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Ecological studies indicate that structurally complex habitats support elevated biodiversity, stability and resilience. The long-term persistence of structured habitats and their importance in maintaining biodiverse hotspots remain underexplored. We combined geohistorical data (dead mollusc assemblages, ‘DA’) and contemporary surveys (live mollusc assemblages, ‘LA’) to assess the persistence of local seagrass habitats over multi-centennial timescales and to evaluate whether they acted as long-term drivers of biodiversity, stability and resilience of associated fauna. We sampled structured seagrass meadows and open sandy bottoms along Florida's Gulf Coast. Results indicated that: (i) LA composition differed significantly between the two habitat types, (ii) LA from seagrass sites were characterized by significantly elevated local biodiversity and significantly higher spatial stability, (iii) DA composition differed significantly between the two habitat types, and (iv) fidelity between LA and DA was significantly greater for seagrass habitats. Contemporary results support the hypotheses that local biodiversity and spatial stability of marine benthos are both elevated in structured seagrass habitats. Geohistorical results suggest that structured habitats persist as local hotspots of elevated biodiversity and faunal stability over centennial-to-millennial timescales; indicating that habitat degradation and concomitant loss within structurally complex marine systems is a key driver of declining biodiversity and resilience.

Good nutrition is an integral component of patient care. Not only does eating correctly provide substantial physical benefits, it also ensures psychological comfort throughout admission. Nevertheless, our formative years as medical students, and now as junior doctors, have shown us that patient nutrition is frequently neglected both in the clinical setting and in the subject matter of our education. Amid the coronavirus pandemic, this is especially problematic; older, frailer patients, with multiple comorbidities and higher rates of malnutrition, are faring much worse with the virus. Combined with the fact that 40% of patients admitted to hospital are malnourished to some degree, we are looking at a huge population of potential COVID-19 patients facing a further decline in nutritional status and higher mortality as a result of this, making attention to nutrition more important than ever. As junior doctors, we have a role in the nutritional assessment of and support for our patients by ensuring that all patients are suitably assessed using a scoring tool with the appropriate ensuing actions taken. We must also ensure that our knowledge regarding nutritional assessment and support is adequate and aim to supplement this via additional learning to meet the minimum requirements for our curriculum.

IntroductionPatients with node-positive breast cancer having primary surgery currently undergo axillary node clearance (ANC) to reduce the risk of breast cancer recurrence. Evidence that this highly morbid procedure improves survival is lacking, but approximately 30% of patients will develop lifelong complications which significantly impact their quality of life.Targeted axillary dissection (TAD) may be a safe, less morbid alternative to ANC and will be evaluated in the upcoming Targeted Axillary Dissection versus axillary node clearance in patients with POsitive axillary Lymph nodes in Early breast cancer (TADPOLE) randomised controlled trial.TAD is not currently routine practice in patients having primary surgery, so it is vital that the procedure is performed in an agreed upon, standardised way within the trial and procedure fidelity monitored to ensure the results are generalisable and will be accepted by the surgical community. Robust surgical quality assurance (SQA) is essential. Here we describe the first phase of the TADPOLE SQA, a consensus process with the breast surgical community to agree upon how (1) surgery should be performed and standardised; (2) procedure fidelity will be monitored and (3) requirements for surgeon credentialling within the trial.Methods and analysisThe consensus process will have three phases:Generation of a long list of possible components of TAD from a scoping review and expert opinion. Identified items will be categorised and formatted into Delphi consensus questionnaire items.At least two rounds of an online Delphi survey in which at least 100 breast cancer surgeons will rate the importance of mandating/prohibiting, standardising and/or monitoring each component.A consensus meeting with surgeons to discuss, agree upon and ratify the approach to SQA within TADPOLE.Ethics and disseminationEthical approval has been obtained from the University of Bristol Faculty of Health Sciences Ethics Committee. Educational materials including videos and webinars will be developed and shared with surgeons participating in TADPOLE. Results will be presented at national/international meetings and published in peer-reviewed journals.

Background Chronic kidney disease (CKD) prevalence is steadily increasing, in part due to increased multimorbidity in our aging global population. When progression to kidney failure cannot be avoided, people need unbiased information to inform decisions about whether to start dialysis, if or when indicated, or continue with holistic person-centred care without dialysis (conservative kidney management). Comparisons suggest that while there may be some survival benefit from dialysis over conservative kidney management, in people aged 80 years and over, or with multiple health problems or frailty, this may be at the expense of quality of life, hospitalisations, symptom burden and preferred place of death. Prepare for Kidney Care aims to compare preparation for a renal dialysis pathway with preparation for a conservative kidney management pathway, in relation to quantity and quality of life in multimorbid, frail, older people with advanced CKD. Methods This is a two-arm, superiority, parallel group, non-blinded, individual-level, multi-centre, pragmatic trial, set in United Kingdom National Health Service (NHS) kidney units. Patients with advanced CKD (estimated glomerular filtration rate < 15 mL/min/1.73 m 2 , not due to acute kidney injury) who are (a) 80 years of age and over regardless of frailty or multimorbidity, or (b) 65–79 years of age if they are frail or multimorbid, are randomised 1:1 to ‘prepare for responsive management’, a protocolised form of conservative kidney management, or ‘prepare for renal dialysis’. An integrated QuinteT Recruitment Intervention is included. The primary outcome is mean total number of quality-adjusted life years during an average follow-up of 3 years. The primary analysis is a modified intention-to-treat including all participants contributing at least one quality of life measurement. Secondary outcomes include survival, patient-reported outcomes, physical functioning, relative/carer reported outcomes and qualitative assessments of treatment arm acceptability. Cost-effectiveness is estimated from (i) NHS and personal social services and (ii) societal perspectives. Discussion This randomised study is designed to provide high-quality evidence for frail, multimorbid, older patients with advanced CKD choosing between preparing for dialysis or conservative kidney management, and healthcare professionals and policy makers planning the related services. Trial registration ISRCTN, ISRCTN17133653 ( https://doi.org/10.1186/ISRCTN17133653 ). Registered 31 May 2017.

IntroductionDepression is three to four times more prevalent in autistic people and is related to reduced quality of life. There is a need for empirically supported psychological interventions for depression specifically adapted to meet the needs of autistic adults. ADEPT-2 aims to establish the clinical and cost-effectiveness of an adapted low-intensity psychological intervention (guided self-help) for depression in autistic adults.Methods and analysisA two parallel-group multicentre pragmatic randomised controlled trial investigating the effectiveness of GSH for depression in autistic adults. Participants (n=248) aged ≥18 years with a clinical diagnosis of autism currently experiencing depression will be randomised to GSH or treatment as usual (TAU). GSH is a low-intensity psychological intervention based on the principles of behavioural activation adapted for autism. GSH comprises informational materials for nine individual sessions facilitated online by a GSH coach who has received training and supervision in delivering the intervention. The primary outcome will be Beck Depression Inventory-II depression scores at 16 weeks post randomisation with follow-up measures at 32 and 52 weeks. Additional measures of anxiety, patient-rated global improvement, quality of life, work and social adjustment, positive and negative affect will be measured 16 and 52 weeks post randomisation. The primary health economic analysis will assess the cost-effectiveness of GSH compared with TAU over 52 weeks, from a societal perspective including the National Health Service, personal social services, personal expenses, voluntary services and productivity. An embedded qualitative study will explore the acceptability, experiences and adherence of participants and therapists to treatment principles.Ethics and disseminationThis trial has been approved by the East of England - Essex Research Ethics Committee on 10 June 2022 (REC Reference number: 22/EE/0091). The findings of the research will be submitted for publication in peer-reviewed journals and disseminated in an appropriate format to trial participants and the wider public.Trial registration number ISRCTN17547011.

ObjectivesTo estimate the cost-effectiveness of a primary care intervention for male lower urinary tract symptoms (LUTS) compared with usual care.DesignEconomic evaluation alongside a cluster randomised controlled trial from a UK National Health Service (NHS) perspective with a 12-month time horizon.SettingThirty NHS general practice sites in England.Participants1077 men aged 18 or older identified in primary care with bothersome LUTS.InterventionsA standardised and manualised intervention for the treatment of bothersome LUTS was compared with usual care. The intervention group (n=524) received a standardised information booklet with guidance on conservative treatment for LUTS, urinary symptom assessment and follow-up contacts for 12 weeks. The usual care group (n=553) followed local guidelines between general practice sites.MeasuresResource use was obtained from electronic health records, trial staff and participants, and valued using UK reference costs. Quality-adjusted life-years (QALYs) were calculated from the EQ-5D-5L questionnaire. Adjusted mean differences in costs and QALYs and incremental net monetary benefit were estimated.Results866 of 1077 (80.4%) participants had complete data and were included in the base-case analysis. Over the 12-month follow-up period, intervention and usual care arms had similar mean adjusted costs and QALYs. Mean differences were lower in the intervention arm for adjusted costs −£29.99 (95% CI −£109.84 to £22.63) while higher in the intervention arm for adjusted QALYs 0.001 (95% CI −0.011 to 0.014). The incremental net monetary benefit statistic was £48.01 (95% CI −£225.83 to £321.85) at the National Institute for Health and Care Excellence UK threshold of £20 000 per QALY. The cost-effectiveness acceptability curve showed a 63% probability of the intervention arm being cost-effective at this threshold.ConclusionsCosts and QALYs were similar between the two arms at 12 months follow-up. This indicates that the intervention can be implemented in general practice at neutral cost.Trial registration numberISRCTN11669964.

Background Lower urinary tract symptoms (LUTS) can relate to urinary storage or voiding. In men, the prevalence and severity of LUTS increases with age, with a significant impact on quality of life. The majority of men presenting with LUTS are managed by their general practitioner (GP) in the first instance, with conservative therapies recommended as the initial treatment. However, the provision of conservative therapies in primary care is variable and can be time and resource limited. GPs require practical resources to enhance patient engagement with such interventions. TRIUMPH aims to determine whether a standardised and manualised care intervention delivered in primary care achieves superior symptomatic outcome for LUTS versus usual care. Methods/design TRIUMPH is a two-arm, cluster randomised controlled trial (RCT) being conducted in 30 National Health Service (NHS) general practices in England. The TRIUMPH intervention comprises a standardised LUTS advice booklet developed for the trial with patient and healthcare professional (HCP) consultation. The booklet is delivered to patients by nurses/healthcare assistants following assessment of their urinary symptoms. Patients are directed to relevant sections of the booklet, providing the manualised element of the intervention. To encourage adherence, HCPs provide follow-up contacts over 12 weeks. Practices are randomised 1:1 to either deliver the TRIUMPH intervention or a usual care pathway. The patient-reported International Prostate Symptom Score (IPSS) at 12 months post consent is the primary outcome. Secondary outcomes include cost-effectiveness, patient-reported outcomes on LUTS, quality of life, and patient and HCP acceptability and experience of the intervention. Primary analyses will be conducted on an intention-to-treat basis. Discussion It is unclear whether conservative therapies for male LUTS are effectively delivered in primary care using current approaches. This can lead to men being inappropriately referred to secondary care or experiencing persistent symptoms. Primary care, therefore, holds the key to effective treatment for these men. The TRIUMPH intervention, through its standardised and manualised approach, has been developed to support GP practices in delivering effective conservative care. This pragmatic, cluster RCT should provide robust evidence in a primary-care setting to inform future guidelines. Trial registration ISCRTN registry, ID: ISRCTN11669964 . Registered on 12 April 2018.

Issue Title: Jellyfish Blooms: Interactions with Humans and Fisheries

Issue Title: Jellyfish Blooms: Interactions with Humans and Fisheries Bacteria decomposed damaged and moribund Chrysaora quinquecirrha Desor, 1848 releasing a pulse of carbon and nutrients. Tissue decomposed in 5-8 days, with 14 g of wet biomass exhibiting a half-life of 3 days at 22°C, which is 3× longer than previous reports. Decomposition raised mean concentrations of organic carbon and nutrients above controls by 1-2 orders of magnitude. An increase in nitrogen (16,117 μg l^sup -1^) occurred 24 h after increases in phosphorus (1,365 μg l^sup -1^) and organic carbon (25 mg l^sup -1^). Cocci dominated control incubations, with no significant increase in numbers. In incubations of tissue, bacilli increased exponentially after 6 h to become dominant, and cocci reproduced at a rate that was 30% slower. These results, and those from previous studies, suggested that natural assemblages may include bacteria that decompose medusae, as well as bacteria that benefit from the subsequent release of carbon and nutrients. This experiment also indicated that proteins and other nitrogenous compounds are less labile in damaged medusae than in dead or homogenized individuals. Overall, dense patches of decomposing medusae represent an important, but poorly documented, component of the trophic shunt that diverts carbon and nutrients incorporated by gelatinous zooplankton into microbial trophic webs.[PUBLICATION ABSTRACT]

In pelagic systems, thin layers (discontinuities with narrow vertical extents and high concentrations of organisms) create patches of food, and aggregations of gelatinous zooplankton can exploit such resources. The establishment, maintenance, and trophic effects of these functional relationships depend on behavioral responses to thin layers by individuals, which remain largely unexplored. In this study, we used laboratory experiments to test the hypothesis that a common and abundant hydromedusa predator, Nemopsis bachei L. Agassiz, 1849, would respond similarly to salinity gradients with and without thin layers of algae and copepods. Approximately 75% of the hydromedusae remained in both types of discontinuities. These distributions were not created solely by passive responses related to osmoconformation or an inability to swim through salinity gradients because approximately 25% of hydromedusae swam through or away from salinity gradients or biological thin layers. Biological thin layers stimulated feeding. Feeding success was related directly to encounter rates and it was independent of swimming, as expected for an ambush predator. Feeding increased at higher prey densities, and capture, handling time, and ingestion were not saturated even at 150-200 copepods l⁻¹. The proportion of N. bachei that ceased feeding and began swimming increased when encounters with prey decreased to approximately 2 encounters hydromedusa⁻¹ 10 min⁻¹. Thus, hydromedusae may seek new patches of prey once encounter rates and subsequent feeding success fall below a threshold. Exposing N. bachei to salinity gradients with and without biological thin layers indicated that these hydromedusae will remain in discontinuities and exert predation pressure that should be considered when assessing trophic webs and estimating carbon flux.