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Background The internet is now the first line source of health information for many people worldwide. In the current Coronavirus Disease 2019 (COVID-19) global pandemic, health information is being produced, revised, updated and disseminated at an increasingly rapid rate. The general public are faced with a plethora of misinformation regarding COVID-19 and the readability of online information has an impact on their understanding of the disease. The accessibility of online healthcare information relating to COVID-19 is unknown. We sought to evaluate the readability of online information relating to COVID-19 in four English speaking regions: Ireland, the United Kingdom, Canada and the United States, and compare readability of website source provenance and regional origin. Methods The Google® search engine was used to collate the first 20 webpage URLs for three individual searches for ‘COVID’, ‘COVID-19’, and ‘coronavirus’ from Ireland, the United Kingdom, Canada and the United States. The Gunning Fog Index (GFI), Flesch-Kincaid Grade (FKG) Score, Flesch Reading Ease Score (FRES), Simple Measure of Gobbledygook (SMOG) score were calculated to assess the readability. Results There were poor levels of readability webpages reviewed, with only 17.2% of webpages at a universally readable level. There was a significant difference in readability between the different webpages based on their information source ( p  < 0.01). Public Health organisations and Government organisations provided the most readable COVID-19 material, while digital media sources were significantly less readable. There were no significant differences in readability between regions. Conclusion Much of the general public have relied on online information during the pandemic. Information on COVID-19 should be made more readable, and those writing webpages and information tools should ensure universal accessibility is considered in their production. Governments and healthcare practitioners should have an awareness of the online sources of information available, and ensure that readability of our own productions is at a universally readable level which will increase understanding and adherence to health guidelines.

Chronic HBV infects 350 million people causing cancer and liver failure. We aimed to assess the safety and efficacy of plasmid DNA (pSG2.HBs) vaccine, followed by recombinant modified vaccinia virus Ankara (MVA.HBs), encoding the surface antigen of HBV as therapy for chronic HBV. A secondary goal was to characterize the immune responses. Firstly 32 HBV e antigen negative (eAg(-)) participants were randomly assigned to one of four groups: to receive vaccines alone, lamivudine (3TC) alone, both, or neither. Later 16 eAg(+) volunteers in two groups received either 3TC alone or both 3TC and vaccines. Finally, 12 eAg(-) and 12 eAg(+) subjects were enrolled into higher-dose treatment groups. Healthy but chronically HBV-infected males between the ages of 15-25 who lived in the western part of The Gambia were eligible. Participants in some groups received 1 mg or 2 mg of pSG2.HBs intramuscularly twice followed by 5×10(7) pfu or 1.5×10(8) pfu of MVA.HBs intradermally at 3-weekly intervals with or without concomitant 3TC for 11-14 weeks. Intradermal rabies vaccine was administered to a negative control group. Safety was assessed clinically and biochemically. The primary measure of efficacy was a quantitative PCR assay of plasma HBV. Immunity was assessed by IFN-γ ELISpot and intracellular cytokine staining. Mild local and systemic adverse events were observed following the vaccines. A small shiny scar was observed in some cases after MVA.HBs. There were no significant changes in AST or ALT. HBeAg was lost in one participant in the higher-dose group. As expected, the 3TC therapy reduced viraemia levels during therapy, but the prime-boost vaccine regimen did not reduce the viraemia. The immune responses were variable. The majority of IFN-γ was made by antigen non-specific CD16(+) cells (both CD3(+) and CD3(-)). The vaccines were well tolerated but did not control HBV infection. ISRCTN ISRCTN67270384.

Plasmodium falciparum (P. falciparum) malaria remains a significant cause of mortality and morbidity throughout the world. Development of an effective vaccine would be a key intervention to reduce the considerable social and economic impact of malaria. We conducted a Phase Ia, non-randomized, clinical trial in 24 healthy, malaria-naïve adults of the chimpanzee adenovirus 63 (ChAd63) and modified vaccinia virus Ankara (MVA) replication-deficient viral vectored vaccines encoding the circumsporozoite protein (CS) of P. falciparum. ChAd63-MVA CS administered in a heterologous prime-boost regime was shown to be safe and immunogenic, inducing high-level T cell responses to CS. With a priming ChAd63 CS dose of 5×109 vp responses peaked at a mean of 1947 SFC/million PBMC (median 1524) measured by ELIspot 7 days after the MVA boost and showed a mixed CD4+/CD8+ phenotype. With a higher priming dose of ChAd63 CS dose 5×1010 vp T cell responses did not increase (mean 1659 SFC/million PBMC, median 1049). Serum IgG responses to CS were modest and peaked at day 14 post ChAd63 CS (median antibody concentration for all groups at day 14 of 1.3 µg/ml (range 0-11.9), but persisted throughout late follow-up (day 140 median antibody concentration groups 1B & 2B 0.9 µg/ml (range 0-4.7). ChAd63-MVA is a safe and highly immunogenic delivery platform for the CS antigen in humans which warrants efficacy testing. ClinicalTrials.gov NCT01450280.

The Republic of Ireland (ROI) has a low incidence of TB. A reform of TB services in 2003 recommended that the delivery of care to patients with TB should primarily be in the outpatient setting, with limited indications for hospitalization. Three hospitals were designated as TB centres. Our aim was to describe the utilization of hospital inpatient care by patients with TB in the ROI. We searched public hospital coding data to identify discharges between 01/01/2015-31/12/18 where TB was the principal diagnosis. The cost of TB episodes of care was calculated using payment rules for public hospitals in the ROI. We identified 1185 discharges with TB as the principal diagnosis. Of these, 68% (801/1185) were emergency episodes of care and 32% (384/1185) were elective. We estimate that 65.1% (818/1257) patients with TB notified in the ROI from 2015 to 2018 who had an episode of care in a public hospital was 65.1% (818/1257) and that 50.8% (639/1257) of those notified had an emergency episode of care. The estimated mean annual cost of TB inpatient care per year in the ROI from 2015 to 2018 was €2,638,828-2,955,047, with emergency episodes of care having a mean annual cost of €2,250,926-2,557,397 per year. The burden of TB on hospital inpatient care in the Republic of Ireland is significant.

Introduction While feedback aims to support learning, students frequently struggle to use it. In studying feedback responses there is a gap in explaining them in relation to learning theory. This study explores how feedback experiences influence medical students’ self-regulation of learning. Methods Final-year medical students across three campuses (Ireland, Bahrain and Malaysia) were invited to share experiences of feedback in individual semi-structured interviews. The data were thematically analysed and explored through the lens of self-regulatory learning theory (SRL). Results Feedback interacts with learners’ knowledge and beliefs about themselves and about learning. They use feedback to change both their cognitive and behavioural learning strategies, but how they choose which feedback to implement is complex. They struggle to generate learning strategies and expect teachers to make sense of the “how” in addition to the “what”” in planning future learning. Even when not actioned, learners spend time with feedback and it influences future learning. Conclusion By exploring our findings through the lens of self-regulation learning, we advance conceptual understanding of feedback responses. Learners’ ability to generate “next steps” may be overestimated. When feedback causes negative emotions, energy is diverted from learning to processing distress. Perceived non-implementation of feedback should not be confused with ignoring it; feedback that is not actioned often impacts learning.

Background Ending tuberculosis (TB) is a global priority and targets for doing so are outlined in the World Health Organization (WHO) End TB Strategy. For low-incidence countries, eliminating TB requires high levels of wealth, low levels of income inequality and effective TB programmes and services that can meet the needs of people who have not benefited from these and are still at risk of TB. In Ireland, numerous reports have noted a need for more funding for TB prevention and control. Aim The aim of this research was to estimate the cost of not meeting the WHO End TB target of a 90% reduction in TB incidence in Ireland between 2015 and 2035. Methods The cost of projected TB cases between 2022 and 2035 is estimated based on trends in surveillance data for the period 2015 to 2019 and outcomes reported in the literature. Results Between 2022 and 2035, it is projected that a failure to meet the WHO End TB Strategy target will result in an additional 989 cases of TB, 577.3 disability-adjusted life years and 35 deaths with TB in Ireland. The cost of this is estimated to be €70.779 million. Conclusion Given the estimated cost, Ireland’s current prospects of eliminating TB and the tendency towards programmatic funding internationally, greater investment in TB prevention and control in Ireland is justifiable. A national elimination strategy with actions at the levels of the social determinants of health, the health system and the TB programme should be funded.

Objectives An estimated 1% of endovascular aneurysm repair (EVAR) devices become infected, carrying a high mortality rate. Surgical explantation is recommended and prognosis is guarded. This retrospective cohort analysis focuses on the role of outpatient parenteral antimicrobial therapy (OPAT) in the management of aortic vascular graft infections following EVAR. Methods Patients who received OPAT for aortic graft infections (AGI) following EVAR from 2014 to 2018 inclusive were identified using the OPAT database. Clinical, microbiological and radiological data were collected. Survivors were followed up for a median of 36 months (range 25–60) after first presentation with infection. Outcomes were assessed. Results Eleven cases with 20 OPAT episodes were identified: 10/11 male, median age 76 (IQR 71–81). Median time to presentation was 7 months (range 0–81 months) after EVAR. OPAT lead to a 55% reduction in length of hospital stay. One patient had graft explantation; four others had temporising measures. Eight of 11 were alive a median of 36 months after presentation with infection, having had a median of 2 re-treatments on OPAT (range 1–3). Seven of the eight survivors were on continuous suppressive oral antimicrobials; three were also intermittently on intravenous antibiotics for flares of infection. Patient/ infection outcomes were cure (1/11), improved (7/11), failure (3/11). Conclusion AGI following EVAR usually presents in the first year after graft deployment. OPAT has an important peri-operative role in patients suitable for curative surgery. OPAT followed by oral suppressive antimicrobial therapy can be a feasible long-term treatment for non-curative management of AGI. Survival in our cohort was longer than expected, and OPAT was feasible despite the complexity of these infections. OPAT can avoid multiple and lengthy hospital admissions and maximise time at home and quality of life in this cohort with life-limiting infection.

There are differing views on how learners' feedback-seeking behaviours (FSB) develop during training. With globalisation has come medical student migration and programme internationalisation. Western-derived educational practices may prove challenging for diverse learner populations. Exploring undergraduate activity using a model of FSB may give insight into how FSB evolves and the influence of situational factors, such as nationality and site of study. Our findings seek to inform medical school processes that support feedback literacy. Using a mixed methods approach, we collected questionnaire and interview data from final-year medical students in Ireland, Bahrain, and Malaysia. A validated questionnaire investigated relationships with FSB and goal orientation, leadership style preference, and perceived costs and benefits. Interviews with the same student population explored their FSB experiences in clinical practice, qualitatively, enriching this data. The data were integrated using the 'following the thread' technique. Three hundred and twenty-five of a total of 514 completed questionnaires and 57 interviews were analysed. Learning goal orientation (LGO), instrumental leadership and supportive leadership related positively to perceived feedback benefits (0.23, 0.2, and 0.31, respectively,  < 0.05). Perceived feedback benefits are related positively to feedback monitoring and inquiry (0.13 and 0.38, respectively,  < 0.05). The personal cost of feedback is unsupported in quantitative data, but was a strong theme in interviews, as was feedback avoidance, peer feedback, and unsupportive learning environment. No differences were observed across sub-groups based on gender, study site, or student nationality. Integrated analysis describes FSB: avoiding 'unsafe' feedback ( ) and overcoming barriers ( ) and goal-centred curation ( ) to optimise benefits. Diverse medical students across three continents undertake FSB with careful navigation, as a valued but risky business, that is highly contextualised. Promoting a constructive FSB is complex. Overcoming outdated theory and practices on the wards remains a challenge to psychologically safe, learner-centred feedback.

Malaria is a major global health problem for which an effective vaccine is required urgently. Prime-boost vaccination regimes involving plasmid DNA and recombinant modified vaccinia virus Ankara-encoding liver-stage malaria antigens have been shown to be powerfully immunogenic for T cells and capable of inducing partial protection against experimental malaria challenge in humans, manifested as a delay in time to patent parasitemia. Here, we report that substitution of plasmid DNA as the priming vector with a specific attenuated recombinant fowlpox virus, FP9, vaccine in such prime-boost regimes can elicit complete sterile protection that can last for 20 months. Protection at 20 months was associated with persisting memory but not effector T cell responses. The protective efficacy of various immunization regimes correlated with the magnitude of induced immune responses, supporting the strategy of maximizing durable T cell immunogenicity to develop more effective liver-stage vaccines against Plasmodium falciparum malaria.

In animals, effective immune responses against malignancies and against several infectious pathogens, including malaria, are mediated by T cells. Here we show that a heterologous prime-boost vaccination regime of DNA either intramuscularly or epidermally, followed by intradermal recombinant modified vaccinia virus Ankara (MVA), induces high frequencies of interferon (IFN)-γ-secreting, antigen-specific T-cell responses in humans to a pre-erythrocytic malaria antigen, thrombospondin-related adhesion protein (TRAP). These responses are five- to tenfold higher than the T-cell responses induced by the DNA vaccine or recombinant MVA vaccine alone, and produce partial protection manifest as delayed parasitemia after sporozoite challenge with a different strain of Plasmodium falciparum . Such heterologous prime-boost immunization approaches may provide a basis for preventative and therapeutic vaccination in humans.