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Mortality remains unacceptably high in patients with heart failure and reduced left ventricular ejection fraction (LVEF) despite advances in therapeutics. We hypothesised that a novel artificial intelligence approach could better assess multiple and higher-dimension interactions of comorbidities, and define clusters of β-blocker efficacy in patients with sinus rhythm and atrial fibrillation. Neural network-based variational autoencoders and hierarchical clustering were applied to pooled individual patient data from nine double-blind, randomised, placebo-controlled trials of β blockers. All-cause mortality during median 1·3 years of follow-up was assessed by intention to treat, stratified by electrocardiographic heart rhythm. The number of clusters and dimensions was determined objectively, with results validated using a leave-one-trial-out approach. This study was prospectively registered with ClinicalTrials.gov (NCT00832442) and the PROSPERO database of systematic reviews (CRD42014010012). 15 659 patients with heart failure and LVEF of less than 50% were included, with median age 65 years (IQR 56–72) and LVEF 27% (IQR 21–33). 3708 (24%) patients were women. In sinus rhythm (n=12 822), most clusters demonstrated a consistent overall mortality benefit from β blockers, with odds ratios (ORs) ranging from 0·54 to 0·74. One cluster in sinus rhythm of older patients with less severe symptoms showed no significant efficacy (OR 0·86, 95% CI 0·67–1·10; p=0·22). In atrial fibrillation (n=2837), four of five clusters were consistent with the overall neutral effect of β blockers versus placebo (OR 0·92, 0·77–1·10; p=0·37). One cluster of younger atrial fibrillation patients at lower mortality risk but similar LVEF to average had a statistically significant reduction in mortality with β blockers (OR 0·57, 0·35–0·93; p=0·023). The robustness and consistency of clustering was confirmed for all models (p<0·0001 vs random), and cluster membership was externally validated across the nine independent trials. An artificial intelligence-based clustering approach was able to distinguish prognostic response from β blockers in patients with heart failure and reduced LVEF. This included patients in sinus rhythm with suboptimal efficacy, as well as a cluster of patients with atrial fibrillation where β blockers did reduce mortality. Medical Research Council, UK, and EU/EFPIA Innovative Medicines Initiative BigData@Heart.

‘Codesign’ and associated terms such as ‘coproduction’ or ‘patient engagement’, are increasingly common in the health research literature, due to an increased emphasis on the importance of ensuring that research related to service/systems development is meaningful to end-users.  However, there continues to be a lack of clarity regarding the key principles and practices of codesign, and wide variation in the extent to which service users are meaningfully engaged in the process. These issues are particularly acute when end-users include populations who have significant health and healthcare disparities that are linked to a range of intersecting vulnerabilities (eg, poverty, language barriers, age, disability, minority status, stigmatised conditions).  The purpose of this paper is to prompt critical reflection on the nature of codesign research with vulnerable populations, including key issues to consider in the initial planning phases, the implementation process, and final outputs.  Risks and tensions will be identified in each phase of the process, followed by a tool to foster reflexivity in codesign processes to address these issues.

Flood risk assessments (FRAs) are essential tools in Scottish planning policy to identify and minimise flood risk in new planning applications. Most FRAs in Scotland are performed in (very) small (< 50km2) < 100km2 catchments, particularly vulnerable to increases in rainfall intensity due to climate change. This study provides a historical overview of the literature used as guidance in FRAs in Scotland and then focuses on their application in smaller catchments, addressing three areas: understanding the different physical processes in smaller catchments, their representation within the guidelines and how these guidelines are applied in practice. Our results highlight the need to move beyond simple mathematical and hydrological methods for FRAs. We find that small catchments' physical processes are not adequately represented in current methods, leading to higher biases and uncertainties in modelling. When applied in practice, these techniques are often used unconventionally for the fulfilment of established guidelines. Finally, climate change science implementation into guidance also needs refinement, with current regulations lacking a sound scientific basis, particularly for smaller catchments. We underscore the need for testing and application of innovative solutions found in academia and utilisation of additional data to provide improved methods for FRAs in smaller catchments, particularly under climate change.

Background Cocreation has the potential to engage people with lived and living experiences in the design and evaluation of health and social services. However, guidance is needed to better include people from equity‐deserving groups (EDGs), who are more likely to face barriers to participation, experience ongoing or historical harm, and benefit from accessible methods of engagement. Objective The aim of this international forum (CoPro2022) was to advance a collective vision for equity‐based cocreation. Design A participatory process of engagement in experiential colearning and arts‐based creative and reflective dialogue. Visual prototypes were created and synthesised to generate a collective vision for inclusive equity‐based cocreation. Setting and Participants The Forum was held at the Gathering Place by the Grand River in Ohsweken, Ontario, Canada. A total of 48 participants attended the forum. They were purposely invited and have intersecting positionalities (21 academic experts, six experience experts, 10 trainees, and 11 members of EDGs) from nine countries (Bangladesh, Botswana, Canada, England, Italy, Norway, Scotland, Singapore, Sweden). CoPro2022 Activities CoPro2022 was an immersive experience hosted on Indigenous land that encouraged continuous participant reflection on their own worldviews and those of others as participants openly discussed the challenges and opportunities with engaging EDGs in cocreation activities. Visual prototypes and descriptions created in small groups were informed by participants' reflections on the panel presentations at the Forum and their own experiences with equity‐based cocreation. Following the event, the authorship team inductively coded themes from the prototype descriptions and met to discuss the cross‐cutting themes. These informed the design of an illustrated collective vision for Equity Based Co‐Creation (EqCC). Results Six prototypes were cocreated by each small group to illustrate their vision for EqCC. Within these, four cross‐cutting themes were identified: (i) go to where people are, (ii) nurture relationships and creativity, (iii) reflect, replenish and grow, (iv) and promote thriving and transformation. These four themes are captured in the Collective EqCC Vision to guide a new era of inclusive excellence in cocreation activities. Patient or Public Contribution Service users, caregivers, and people with lived experience were involved in leading the design of the CoPro2022 and co‐led the event. This included activities at the event such as presenting, facilitating small and large group discussion, leading art‐based activities, and reflecting with the team on the lessons learned. People with lived experience were involved in the analysis and knowledge sharing from this event. Several members of the research team (students and researchers) also identified as members of EDGs and were invited to draw from their personal and academic knowledge.

[...]the uptake of codesign has contributed to what has been called a ‘Participatory Zeitgeist’, whereby codesign and coproduction have become the spirit of our contemporary times. 1 Despite growing attention and uptake of codesign approaches and the potential for positive impact, there continue to be significant gaps and inconsistencies in evaluation. Health Expectations has published much of this study, including a recent systematic review of evaluation in patient and public engagement in research and health system decision-making. 2 While the review found a growing number of published evaluation tools, it also found that many of these tools lacked an explicit conceptual framework that is needed to link empirical evaluation with a theoretical foundation. A DE approach is appropriate in circumstances where project/program team members, especially decision makers, are open to reflexive practice and critical thinking and are committed to actively engaging in an iterative evaluation process. 3 Unlike traditional approaches, DE positions evaluation as an internal team function within the context of the project/program and is integrated into the process of gathering and interpreting data, framing, and surfacing issues and testing model developments. Unlike traditional evaluation approaches that require specific and measurable goals to be achieved by a step-by-step process, our Hub follows a set of core principles that emphasize authentic engagement of diverse stakeholders, taking time to listen for understanding and moving forward when participants and communities are ready for system change. 1 DE provided a process for periodic reflection on these principles to gauge progress, harvest important lessons and systematically examine what was working and what was not.

Almost all early cognitive development takes place in social contexts. At the moment, however, we know little about the neural and micro-interactive mechanisms that support infants’ attention during social interactions. Recording EEG during naturalistic caregiver-infant interactions (N=66), we compare two different accounts. Traditional, didactic perspectives emphasise the role of the caregiver in structuring the interaction, whilst active learning models focus on motivational factors, endogenous to the infant, that guide their attention. Our results show that, already by 12 months, intrinsic cognitive processes control infants’ attention: fluctuations in endogenous oscillatory neural activity associated with changes in infant attentiveness. In comparison, infant attention was not forwards-predicted by caregiver gaze or vocal behaviours. Instead, caregivers rapidly modulated their behaviours in response to changes in infant attention and cognitive engagement, and greater reactive changes associated with longer infant attention. Our findings suggest that shared attention develops through interactive but asymmetric, infant-led processes that operate across the caregiver-child dyad.