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Purpose of ReviewSepsis is a leading cause of death worldwide. Groundbreaking international collaborative efforts have culminated in the widely accepted surviving sepsis guidelines, with iterative improvements in management strategies and definitions providing important advances in care for patients. Key to the diagnosis of sepsis is identification of infection, and whilst the diagnostic criteria for sepsis is now clear, the diagnosis of infection remains a challenge and there is often discordance between clinician assessments for infection.Recent FindingsWe review the utility of common biochemical, microbiological and radiological tools employed by clinicians to diagnose infection and explore the difficulty of making a diagnosis of infection in severe inflammatory states through illustrative case reports. Finally, we discuss some of the novel and emerging approaches in diagnosis of infection and sepsis.SummaryWhile prompt diagnosis and treatment of sepsis is essential to improve outcomes in sepsis, there remains no single tool to reliably identify or exclude infection. This contributes to unnecessary antimicrobial use that is harmful to individuals and populations. There is therefore a pressing need for novel solutions. Machine learning approaches using multiple diagnostic and clinical inputs may offer a potential solution but as yet these approaches remain experimental.

In many social vertebrates, variation in group persistence exerts an important effect on individual fitness and population demography. However, few studies have been able to investigate the failure of groups or the causes of the variation in their longevity. We use data from a long‐term study of cooperatively breeding meerkats, Suricata suricatta, to investigate the different causes of group failure and the factors that drive these processes. Many newly formed groups failed within a year of formation, and smaller groups were more likely to fail. Groups that bred successfully and increased their size could persist for several years, even decades. Long‐lived groups principally failed in association with the development of clinical tuberculosis, Mycobacterium suricattae, a disease that can spread throughout the group and be fatal for group members. Clinical tuberculosis was more likely to occur in groups that had smaller group sizes and that had experienced immigration. In social vertebrates, the persistence of groups is important for both individual fitness and population demography. Here, we investigate the causes of group failure in the cooperatively breeding meerkats, showing that larger groups will persist the longest, being buffered against all forms of group failure, and are also less likely to be infected by tuberculosis, a disease often fatal for groups.

For over a decade, Scotland has implemented and operationalized a system of Safe Havens, which provides secure analytics platforms for researchers to access linked, deidentified electronic health records (EHRs) while managing the risk of unauthorized reidentification. In this paper, a perspective is provided on the state-of-the-art Scottish Safe Haven network, including its evolution, to define the key activities required to scale the Scottish Safe Haven network’s capability to facilitate research and health care improvement initiatives. A set of processes related to EHR data and their delivery in Scotland have been discussed. An interview with each Safe Haven was conducted to understand their services in detail, as well as their commonalities. The results show how Safe Havens in Scotland have protected privacy while facilitating the reuse of the EHR data. This study provides a common definition of a Safe Haven and promotes a consistent understanding among the Scottish Safe Haven network and the clinical and academic research community. We conclude by identifying areas where efficiencies across the network can be made to meet the needs of population-level studies at scale.

We show that a fixed smartphone network can provide robust Earthquake Early Warning for at least two orders of magnitude less cost than scientific‐grade networks. Our software and cloud‐based data architecture that we have constructed for the Alerta Sismica Temprana Utilizando Teléfonos Inteligentes (ASTUTI; Earthquake Early Warning Utilizing Smartphones) network in Costa Rica is easily scaled and exported. Implementation comprises provisioning and installing modern smartphones in judicious locations. Stand‐up time for regionally operational networks can be on the order of days. We evaluated a non‐parametric ground‐motion detection and alerting strategy that would alert the entire Costa Rican population of any event with a ground motion detection threshold of 0.55–0.65 %g at four neighboring stations. During a 6‐month evaluation period ASTUTI detected and alerted on five of 13 earthquakes with Mw 4.8–5.3 that caused felt Modified Mercalli Intensity shaking levels of 4.3–6. The system did not produce any false alerts and the undetected events did not produce wide‐spread or significant felt shaking. System latencies were less than or similar to scientific‐grade latencies. Alerts for all five detected events would have reached the capital city, San Jose, before strong S‐wave shaking. This would have afforded time for Drop Cover Hold On actions by most residents. Two of the five alerts were triggered by P‐waves suggesting that smartphone‐based networks could approach the fastest theoretical EEW performance, especially with future expected improvements in smartphone sensors and processing algorithms. Plain Language Summary We demonstrate that a network of smartphones deployed in fixed locations can provide Earthquake early warning (EEW) performance on par with scientific grade instrumentation at a fraction of the cost. This approach makes EEW accessible to resource‐limited countries that may have not been to able to previously benefit from some form of EEW. In particular, combining the fixed‐network smartphone sensors with a strategy targeting low cost of action protective measures such as Drop Cover Hold On could be very effective. Key Points Smartphones used in a fixed network can provide earthquake early warning performance similar to scientific‐grade instrumentation. Operating in Costa Rica over 6 months, the Alerta Sismica Temprana Utilizando Teléfonos Inteligentes (Earthquake Early Warning Utilizing Smartphones) project detected five events that caused wide‐spread felt shaking and had zero false alarms The detections and alerts would have provided time for drop‐cover‐hold‐on protective actions to be taken before S‐wave arrival for large percentages of the Costa Rican population Two of the five events were triggered by P‐waves on the phones, suggesting that smartphone‐based earthquake early warning could be more effective than previously thought

The complete resource on performing sustainable renovations for both Historic and modern existing buildings This forward-looking and insightful guide explores how the sustainable renovation of existing buildings presents great opportunities for initiating extensive changes in the performance of the built environment.

One important but understudied way in which climate change may impact the fitness of individuals and populations is by altering the prevalence of infectious disease outbreaks. This is especially true in social species where endemic diseases are widespread. Here we use 22 years of demographic data from wild meerkats (Suricata suricatta) in the Kalahari, where temperatures have risen steadily, to project group persistence under interactions between weather extremes and fatal tuberculosis outbreaks caused by infection with Mycobacterium suricattae. We show that higher temperature extremes increase the risk of outbreaks within groups by increasing physiological stress as well as the dispersal of males, which are important carriers of tuberculosis. Explicitly accounting for negative effects of tuberculosis outbreaks on survival and reproduction in groups more than doubles group extinction risk in 12 years under projected temperature increases. Synergistic climate–disease effects on demographic rates may therefore rapidly intensify climate-change impacts in natural populations.Using 22 years of demographic data from wild meekats in the Kalahari, the authors project group persistence in the context of weather extremes and outbreaks of end-stage tuberculosis. They find that synergistic climate–disease effects on key demographic rates may exacerbate future disease impacts.

Kin selection theory suggests that altruistic behaviors can increase the fitness of altruists when recipients are genetic relatives. Although selection can favor the ability of organisms to preferentially cooperate with close kin, indiscriminately helping all group mates may yield comparable fitness returns if relatedness within groups is very high. Here, we show that meerkats (Suricata suricatta) are largely indiscriminate altruists who do not alter the amount of help provided to pups or group mates in response to their relatedness to them. We present a model showing that indiscriminate altruism may yield greater fitness payoffs than kin discrimination where most group members are close relatives and errors occur in the estimation of relatedness. The presence of errors in the estimation of relatedness provides a feasible explanation for associations between kin discriminative helping and group relatedness in eusocial and cooperatively breeding animals.

High-sensitivity cardiac troponin assays permit use of lower thresholds for the diagnosis of myocardial infarction, but whether this improves clinical outcomes is unknown. We aimed to determine whether the introduction of a high-sensitivity cardiac troponin I (hs-cTnI) assay with a sex-specific 99th centile diagnostic threshold would reduce subsequent myocardial infarction or cardiovascular death in patients with suspected acute coronary syndrome. In this stepped-wedge, cluster-randomised controlled trial across ten secondary or tertiary care hospitals in Scotland, we evaluated the implementation of an hs-cTnI assay in consecutive patients who had been admitted to the hospitals' emergency departments with suspected acute coronary syndrome. Patients were eligible for inclusion if they presented with suspected acute coronary syndrome and had paired cardiac troponin measurements from the standard care and trial assays. During a validation phase of 6–12 months, results from the hs-cTnI assay were concealed from the attending clinician, and a contemporary cardiac troponin I (cTnI) assay was used to guide care. Hospitals were randomly allocated to early (n=5 hospitals) or late (n=5 hospitals) implementation, in which the high-sensitivity assay and sex-specific 99th centile diagnostic threshold was introduced immediately after the 6-month validation phase or was deferred for a further 6 months. Patients reclassified by the high-sensitivity assay were defined as those with an increased hs-cTnI concentration in whom cTnI concentrations were below the diagnostic threshold on the contemporary assay. The primary outcome was subsequent myocardial infarction or death from cardiovascular causes at 1 year after initial presentation. Outcomes were compared in patients reclassified by the high-sensitivity assay before and after its implementation by use of an adjusted generalised linear mixed model. This trial is registered with ClinicalTrials.gov, number NCT01852123. Between June 10, 2013, and March 3, 2016, we enrolled 48 282 consecutive patients (61 [SD 17] years, 47% women) of whom 10 360 (21%) patients had cTnI concentrations greater than those of the 99th centile of the normal range of values, who were identified by the contemporary assay or the high-sensitivity assay. The high-sensitivity assay reclassified 1771 (17%) of 10 360 patients with myocardial injury or infarction who were not identified by the contemporary assay. In those reclassified, subsequent myocardial infarction or cardiovascular death within 1 year occurred in 105 (15%) of 720 patients in the validation phase and 131 (12%) of 1051 patients in the implementation phase (adjusted odds ratio for implementation vs validation phase 1·10, 95% CI 0·75 to 1·61; p=0·620). Use of a high-sensitivity assay prompted reclassification of 1771 (17%) of 10 360 patients with myocardial injury or infarction, but was not associated with a lower subsequent incidence of myocardial infarction or cardiovascular death at 1 year. Our findings question whether the diagnostic threshold for myocardial infarction should be based on the 99th centile derived from a normal reference population. The British Heart Foundation.