general hospital. Should similar patterns of care be found elsewhere, the delivery of high-quality care in an equitable manner (as identified by the National Service Framework for coronary heart disease) may require considerably more resources than have been allocated.