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Increasing water scarcity causes a variety of pressures on agricultural production given current and growing food demands. This paper seeks to add to our understanding of water scarcity adaptations by explicitly addressing linkages between water scarcity, water productivity, cropping choices, and farm labor. We challenge the widespread claim that tightening foreign (especially Mexican) labor supply will necessarily result in less labor-intensive crop choices. Instead, by linking water scarcity and farm labor through the lens of water productivity we illustrate scenarios under which climate and technological change result in greater future labor demand in agriculture, including temporary and seasonal workers, largely due to water productivity increases resulting from switching to more labor-intensive crops. We conclude that a focus on crop choices is central to understanding changes in water productivity, labor demand, and technological innovations in response to water scarcity.

Microsurgery serves as the foundation for numerous operative procedures. Given its highly technical nature, the assessment of surgical skill becomes an essential component of clinical practice and microsurgery education. The interaction forces between surgical tools and tissues play a pivotal role in surgical success, making them a valuable indicator of surgical skill. In this study, we employ six distinct deep learning architectures (LSTM, GRU, Bi-LSTM, CLDNN, TCN, Transformer) specifically designed for the classification of surgical skill levels. We use force data obtained from a novel sensorized surgical glove utilized during a microsurgical task. To enhance the performance of our models, we propose six data augmentation techniques. The proposed frameworks are accompanied by a comprehensive analysis, both quantitative and qualitative, including experiments conducted with two cross-validation schemes and interpretable visualizations of the network’s decision-making process. Our experimental results show that CLDNN and TCN are the top-performing models, achieving impressive accuracy rates of 96.16% and 97.45%, respectively. This not only underscores the effectiveness of our proposed architectures, but also serves as compelling evidence that the force data obtained through the sensorized surgical glove contains valuable information regarding surgical skill.

ObjectivesTo identify factors and contexts that may contribute to mental health and recovery from psychological difficulties for emergency service workers (ESWs) exposed to occupational trauma, and barriers and facilitators to help-seeking behaviour among trauma-exposed ESWs.BackgroundESWs are at greater risk of stressor-related psychopathology than the general population. Exposure to occupational stressors and trauma contribute to the observed rates of post-trauma psychopathology in this occupational group with implications for workforce sustainability. Types of organisational interventions offered to trauma-exposed ESWs are inconsistent across the UK, with uncertainty around how to engage staff.DesignFour databases (OVID MEDLINE, EMBASE, PsycINFO and SCOPUS) were systematically searched from 1 January 1980 to March 2020, with citation tracking and reference chaining. A modified Critical Appraisal Skills Programme tool and quality appraisal prompts were used to identify fatally flawed studies. Qualitative studies of trauma-exposure in front-line ESWs were included, and data were extracted using a customised extraction table. Included studies were analysed using thematic synthesis.ResultsA qualitative evidence synthesis was conducted with 24 qualitative studies meeting inclusion criteria, as defined by the PerSPEcTiF framework. Fourteen descriptive themes emerged from this review, categorised into two overarching constructs: (1) factors contributing to mental health (such as the need for downtime, peer support and reassurance) and (2) factors influencing help-seeking behaviour (such as stigma, the content/form/mandatory nature of interventions, and mental health literacy issues including emotional awareness and education).ConclusionESWs reported disconnect between the organisations’ cultural positioning on trauma-related mental health, the reality of undertaking the role and the perceived applicability and usefulness of trauma interventions. Following traumatic exposure, ESWs identify benefitting from recovery time and informal support from trusted colleagues. A culture which encourages help seeking and open dialogue around mental health may reduce stigma and improve recovery from mental ill health associated with trauma exposure.

Background Major trauma places substantial demand on critical care services, is a leading cause of death in under 40-year-olds and causes significant morbidity and mortality across all age groups. Various factors influence patient outcome and predefining these could allow prognostication. The aim of this study was to identify predictors of mortality from major trauma in intensive care. Methods This was a retrospective study of adult trauma patients admitted to general intensive care between January 2018 and December 2019. We assessed the impact on mortality of patient demographics, patterns of injury, injury scores (Glasgow Coma Score (GCS), Charlson's comorbidity index (CCI), Acute Physiology and Health Evaluation II (APACHE II), Injury Severity Score (ISS) and Probability of Survival Score (Ps19)), number of surgeries and mechanism of injury using logistic regression. Results A total of 414 patients were included with a median age of 54 years (IQR 34-72). Overall mortality was 18.6%. The most common mechanism of injury was traffic collision (46%). Non-survivors were older, had higher ISS scores with lower GCS on admission and lower probability of survival scores. Factors independently predictive of mortality were age 70-80 (OR 3.267, p = 0.029), age >80 (OR 27.043, p < 0.001) and GCS < 15 (OR 8.728, p < 0.001). Ps19 was the best predictor of mortality (p <0.001 for each score category), with an AUROC of 0.90. Conclusions The significant mortality predictors were age, fall from <2 metres, injury of head or limbs, GCS <15 and Ps19. Contrary to previous studies, CCI and APACHE II did not significantly predict mortality. Although Ps19 was found to be the best current prognostic score, trauma prognostication would benefit from a single validated scoring system incorporating both physiological variables and injury patterns.

ObjectiveTo explore what factors are associated with ambulance use for non-emergency problems in children.MethodsThis study is a systematic mapping review and qualitative synthesis of published journal articles and grey literature. Searches were conducted on the following databases, for articles published between January 1980 and July 2020: MEDLINE, EMBASE, PsycINFO, CINAHL and AMED. A Google Scholar and a Web of Science search were undertaken to identify reports or proceedings not indexed in the above. Book chapters and theses were searched via the OpenSigle, EThOS and DART databases. A literature advisory group, including experts in the field, were contacted for relevant grey literature and unpublished reports. The inclusion criteria incorporated articles published in the English language reporting findings for the reasons behind why there are so many calls to the ambulance service for non-urgent problems in children. Data extraction was divided into two stages: extraction of data to generate a broad systematic literature ‘map’, and extraction of data from highly relevant papers using qualitative methods to undertake a focused qualitative synthesis. An initial table of themes associated with reasons for non-emergency calls to the ambulance for children formed the ‘thematic map’ element. The uniting feature running through all of the identified themes was the determination of ‘inappropriateness’ or ‘appropriateness’ of an ambulance call out, which was then adopted as the concept of focus for our qualitative synthesis.ResultsThere were 27 articles used in the systematic mapping review and 17 in the qualitative synthesis stage of the review. Four themes were developed in the systematic mapping stage: socioeconomic status/geographical location, practical reasons, fear of consequences and parental education. Three analytical themes were developed in the qualitative synthesis stage including practicalities and logistics of obtaining care, arbitrary scoring system and retrospection.ConclusionsThere is a lack of public and caregiver understanding about the use of ambulances for paediatrics. There are factors that appear specific to choosing ambulance care for children that are not so prominent in adults (fever, reassurance, fear of consequences). Future areas for attention to decrease ambulance activation for paediatric low-acuity reports were highlighted as: identifying strategies for helping caregivers to mitigate perceived risk, increasing availability of primary care, targeted education to particular geographical areas, education to first-time parents with infants and providing alternate means of transportation.PROSPERO registration numberCRD42019160395.

Abstract INTRODUCTION Mild Traumatic Brain Injury (MTBI) is often treated as a homogenous group in current practice. Stratifying patients more accurately may result in the implementation of more effective, individualized treatment. We aimed to identify prognostic indicators of recovery 1-yr following MTBI. METHODS Using a prospective, observational study design, a large MTBI population (N = 596) was recruited following admission to the Emergency Department. Data was collected at brain injury clinics between August 2011 and July 2015. Functional recovery at 1-yr was assessed using the Glasgow Outcome Scale-Extended (GOSE). RESULTS A follow-up rate of 92% was achieved. The most common aetiologies of MTBI were falls (n = 222) and road traffic collisions (n = 154). Distribution of Glasgow Coma Scale (GCS) was 15 (n = 363), 14 (n = 156) and 13 (n = 77). Multiordinal logistic regression of the GOSE found that psychiatric history (P < .001), alcohol intoxication (P = .011), assault (P = .022) and GCS <15 (P = < .001), led to worse outcome. An abnormal CT scan was not a predictor of functional recovery. CONCLUSION Our findings indicate that after MTBI, patients with previous psychiatric history, GCS <15, aetiology of assault and alcohol intoxication result in worse long-term outcomes. Future work into developing a full prognostic model for MTBI may help to tailor individual treatment and improve long-term outcomes.

ObjectiveThis study aims to develop a comprehensive process map for patients with brain tumours to identify opportunities for quality improvement and automated data collection. Through optimising workflows, the overall goal is to improve patient recruitment to clinical trials.DesignA two-stage mixed methods design, combining qualitative development of a process map with quantitative validation using electronic health records (EHR). Following this, a cross-sectional survey was conducted to assess how patients learn about clinical trials.SettingA single neurosurgery centre in the United Kingdom.ParticipantsThe process map was developed through stakeholder interviews with neuro-oncology multidisciplinary team members and patients (n=13). Clinical encounters were validated with EHR data from 50 patients. A cross-sectional survey presented the validated process map to 25 postoperative patients to identify the resources they used to learn about ongoing clinical trials.InterventionsPostoperative questionnaires were given to patients after brain tumour surgery, either on the ward or in follow-up clinic.Primary and secondary outcome measuresThe primary outcome was the percentage of the study cohort that was present at encounters on the process map. Key timepoints were defined if >80% of patients were present. They represent high-yield opportunities to offer information on clinical trial recruitment. The secondary outcome was the resources used by patients to learn about ongoing clinical trials.ResultsQuantitative validation of patient pathways identified 345 encounters involving 19 discrete events, including clinics, telephone follow-ups and treatments. The flow of encounters reflected the process map with 90.7% accuracy, with key timepoints identified at imaging and biopsy/surgical procedures. A cross-sectional survey conducted during outpatient neuro-oncology clinics identified that patients predominantly used self-directed internet searches (n=17, 68%) and verbal information from their neurosurgeon (n=16, 64%) to learn about clinical trials.ConclusionsThis study demonstrates the effectiveness of process mapping in identifying key timepoints for automated data collection and opportunities for quality improvement for clinical trial recruitment. Integrating online and in-clinic education strategies could enhance patient awareness and participation in clinical trials.

ObjectiveDevelop a process map of when patients learn about their proposed surgery and what resources patients use to educate themselves.DesignA mixed methods design, combining semistructured stakeholder interviews, quantitative validation using electronic healthcare records (EHR) in a retrospective cohort and a cross-sectional patient survey.SettingA single surgical centre in the UK.ParticipantsFourteen members of the spinal multidisciplinary team were interviewed to develop the process map.This process map was validated using the EHR of 50 patients undergoing elective spine surgery between January and June 2022. Postprocedure, feedback was gathered from 25 patient surveys to identify which resources they used to learn about their spinal procedure. Patients below the age of 18 or who received emergency surgery were excluded.InterventionsElective spine surgery and patient questionnaires given postoperatively either on the ward or in follow-up clinic.Primary and secondary outcome measuresThe primary outcome was the percentage of the study cohort that was present at encounters on the process map. Key timepoints were defined if >80% of patients were present. The secondary outcome was the percentage of the study cohort that used educational resources listed in the patient questionnaire.ResultsThere were 342 encounters which occurred across the cohort, with 16 discrete event categories identified. The initial surgical clinic (88%), anaesthetic preoperative assessment (96%) and admission for surgery (100%) were identified as key timepoints. Surveys identified that patients most used verbal information from their surgeon (100%) followed by written information from their surgeon (52%) and the internet (40%) to learn about their surgery.ConclusionsProcess mapping is an effective method of illustrating the patient pathway. The initial surgical clinic, anaesthetic preoperative assessment and surgical admission are key timepoints where patients receive information. This has future implications for guiding patient education interventions to focus at key timepoints.

Timely care in a specialised neuro-intensive therapy unit (ITU) reduces mortality and hospital stays. Planned admissions to ITU following surgery are safer than unplanned ones. However, post-operative care decisions remain subjective. This study used artificial intelligence (AI), specifically natural language processing (NLP) to analyse electronic health records (EHRs) of elective neurosurgery patients from University College London Hospital (UCLH) and predict ITU admissions. Using a refined CogStack-MedCAT NLP model, we extracted clinical concepts from 2268 patient records and trained AI models to classify admissions into ward and ITU. The Random Forest model achieved a recall of 0.87 (CI 0.82–0.91) for ITU admissions, reducing the proportion of unplanned ITU cases missed by human experts from 36% to 4%. Interpretability analysis confirmed the use of clinically relevant concepts. The study highlights the opportunity for AI to aid in allocating resources for neurosurgical patients but requires further research and integration into practice.

ObjectivesTo explore what factors shape a service user’s decision to call an emergency ambulance for a ‘primary care sensitive’ condition (PCSC), including contextual factors. Additionally, to understand the function and purpose of ambulance care from the perspective of service users, and the role health professionals may play in influencing demand for ambulances in PCSCs.DesignAn ethnographic study set in one UK ambulance service. Patient cases were recruited upon receipt of ambulance treatment for a situation potentially manageable in primary care, as determined by a primary care clinician accompanying emergency medical services (EMS) crews. Methods used included: structured observations of treatment episodes; in-depth interviews with patients, relatives and carers and their GPs; purposeful conversations with ambulance clinicians; analysis of routine healthcare records; analysis of the original EMS ‘emergency’ telephone call recording.ResultsWe analysed 170 qualitative data items across 50 cases. Three cross-cutting concepts emerged as central to EMS use for a PCSC: (1) There exists a typology of nine ‘triggers’, which we categorise as either ‘internal’ or ‘external’, depending on how much control the caller feels they have of the situation; (2) Calling an ambulance on behalf of someone else creates a specific anxiety about urgency; (3) Healthcare professionals experience conflict around fuelling demand for ambulances.ConclusionsPrevious work suggests a range of sociodemographic factors that may be associated with choosing ambulance care in preference to alternatives. Building on established sociological models, this work helps understand how candidacy is displayed during the negotiation of eligibility for ambulance care. Seeking urgent assistance on behalf of another often requires specific support and different strategies. Use of EMS for such problems—although inefficient—is often conceptualised as ‘rational’ by service users. Public health strategies that seek to advise the public about appropriate use of EMS need to consider how individuals conceptualise an ‘emergency’ situation.