As a part of routine clinical care, the Ealing Liaison Psychiatry Service (ELPS) uses the Clinical Global Impressions (CGI) scale to assess patient-reported outcomes. We would like to share our findings and the challenges in interpreting CGI ratings.1 and have since been adapted for use in liaison psychiatry as a part of a nationwide evaluation. The Framework for Routine Outcome Measurement in Liaison Psychiatry2 proposed that all liaison psychiatry services use CGI scales for consistent data collection and national reporting of outcomes, although there is no guidance on a standard to aim for.CGI scales in psychiatry were initially used to assess efficacy in clinical drug trialspercentages of patients reporting changes in their mental health and potential reasons for this;concordance between patient and clinician ratings.Fifty-nine per cent of patients reported an improvement in their mental health, although the reasons for this were unclear, given that the CGI questionnaire has no section for patients to justify their rating. A variety of factors may be involved, including having a focused consultation with a clinician, a decrease in symptom severity, and improvements in physical or social symptoms during the hospital stay, as these are often inextricably linked with mental health.Our methodology involved patients and their ELPS clinicians providing a CGI rating on whether the patient's mental health had improved, not changed or become worse after ELPS contact. This study looked at all 205 patients between January 2018 and November 2019 who had filled out a CGI questionnaire, and the following analyses were made:Forty per cent felt there was no change after ELPS intervention, and 1% (three patients) indicated feeling worse. Of the latter, two patients had to be admitted to an in-patient psychiatric unit, which could suggest that their lack of improvement was due to the severity of their mental health condition itself. There was 91% concordance between patient and clinician ratings, suggesting that subjective ratings from patients may not be needed if clinicians’ objective ratings are so closely tallied.3 and its advantages lie in its ease of understanding by both professionals and lay people, its ability to track progress across time and its swiftness of application. On reflection of our findings, we are unable to comment on our performance given the dearth of literature discussing what constitutes the gold standard. However, encouragingly, most patients reported improvement while only a very small minority reported deterioration, indicating that liaison psychiatry interventions are effective and largely beneficial.The CGI scale has been correlated with more time-consuming rating scales used in psychiatry,By nature, the liaison psychiatry population comprises patients with both physical and mental health conditions, causing relative difficulty in teasing out which of the two issues is better manifested in the desirable outcome. In addition, the heterogeneity of the liaison psychiatry population makes it difficult to make direct comparisons of validity between different psychiatric conditions.This simple service evaluation suggests that ELPS improves patients’ well-being according to CGI scales. Nevertheless, wider-scale studies should be performed to elucidate how liaison psychiatry interventions are beneficial and to inform what the standard of care should be.


In the Philippines, drug-resistant tuberculosis (DRTB) is a growing concern. Healthcare workers face challenges in retaining patients with DRTB in care. This study intends to understand their perspectives on the factors that influence patient treatment outcomes and to propose potential programmatic solutions for strengthening care services for the patients.  A mixed-methods study was conducted in the Philippines between December 2017 and March 2018 to understand the major barriers for healthcare workers to provide quality care to DRTB patients across the care continuum. In the quantitative phase, healthcare workers participated in an online survey; in the qualitative phase, in-depth interviews were conducted with a select number of the survey respondents to better understand their survey responses.  272 healthcare workers participated in the survey, and of those, 11 were interviewed. Survey results identified economic constraints, patient perceptions of care, family-related concerns, and limited accessibility to healthcare services as the major patient-related barriers across the care continuum. Major health-system-related barriers were insufficient human resources, lack of financial and political support, and limited knowledge about DRTB by healthcare providers. Interviews revealed more elaborate, contextualized, and nuanced aspects of each of the major challenges. The elaborated patient-related barriers included expenses needed during treatment ; fear of being stigmatized by family, community, or healthcare staff; worries about adverse drug reactions from medication; a lack of family support; and the location of patients' homes. The health-system-related barriers revealed through interviews included the limited capacities of facility staff to provide DRTB care due to insufficient human resources; the shortage of funds to support treatment completion ; and discrimination by healthcare staff against patients with DRTB attributed to the staff's limited knowledge and experiences of treating the patients.  This study identified the main barriers for DRTB facility staff in the Philippines from the perspectives of providers. Further exploration of the barriers and best practices in facilities may be useful for improving DRTB care in the Philippines. Tuberculosis (TB) is a major public health issue in the Philippines. Nearly one million people had active TB in 2019, which is the third highest prevalence in the world .Across the care continuum , studies conducted in the Philippines have underscored challenges to TB care services. These studies have divided barriers into patient-related barriers and health-system-barriers –6. PatieAlthough various barriers to accessing quality TB care have been identified from both the patient's and community's perspectives in the Philippines –9, the pA mixed methods study was conducted between December 2017 and March 2018. Quantitative data were collected from December 2017 to January 2018 using an online survey developed with a web-based tool, SurveyMonkey®. The survey was sent to healthcare workers responsible for providing services to patients with DRTB across the Philippines. Contact information was obtained from the DRTB facility staff registry provided by a nongovernmental organization (NGO), a partner of the National TB Program (NTP), charged with hiring health professionals and deploying them to DRTB referral centers throughout the country. Emails were sent to healthcare workers by the NGO's management with a separate survey link sent by the principal investigator, YE. The survey was written in English, one of the official languages in the Philippines. Only those who provided consent at the beginning of the survey were asked to complete the survey.The survey was developed based on our prior research and TB expert consultations with WHO on barriers and facilitators to delivering quality TB care –9. The sFollowing the survey, qualitative data were collected through semistructured telephone interviews with healthcare workers. Sampling is aimed at providing representative coverage across regions and facilities in the Philippines. The interviewed workers were purposefully selected from among those who had provided complete responses to the closed and open-ended questions on the survey in order to more profoundly understand, verify, and contextualize survey responses. Hence, this study applied a two-phase mixed methods design named the Explanatory Design, which purpose is that qualitative data help explain or build upon initial quantitative results . ThroughSurvey responses to both closed and open-ended questions collected through the survey were exported from the online platform onto an MS Excel® spreadsheet. First, responses to the closed-ended questions were counted and ranked based on the numbers in each question in order to identify major knowledge gaps, attitudes, and practices related to specific TB policies and guidelines. For the responses to the open-ended questions in the survey, the lead author (YE) read through every response to become familiar with the data and identify preliminary themes emerging from the data before exporting the responses to QDA Miner Lite®, qualitative data analysis software, for further analysis. Using the query and coding functions in the software, broad categories were developed  whereby YE coded each individual response, and then measured the frequency of the categories most often mentioned by respondents in order to identify the most common barriers and recommendations. To identify emerging themes, YE re-read responses that were grouped in broad categories. Major themes were organized across patient-and health system levels. Interviews were transcribed by an independent, transcription company, and transcripts were analyzed using again QDA Miner Lite®. For the purposes of this paper, only participant responses to questions pertaining to their open-ended survey responses were analyzed.From a total of 322 invitations sent, 272 participants from 146 DRTB treatment facilities across all 18 regions in the country completed the survey, with a response rate of 84.5% (272/322). On average, the survey took 90 minutes to complete. During the in-depth interviews, respondents further revealed that many patients could not afford treatment-related expenses, such as transportation, or stopped working to be able to complete their treatment. Many patients were the breadwinners in their households and therefore struggled with providing for their family while remaining in treatment.“They always prioritize what their family needs... [They] are breadwinners... [and] have to work.” .According to respondents, “patients' perceptions” specifically referred to patient concerns that prevented them from initiating treatment, such as fear of being stigmatized by their family or community, worries about ADRs during treatment or complete denial of TB-positive test results.“Patients… [are] afraid about [sic] ADRs… They can see other patients… who are already vomiting.” .When asked to expand about “family-related issues” mentioned in the survey, healthcare workers alluded to their patients who did not live with their families or those who did not have a strong support system. Limited understanding of TB by families was also related to insufficient psychosocial support provided to patients as a barrier to treatment initiation.“He was separated from his family… [and] prefers to drink… rather than the medicines.” .Based on responses from 211 participants, the most frequently mentioned health-system-related barriers included insufficient human resources (57%), inadequate financial support (29%), and poor political support (13%).Interviewees expounded primarily on inadequate human resources. When considering the number of patients with DRTB and their other work duties, including seeing patients with other diseases, health workers felt that they did not have enough time nor the resources to provide quality care to new patients looking to begin treatment in their facilities.“We cater [to] 80 patients… Daily DOT is not just our work… We do documentation, reporting, finances.” .Interviewees felt that more financial support from the government was needed, such as increasing the current transportation allowance for commuting to facilities and providing food packages to patients.“Some of the patients… are very far, the transportation allowance is not enough.” .Interviews clarified that the food package support was being programmatically implemented until it was discontinued in 2018, which limited the financial and political support offered to health facilities responsible for providing care to patients with TB.A total of 211 participants indicated that the main patient-related barriers impacting treatment retention under quality DRTB care were the perceptions of patients (28%), the location of patients' homes (18%), and a lack of family support (12%).When asked to expand on patient perceptions, healthcare workers mentioned the difficulties to ensuring continued care of patients, particularly when symptoms waned while on treatment and patients felt “cured”, thus not feeling the need to continue treatment.“Some patients thought that once they feel better, they are cured of tuberculosis.” .According to interviewees, other patients who discontinued treatment felt stigmatized by other healthcare workers. The location of patients' homes was also considered a burden for patients both physically and financially, leading them to discontinue treatment.“During rainy seasons, they cannot go to the center… really muddy.” .Lack of family support, especially emotional and financial support, were also obstacles mentioned that affected patients' continuation and completion of treatment.“There is no family support… if he won't work, he won't eat.” .As compared to the aforementioned patient-related barriers, 176 respondents considered insufficient human resources (41%), facility capacity to accept decentralized patients (25%), and inadequate political support (15%) as major hindrances within the health-system.Interviewees further explained that community treatment partners—those that treat patients at the community level and provide accessible care—were difficult to locate and provided inadequate care and treatment when the patient was decentralized. To them, the limited capacity to train treatment partners resulted from shortages in human resources.“Much [sic] more patients than the [community health workers] and sometimes it's only one nurse [at community level].” .Other healthcare workers expressed that when they referred a patient to another facility closer to the patient's residence, the facility did not accept the patient because of issues like lack of space, heavy workloads, or discrimination of patients by staff.“They (patients with DRTB) are… discriminated by the [referred] health center's staff.” .According to them, the discrimination experienced in these facilities where patients were referred and decentralized was due to a lack of knowledge about DRTB and infection control practices from health workers who used to deliver care for only patients with drug susceptible and thus did not have expertise in DRTB care and management. Political support from local government units for patient rehabilitation was also perceived as insufficient and considered as inadequate.“Maybe there are some LGUs  not to give a certain budget to health.” .The main patient-related obstacles identified through 371 responses included patient adherence (31%), limited contact information (30%), and remoteness of patients' homes (23%). When attempting to reengage patients back into care, healthcare workers alluded to their experiences contacting patients who expressed anger or evaded communication with them. Some patients turned their phones off or refused to leave their homes to take directly observed treatment at health facilities according to respondents.“There's a patient who gets angry at us [when we conduct a home visit], ‘Why are you here? Why are you here?'” .Healthcare workers also found it challenging to carry out patient outreach actions when they could not obtain the patient's correct or complete contact information. Some patients did not have a phone, while others filled in incorrect contact information on the registry form. The distance and inaccessibility of patients' homes from DRTB treatment sites also made outreach actions challenging, given the limited time and budget required for home visits.“If the patient's address is really from the [sic] far-flung area… most of the time I do not manage to go.” .Insufficient human resources (58%), inadequate financial support (16%), and poor phone network (9%) were identified as the most frequent challenges related to the health-system, according to 316 survey responses. A shortage of healthcare workers dedicated to DRTB and heavy workloads made it difficult to conduct outreach actions such as calling and visiting patients. Healthcare workers also found it difficult to contact patients located outside of the phone network.Additional financial and logistical support were needed by healthcare workers particularly to contact patients, according to interviewees. This is because facilities that serviced a higher number of patients who discontinued treatment received limited funds and could not afford the costs incurred from calling or texting patients from personal mobiles. Additionally, most healthcare workers did not possess dedicated service vehicles from their respective facilities. Therefore, they needed to resort to public transportation.“Often, we commute… [by] bus, tricycle .” .According to 151 participant responses, the main patient-related challenge found regarding the management of adverse drug reactions was patient perceptions of medication (36%). Interviews suggested that some patients worried that ancillary drugs prescribed for mitigating nausea and vomiting would negatively affect their organs and worsen their health, especially if they were taking medications for other chronic conditions. This resulted in patients refusing ancillary drugs and to continue taking their treatment, according to healthcare workers.“There are some patients who complain of pill burden... the additional pill load.” .Regarding health-system-related barriers, insufficient human resources (24%), and unavailable drugs (16%) were identified as major concerns. According to the participants that were interviewed, some ancillary drugs were not available in certain facilities, which may have reduced the likelihood of managing ADRs.“Some of [the ancillary] drugs are not available… not being provided by the program.” .This study identified the main barriers to providing quality care to patients affected by DRTB in the Philippines from the perspective of frontline healthcare staff. They were identified from a wide range of views of healthcare staff collected through the distribution of a nation-wide online survey and further explored through in-depth interviews consecutively. Most of the barriers were derived from hardships that patients experienced, such as economic constraints, family-related concerns, and limited accessibility to healthcare services. On the other hand, main health-system-related challenges identified included insufficient human resources, insufficient financial and political support, and limited knowledge about DRTB by healthcare providers. Potential solutions are divided based on each primary barrier identified in the study to support health staff in the delivery of patient-centered DRTB care.One commonly perceived barrier found in the study was the increased financial burden on patients under DRTB care, a process that takes at least nine months and can last even up to two years . A 2020 Rather than relying on the standard rate of 100 pesos, one potential solution would be for the government to provide sufficient financial support to patients to cover loss of income and transport costs. In Niger, the NTP supported a comprehensive package for multidrug-resistant TB management, including funding sufficient to transport patients from their homes to healthcare facilities as well as nutritional support . Other sLimited budget at health facilities was also perceived as an obstacle for quality healthcare delivery; unavailability of facility-owned service vehicles and absence of funds for phone calls prevented healthcare workers from conducting sufficient and timely outreach activities. Given that studies emphasize the importance of adequate efforts for patient outreach actions by healthcare workers , adequatBecause insufficient human resources were also identified as a key administrative barrier, one possible measure to address the consequential issue of over-burdened healthcare workers is to provide basic DRTB care  at the community or home level, as indicated in the national DRTB guidelines  and as rThe fear of being stigmatized by the community, family, or health facility staff, as well as concerns about ADRs, were other main barriers identified by healthcare workers about why they thought patients had difficulties initiating and completing treatment. One study in Peru showed that the fear of being stigmatized among patients with DRTB was mitigated by the psychosocial support of psychiatrists and nurses . In EthiRecommended measures for minimizing patients' negative feelings about ADRs include understanding patients' views about medication therapy, educating patients about the benefits of treatment, informing patients about potential ADRs and management strategies, and ensuring an updated and accurate medication list . These sIn addition, recent studies have found that financial, physical, and emotional family support are important factors in adherence to treatment , 32. Potn = 11) needs to be mentioned. Although this may have had a limiting influence on fully exploring the participants' perspectives, they were carefully selected based on the completeness and comprehensiveness of responses expressed in the preliminary survey. That is expected to mitigate the risk to some extent. Lastly, to declare this study's independence of and impartiality from any influences of other individuals or organizations than the authors, the authors had full control over the data and had no agreements with funders who may have limited the study's completion. No funders had a role in the study design, data collection and analysis, decision to publish, or preparation of the manuscript.However, some limitations should be noted. First, there may have been response bias, and the collected responses may have been skewed towards positive responses, responses that participants only wanted to answer, or topic areas that they wanted to highlight. Since the survey was designed to permit participants to proceed throughout the survey without having to answer each question, the completeness of the data was affected. This was done to lessen the burden for healthcare workers and was mitigated through additional verification from the in-depth interviews. Next, the ambiguity of some responses to open-ended questions is noticed. However, most participants provided enough description in their answers, and only a small proportion of the open-ended answers were described with vague expressions, such as 'financial', ‘family', and ‘politic'. To avoid the risk of misinterpretation for such expressions, the authors conducted the coding process, carefully following the thematic analysis protocol and carefully considering whether to be included under a category of a particular theme or omitted from the analytic process. Additionally, the limited number of the interviewees (This is the first mixed-methods study to identify major barriers impacting the initiation and retention of patients with DRTB from the perspectives of providers across the Philippines. The findings were based on the perspectives of DRTB treatment facility staff alone and excluded other actors, such as community treatment partners and patients with DRTB. However, the study explored different aspects of the treatment continuum for patients with DRTB from the perspectives of a nationally representative sample of healthcare workers.This study identified the main patient- and health system-related barriers DRTB facility staff faced when providing care to patients and the factors affecting sustained medication adherence in the Philippines. The recommendations generated by this study provide guidance to the NTP program of the Philippines and advocate for improved quality care for patients affected by TB worldwide. Further exploration of the barriers, best practices in facilities, and recommendations for strengthening the NTP program from the perspective of providers could be useful for improving DRTB care in the Philippines. Evidence-based programmatic measures must be implemented to alleviate health system gaps across facilities that offer care to patients with DRTB.


Identifying drivers of transmission—especially of emerging pathogens—is a formidable challenge for proactive disease management efforts. While close social interactions can be associated with microbial sharing between individuals, and thereby imply dynamics important for transmission, such associations can be obscured by the influences of factors such as shared diets or environments. Directly-transmitted viral agents, specifically those that are rapidly evolving such as many RNA viruses, can allow for high-resolution inference of transmission, and therefore hold promise for elucidating not only which individuals transmit to each other, but also drivers of those transmission events. Here, we tested a novel approach in the Florida panther, which is affected by several directly-transmitted feline retroviruses. We first inferred the transmission network for an apathogenic, directly-transmitted retrovirus, feline immunodeficiency virus (FIV), and then used exponential random graph models to determine drivers structuring this network. We then evaluated the utility of these drivers in predicting transmission of the analogously transmitted, pathogenic agent, feline leukemia virus (FeLV), and compared FIV-based predictions of outbreak dynamics against empirical FeLV outbreak data. FIV transmission was primarily driven by panther age class and distances between panther home range centroids. FIV-based modeling predicted FeLV dynamics similarly to common modeling approaches, but with evidence that FIV-based predictions captured the spatial structuring of the observed FeLV outbreak. While FIV-based predictions of FeLV transmission performed only marginally better than standard approaches, our results highlight the value of proactively identifying drivers of transmission—even based on analogously-transmitted, apathogenic agents—in order to predict transmission of emerging infectious agents. The identification of underlying drivers of transmission, such as through our workflow here, therefore holds promise for improving predictions of pathogen transmission in novel host populations, and could provide new strategies for proactive pathogen management in human and animal systems. Infectious disease outbreaks can have profound impacts on conservation, food security, and global health and economics. Mathematical models have proven a vital tool for understanding transmission dynamics of pathogens , but strA handful of studies have evaluated whether common infectious agents present in the healthy animal microbiome or virome can indicate contacts between individuals that may translate to interactions promoting pathogen transmission –22. Suchapathogenic agents) for use as markers of transmission-relevant interactions. Such apathogenic agents should have rapid mutation rates to facilitate discernment of transmission relationships between individuals over time  are an endangered subspecies of puma found only in southern Florida. We have documented that this population is infected by several feline retroviruses relevant to our study questions  to determine which drivers shape FIV transmission in Florida panthers, and (2) test if these drivers are consistent with and can predict transmission of analogously transmitted FeLV in panthers. Success of this approach in our panther system would encourage testing similar apathogenic agents in other host-pathogen systems, with potential to improve our understanding of drivers of individual-level heterogeneity in transmission and consequently our ability to predict transmission dynamics of novel agents in human and animal populations.via aircraft typically three times per week. Previous panther research has generated a microsatellite dataset for monitored panthers  telemetry collars, with relocations determined panthers , and a dpanthers ]. In addpanthers , we levek) to 0. We used a patristic distance threshold of 0.05 and allowed missing and more complex transmission relationships. Because we had uneven read depth across FIV genomes, we downsampled to a maximum of 200 reads per host. The output of the full Phyloscanner analysis was a single transmission network .To determine drivers of FIV transmission, we first generated a “who transmitted to whom” transmission network using 60 panther FIV genomes collected from 1988 to 2011 . We usesummary FIV networks, varying the degree of window overlap in the first step of Phyloscanner analysis and re-running the random read downsampling in the second step. With Phyloscanner step one set to 25bp overlap, we generated four additional FIV transmission networks, but kept only those edges that were found in at least two of these four networks. We repeated this process with Phyloscanner step one set to 0bp overlap, again keeping only those edges found in at least two of four resulting transmission networks.To test sensitivity of our subsequent inference to variations in Phyloscanner output , we also generated two a priori expected to influence direct transmission processes in panthers. We considered several structural variables: an intercept-like edges term ; alternating k-stars ; and 2-paths . ERGMs ges term ; geometrk via j; ]. In addk via j; ]; positi ArcGIS; ]; pairwi ArcGIS; ; and pai ArcGIS; , 43]. Weergm package . Hereafter, a full simulation includes both simulation of the panther population with its likely transmission pathways  and simulation of FeLV transmission within that population. This strategy of simulating new populations for each transmission simulation avoided putting excess weight on a small number of simulated and therefore uncertain networks. Below, we describe the process for a single simulation, but these procedures were repeated for each full simulation.We first simulated panther populations that were representative of the population during the 2002-04 FeLV outbreak. Here, network edges represented likely transmission pathways based on ERGM-identified drivers of FIV transmission  are infectious (β), develop clinical disease, and die due to infection (μ). Regressive infections  recover from infection  and, having entered a state of viral latency, are not considered at risk of FeLV reinfection . Abortive infections (probability 1-2P) are never infectious, clearing infection and joining the recovered class. While the duration of immunity in abortive cases has not been studied in panthers, because abortive cases clear infection through a strong immune response and develop anti-FeLV antibodies, reinfection with FeLV is considered extremely unlikely . Because panthers were vaccinated in the empirical outbreak with a domestic cat vaccine with unknown efficacy in panthers, we allowed vaccinated individuals to become infected in transmission simulations by including a binomial probability for vaccine failure  across a range of reasonable parameter space  between 19 individuals  and star structures  as key structural variables, and age category and log transformed pairwise geographic distance as key transmission variables . Feasible parameter sets from both the FIV-based and overlap-based models produced some evidence of local and global spatial clustering of simulated FeLV cases  results. However, the parameter shaping transmission from regressively infected individuals (C), consistently showed support for weak to moderate transmission from regressives -based approach focused on underlying drivers or mechanisms of transmission and could be used to prospectively identify management-relevant predictors of transmission and develop disease control plans prior to an outbreak of a virulent pathogen (FeLV). We found that FIV transmission in panthers is primarily driven by adults and proximity between home range centroids, and that our FIV-based drivers of transmission predicted FeLV transmission dynamics at least as well as simpler alternative models in a prospective modeling framework (comparable to predicting transmission dynamics of novel or emerging pathogens). While we do not propose that this apathogenic agent approach could accurately predict exactly when, where, and to whom transmission might occur, our results support the role of apathogenic agents as novel tools for prospectively determining sources of individual-level heterogeneity in transmission and consequently improving proactive disease management.via transmission tree and ERGM analyses) and then translate to predictions of FeLV transmission, rather than relying on retrospective FeLV spatial analyses. Furthermore, while more complex potential drivers of transmission  were not found to be important for FIV transmission in this host-pathogen system, these may yet be key for driving transmission in other systems. Simpler model types like random networks or metapopulation models may struggle to make transmission predictions that incorporate these drivers of transmission-relevant contact. The predictive capabilities we observed here using drivers of an apathogenic virus could thus open new opportunities to determine behavioral and ecological drivers of individual-level heterogeneity in the context of pathogen transmission, and even shape epidemic management strategies for pathogens such as FeLV.We found that our network model based on drivers of FIV transmission produced FeLV outbreak predictions consistent with the observed FeLV outbreak. The FIV-based approach performed at least as well as simpler models, per our GLMM analysis, with evidence that FIV better predicted the observed spatial dynamics for FeLV transmission. A key difference between the FIV-based approach and other spatially explicit methods is that FIV allowed us to determine the importance of spatial dynamics prospectively  determined that pairwise geographic distances and age category structure FIV transmission in the Florida panther. These findings were generally robust to variations in the transmission network and are well supported by panther and FIV biology, providing confidence in the functioning of our workflow for identifying drivers of transmission. For example, panthers are wide-ranging animals but maintain home ranges, and this appears to translate to increased transmission between individuals that are close geographically. This finding is supported by the tendency for FIV phylogenies to show distinct broad  and fineificance . The widificance , with FIWith these ERGM results in mind, key components of the success of our FIV-based approach are likely that (1) FIV is a largely species-specific virus with transmission pathways closely matching intraspecific transmission of FeLV, and (2) both FIV and FeLV, perhaps unusually for infectious agents of puma, display spatial clustering of infection. Here, FIV fundamentally acted as a proxy for close, direct contact in panthers, and could consequently determine drivers of such contacts. If, for example, FIV also exhibited strong vertical or environmental transmission, we would no longer expect the predictive success for FeLV we observed here. This consideration highlights the importance of careful apathogenic agent selection when attempting to identify drivers of transmission relevant to novel or emerging pathogen transmission. For example, the mixed results when using commensal agents to identify close social relationships in other systems , 21, 22 We propose that apathogenic agent selection should carefully consider agent genetic diversity within a target population—not just expected diversity based on typical mutation rates –27, as iOur FIV-based approach to identifying drivers of transmission required extensive field sampling, though this is not infeasible in wildlife species of conservation concern or many livestock systems , 63. Wita priori expectations for novel or emerging agent transmission dynamics that can aid in proactively designing targeted intervention strategies, and (2) a platform for updating strategies as new information becomes available in the event of an outbreak. Indeed, we have used a similar approach to determine optimal FeLV management strategies in panthers, including exploring a broad range of parameter space to determine how uncertainties in transmission parameters affect expected outcomes .The datasets presented in this study can be found in online repositories. The names of the repository/repositories and accession number(s) can be found below: Data and R code for replication of simulations and analyses is archived and available on Zenodo . MG was supported by the Office of the Director, National Institutes of Health (NIH T32OD010993), the University of Minnesota Informatics Institute MnDRIVE program, and the Van Sloun Foundation. JM was supported by the ACVP/STP Coalition for Veterinary Pathology Fellows and the Linda Munson Fellowship for Wildlife Pathology Research. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.


Many simulation-based clinical education events (SBCEE) aim to prepare healthcare professionals with the knowledge, skills, and features of professionalism needed to deliver quality patient care. However, how these SBCEE learnings are translated into broader workplace practices by learners from different craft groups has not been described.To understand how learners from different craft groups (doctors and nurses) anticipate simulation-based learnings will translate to their workplaces and the process by which translation occurs.Qualitative descriptive study design using pre- and post-SBCEE questionnaires.A large tertiary Australian hospital-based simulation centre that facilitates SBCEE for multi-professional graduate and undergraduate clinicians from 16 hospitals.Participants who attended SBCEEs between May and October 2021 completed questionnaires at two touchpoints, on the day of attending a SBCEE and 6 weeks after. Based on a phenomenological approach, the study examined clinicians’ experiences in relation to simulation education, intended simulation learning use in the workplace, and perceived success in subsequently using these learnings to improve clinical outcomes. Qualitative inductive thematic data analysis was used to develop narratives for different learner cohorts.Three overarching themes were identified regarding simulation participants’ perceptions of the success of translating simulation learnings into the workplace. These were: scenario-workplace mirroring, self-assessment, and successful confidence. Doctor participants found it difficult to map SBCEE learnings to their workplace environments if they did not mirror those used in simulation. Nurses sought peer evaluation to analyse the effectiveness of their workplace translations, whereas doctors relied on self-assessment. Learners from both craft groups highly prized ‘confidence-building’ as a key indicator of improved workplace performance achieved through SBCEE learning.A diverse range of factors influences healthcare workers’ experiences in translating simulation learnings to their workplace. To equip simulation learners to translate learnings from a SBCEE into their clinical practices, we suggest the following areas of focus: co-development of translation plans with learners during the delivery of an SBCEE including the indicators of success, above table discussions on the generalisability of learnings to different environments and contexts, smart investment in simulation outputs, and cautious championing of confidence-building. The goal of many simulation-based clinical education events (SBCEE) is to prepare healthcare professionals with the knowledge, skills and features of professionalism needed to deliver quality patient care . The simProviding evidence for the clinical impact of an SBCEE is difficult , 10, 11.Whilst this systems-based approach provides a framework for SBCEE interventions to affect change in healthcare institutions, it largely omits the individual learner narratives surrounding the process of implementation and guidance on how they themselves might act as agents for change. Furthermore, most SBCEEs are delivered to groups of diverse learners; healthcare teams with staff of different craft groups, levels of seniority and experience. Thus, further research is urgently needed to help identify the specific needs different cohorts of learners require to translate their SBCEE learnings into improved clinical outcomes.Hence this study aimed to understand the “lived-experience” of clinicians who attend a simulation-based education event and how these learnings are translated to the clinical workplace.what learners experienced and how, gaining a deeper understanding of the nature or meaning of the SBCEE experience phenomena.The study used an explorative qualitative design to explore the cohort narrative . The “liThe study recruited from a single Victorian hospital-based simulation centre that provides 16 different SBCEE types to a variety of learners from ward, emergency and theatre-based roles. These events were attended by both clinicians and health professions from a variety of Victorian health networks. During COVID-19 restrictions, on average 40 participants attended the simulation centre each week. All learners who attended an education event at the simulation centre between May to October 2021 were eligible for participation.SBCEE comprised of learners from different craft groups and job roles who work across various health sites, including medical students, nursing students, trainee doctors from multiple subspecialties and levels of seniority, graduate nurses from multiple subspecialties and level of seniority, consultant doctors and nurse unit managers.Participants were identified via an opt-in process. Depending on the number of volunteers, the researchers purposively selected a mix of participants from different worksites to capture differences in education impacts experienced in different roles. Once ethics approval was attained, participants were recruited on completion of all Monash Simulation Centre education events.The simulation centre facilitated 16 different types of SBCEE: each whole day events with different aims and content of workshops and simulation scenarios. Twelve event types were opt-in and occurred outside rostered teaching time. The details of each differed to align with learning needs, the scope of practice and local protocols applicable to the direct clinical management of patients in different learners’ settings. However, there was also significant overlap of content between sessions, as each type of event focussed on discussing how human factors influence our ability to work as a team during high stress events. Participants then had the opportunity to practice these principles with Inter-professional simulated scenarios, each one followed by a debrief and discussion to explore the team performance.The study was conducted via questionnaires at two-time points: immediately after completing the simulation session Q1) and again 8 weeks later (Q2) to ensure time to trial the learnings in the workplace after participation in a SBCEE. The questionnaires were distributed and collected by the administrative staff organising the SBCEE. These were completed on-site. The second survey was accessed via a QR code sent via letter together with the participant's first questionnaire responses to prompt reflection on intended workplace translation (Table  and agaiQuestionnaires were coded independently by two investigators (JG and IS) following an iterative process with comparison. Coding was conducted using NVivo, Release 1.4 . These were reviewed by JG and IS and further discussed as a team to compare, contrast and negotiate team-based interpretations of the themes and sub-themes generated. The discussions included a notion of reflexivity where the researchers examined their positioning within the research. Narrative analysis . Sixty-seven completed both questionnaires (participation rate 30%) consisting of 37 doctors, 26 nurses and 4 students. Their years of experience ranged from 1 to 51 years, with a median of 12 years. Participants held different job roles and worked across various health sites and subspecialties.The qualitative data from questionnaires Table  was anal“I will know I have improved if I:Use the communication strategies within a team.Am recognising cognitive overload & [using] de-stressing strategies” Whilst the content of some of the SBCEE differed, the technical skill teachings, settings, and contexts were tailored to learner groups, other teaching topics were common to all sessions, including crisis resource management, optimising interprofessional teamwork, communication skills and management of cognitive load. Immediately following the SBCEE, many learners identified these universal teachings as key, and their successful use in day-to-day practice across all settings would result in measurable change.However, many doctor participants later reported difficulty in applying these SBCEE learnings to work unless they had encountered a clinical situation that mirrored the specific setting and context of the simulation sessions.“Had a lot of cover shifts so have not been dealing with a lot of the intraoperative issues that we tackled in the simulation session...” This contrasted with most of the nurse participants who more readily identified opportunities to use simulation learnings, regardless of their workplace setting or role.“Beneficial in real scenario-witnessed a new complete heart block whilst seeing a patient in the ICU and used a shared mental model to work out the cause and plan” “When I had to transfer a patient with abdominal pain from ED... the pain was so severe that they were having difficulty answering my questions, so I escalated my concern for the patient’s safety. I later went back to review once ED (clinicians) provided analgesia and we were happy the patient had stabilised” “Being calmer thinking of wider differentials. Not narrow view.” An overwhelming majority of doctors (35/37 participants) cited that successful workplace learning translation would be self-measured-identified only by internalised markers like improved emotional regulation, recall and use of self-reference guides or different thinking patterns.Only nursing participants proffered that they may seek external validation of clinical practice change from senior peers.“I will know from better patient outcomes and feedback from supervisors” “On the ward a patient had a clinical review for reduced GCS  so the HMO  and I used the systematic method to determine it was likely from aspiration pneumonia and so we organised investigation and management things like oxygen and fluids to stabilise the patient. We also worked with nursing staff to get their impression of the patient’s condition and communicated our plan so they could help us manage the patient. I noticed that I responded to this emergency more quickly and with a clearer approach than before. I am using the session's teachings well” “At MET [medical emergency] calls where I am not familiar with the patient history, I am going back to the basics as practised during simulations to ensure the emergency priorities are assessed and optimised as best I can. I asked my ANUM [supervisor] and other nurses who attended the call to give me feedback - and this was good, so I am comfortable that I am doing well [translating these learnings to the workplace]” Curiously, after returning to the workplace post-SBCEE, only nurse participants reported external feedback as a marker of whether their learnings had been harnessed in their clinical practice.I hope I will be able to perform more confidently in scenarios where I may need to stabilise unconscious patient” “The focus of most (184/206) participants simulation learning translation was “confidence”. Participants consistently prized “confidence” as the greatest change to their clinical practice that could be gained from an SBCEE.“Confidence in being first responder to MET call and being able to initiate basic airway management” This idea of “confidence” gained from an SBCEE varied widely between participants, regardless of craft group, seniority in clinical experience and workplace setting. Some championed its use in facilitating better communication, others in teamwork or wielding medical equipment.“I will know that I have translated the learnings to the workplace because the skills will just come naturally, and I will feel more at ease.” .Many learners viewed that this “confidence” would change how their minds and emotions responded during a challenging experience; that it would reduce their cognitive load, improve recall, eliminate anxiety, and the ability for observes to perceive their anxieties.“Yes [I have had the opportunity to use the learnings in my workplace] and will continue to use it to build confidence in fluid resus, workup of sepsis, ordering early investigations and altered conscious state exam.” .Even after returning to the workplace, many participants still viewed “confidence” as the key indicator of mastery in implementing simulation learnings.Taken together, our findings indicate that in our setting, the universal teachings of simulation are variably translated to the workplace and that these variables differ between learners of different craft groups. Whilst most doctor participants felt ill-equipped to use SBCEE learnings in unmatched environments, nursing simulation learners were more readily able to connect SBCEE teachings to novel bedside environments and contexts. Participants' perceived locus of control in simulation translation differed widely, with doctors feeling empowered in their abilities to accurately self-assess and reflect, whilst their nursing colleagues relied on others to provide insight on their clinical performance. This may be due to the differences in how each craft groups learn traditionally , 15; nurParticipants from both craft groups perceived that a successful translational simulation resulted in the cultivation of a confidence that afforded enhanced clinical acumen, efficiency and cognitive ease. Interestingly, there were found a great number of differences between craft groups, than commonalities in the transfer of learnings to the bedside (or lack thereof). Overall, our study highlighted the need for SBCEE educators to help learners codevelop workplace translation strategies, facilitate deeper self-reflection and guide the choice of performance indicators.Translational simulation can be conceptualised operationally as a framework of three phases: input, process and output (IPO) . DespiteMost doctor participants described a cognitive dissonance between work-based experiences and the types of activities they were primed to use the learnings for during an SBCEE. This contrasts with many nursing participants who recognised their applicability in different settings. Whilst a cause for this craft group difference could not be triangulated, previous studies have proposed the robust psychosocial dimensions afforded by common nursing learning environments compared to those doctors are commonly offered by doctor training . A key pAn overwhelming majority of participants cited that successful workplace learning translation would be self-measured, identified only by internalised markers like improved emotional regulation, recall and use of self-reference guides or different thinking patterns.Research suggests however that, unfortunately, clinicians may not be the best reporters of their own abilities . CognitiA significant finding of the study was the pervasive learner assumption that SBCEE affords opportunities for ‘confidence building’. Moreover, the accrual of confidence was essential to embed in learning, achieve skill mastery, and allow them to feel safe in high-stress environments to explore new learnings and optimise their clinical performance. Whilst participation in an SBCEE can positively affect learners ‘confidence in their knowledge and skills , this coThe accuracy and volume of recalled events may have differed between participants. The study selected a mix of volunteer participants from different work sites, roles, and levels of clinical seniority to capture differences in education impacts experienced by different types of simulation learners. The study did not investigate the characteristics of those who did not volunteer. We can postulate that several factors may have contributed to non-participation including role busyness limiting time for participation, disconnection from the hospital learning community, perceived failure in learning translation and lack of agency. Fundamentally, a limitation of this study is that the data collected represents the subjective learner's perspective. Although learners are often able to predict how well they will remember and follow through with an intention (such as simulation translation), their metacognitive abilities are not veridical, and learners are often overconfident in their predictions and underconfident in post-dictions  . As partTranslational simulation is an emerging and promising strategy for improving health service performance and patient outcomes. However, a diverse range of factors influence healthcare workers’ experiences in translating simulation learnings to their workplace. To equip simulation learners to translate learnings from a SBCEE into their clinical practices we suggest the following areas of focus: co-development of translation plans with learners during the delivery of an SBCEE including the indicators of success, the development of shared goals of success, above table discussions on the generalisability of learnings to different environments and contexts, smart investment in translation simulation outputs, and cautious championing of confidence-building. Further evaluation of translation to practice and effect on patient outcomes is warranted in assessing the effectiveness of simulation-based education.


This review article highlights gaps in the current system of drug development and personalized medicine for cancer therapy. The ex vivo model system using tissue biopsy from patients will advance the development of the predictive disease specific biomarker, drug screening and assessment of treatment response on a personalized basis. Although this ex vivo system demonstrated promises, there are challenges and limitations which need to be mitigated for further advancement and better applications.The field of cancer research is famous for its incremental steps in improving therapy. The consistent but slow rate of improvement is greatly due to its meticulous use of consistent cancer biology models. However, as we enter an era of increasingly personalized cancer care, including chemo and radiotherapy, our cancer models must be equally able to be applied to all individuals. Patient-derived organoid (PDO) and organ-in-chip (OIC) models based on the micro-physiological bioengineered platform have already been considered key components for preclinical and translational studies. Accounting for patient variability is one of the greatest challenges in the crossover from preclinical development to clinical trials and patient derived organoids may offer a steppingstone between the two. In this review, we highlight how incorporating PDO’s and OIC’s into the development of cancer therapy promises to increase the efficiency of our therapeutics. From the time of its inception in a research laboratory, delivering a cancer therapeutic to a patient often takes about fifteen years . Even afSpecifically, there are two separate situations that require more physiologically accurate models. The first is drug screening and validation as part of a developmental process that requires translationally relevant models to reduce false positive drug candidates. Next, determination of personalized differences in the treatment response is also important to predict therapeutics’ efficacy. It is critical that models used in these two processes are able to physiologically replicate the tissue they are derived from and can also be replicable between academic institutions. An effective model is one that is scalable, personalized, and able to mimic human physiology.Immortalized human cell lines with a two-dimensional culture system have proven useful in therapeutic development but inherently fall short of having bedside prediction. In the case of immortalized human cell lines, known patterns of genetic expression are useful in target optimization but require testing across a multitude of cell lines to determine any unforeseen molecular interactions. Conditionally reprogrammed patient-derived samples have been successfully converted into a two-dimensional culture, thus adding genetic diversity to the lines of cells tested . HoweverIn this facet, patient-derived xenograft (PDX) models are a step closer in recreating physiological conditions. However, PDX’s predictive weakness stems from genetic change driven by mouse implantation ,8. This It is also worth mentioning the progression of in silico models to this point. Processing high volume cancer genome datasets has enabled the identification of new driving mutations for therapeutic development . In the Organoid-based models have begun to address some of these shortcomings. The fundamental basis of an organoid is that of a cluster of cells derived from a stem cell that self-renews and differentiates into several functional cell types with a morphology representing their tissue/organ-of-origin . The posIt was in the 1980s that groups began to understand the effect of media conditions on organoid culture. Li et al. demonstrated that breast epithelial cells were able to form ducts and produce milk given the right extracellular matrix, where 2D media failed to form any milk . The watThis replication of native tissue morphology and cellular differentiation is fundamental in observing a response to treatment. The range of tissue specific cell types and three-dimensional structure achieved in organoids better represents the cellular interplay within the human body. Highly complicated processes such as angiogenesis  and neurPatient-derived organoids (PDOs) are, most simply, an organoid culture established from stem cells derived from patient biopsy. This can include tumor or normal tissue samples. Since the first established murine culture in 2009, a multitude of disease pathologies have been successfully established in human tissues using this model . To datePatient-derived organoids have been demonstrated to be superior to two-dimensional culture and PDX in several consequential areas. The first is the maintained degree of genetic similarity to the original biopsy . LeveragWhile organoids better model the morphology of their native tissue, the absence of stroma and microenvironment significantly limits their translational relevance. Inclusion of stromal niche to mimic the micro-environment is very critical to study the complex tissue system, such as the tumor. Tumors have a complex microenvironment, including dense extracellular matrix, stromal, immune, and irregular vascular infiltrate ,48. It hThe ex vivo modeling of immunotherapies is difficult for this exact reason and possibly why immunotherapy has had such mixed clinical results . AdaptinFor instance, irritable bowel syndrome (IBS) is a disease that extends beyond the complexity of intestinal epithelial PDO models. The intestinal response in IBS mimics one of infection or inflammation and leads to a cascade of inflammatory cells, edema, and release of cytokines . FurtherThe extracellular matrix is another important variable in organoid culture. The hydrogel scaffold used to support organoid growth can cover a wide range of stiffnesses that introduce a variety in cell differentiation . CommercIn more complex disease systems such as those mentioned, utilizing organ-in-chip (OIC) acts as a system to utilize the necessary components of a good model: scale, personalization, and mimicry . OIC modOIC is also unique in offering a means of studying distal organ interactions. A unique example of this is the hepatocellular/testis model developed by Baert et al. that was used to study male repro-toxicity . StudyinIn addition to these unique insights on drug development and toxicity, the organ-in-chip offers a means of studying metastatic tumorigenesis and prevention. Hemodynamic force facilitates the transport of bloodborne metastasis and is therefore a pathology well suited to be studied in OIC models. Mimicking blood flow on the chip, it is possible to label metastatic cells to determine the extent to which they encounter rolling adhesions in the same way they would distally attach in vivo ,72. DistOne drawback to OIC modeling is pointed out by Miura et al., in that it inherently limits cellular self-organization . In theiThese progressive models—PDO and OIC—are well poised to play two separate but related roles in cancer therapy. The first is drug development. Using large scale biobanks of PDOs, high throughput testing can break away from the shortfalls and inefficiencies of 2D culture and PDX, as discussed previously. The second and most exciting application is real-time personalized medicine .Becoming more efficient in our preclinical models in oncology is imperative, as the field faces soaring drug development costs  and an aVerissimo et al. utilized a biobank such as this to select a subset of RAS mutant colorectal cancers to test combinational drug testing demonstrating the potential of this system . TestingA crucial component of drug development that could be streamlined with these models is normal tissue toxicity investigation. Early phase clinical trials could greatly benefit from studying drug effects in patient-derived systems—and could very well prove more enlightening than the industry standard animal testing. Utilizing already existing organoid biobanks to evaluate toxicity in this way could prevent inappropriate drug advancement while minimizing animal costs. We have demonstrated that the patient-specific same-organ paired organoid system  can be uAn equally important preclinical metric of pharmaceutical development is that of absorption and excretion. One existing OIC duodenum model gives insight into drug effect on permeability, microvilli, and tissue morphology . SimilarFurthermore, the OIC model, in particular among ex vivo models, offers an advantage in understanding the tumor microenvironment’s influence during drug development. The degrees of freedom offered in this model—timing of pulsatile signaling, rate of fluidic streams, or timing of toxin exposure—allows for the identification of biokinetic influences. For instance, altering electrical stimulation of cardiomyocytes in vitro greatly dictates cell maturation and therefore response to pharmaceuticals . MultiarAs biobanks begin to grow, it will be important to create multiple biopsy profiles to take advantage of multisystem models such as OIC or paired organoids. Creating a high throughput system of biopsy and subsequent OIC culturing would be the ultimate preclinical trial in therapeutics and could revolutionize industry efficiency.Lastly, a dimension of drug development that can benefit from PDO models is the novel biomarker discovery. Culture media of known organoid pathologies can be matched with patient plasma to aid in diagnosis  and in dWhile organoids demonstrate obvious advantages in drug development and basic research, their application has the most revolutionizing impact on personalized medicine. Currently, there are 586 FDA approved anti-cancer drugs . With suGenotypic onco-typing has already acted as an oncologist’s greatest guidance in selecting therapy—especially as more therapies have come to market. Clinical trials have trudged forward to prove which doses, drug combinations, and therapies are most effective through statistical power and large numbers. Massive trials such as the MAGRIT trial, which has enrolled 2661 patients across some 400 centers in 33 countries, have pushed the envelope in capturing massive amounts of the effected population ,94. ThesIndeed, there are already cases in which PDO and OIC systems have been able to guide treatment. Loong et al. reported the case of a 58-year-old male diagnosed with glioblastoma multiforme (GBM), where patient-derived organoids were used to guide treatment . Using gThe importance of the parallel PDO model as a preliminary study of therapeutic response is highlighted in ovarian cancer organoids . In thisCystic fibrosis (CF) management has also demonstrated the impact PDOs can have on choosing a treatment. In a cohort of 24 CF patients, patient-derived rectal organoids were used to pair in vitro and in vivo responses . The PDOAgain, in oncology, Narasimhan et al. sequenced and drug panel-tested PDOs in 28 patients with colorectal cancer with peritoneal masses (CRPMs) . PDOs weOn a larger scale, A phase II trial of the Aurora Kinase A inhibitor alisertib was conducted . PatientIn order to improve the rate of development in new therapeutics, the National Center for Advancing Translational Sciences (NCATS), in conjunction with several other National Institutes of Health (NIH), has recently funded ten projects utilizing OIC to inform clinical trial planning . CurrentAs oncology progresses towards the goal of personalized medicine, validated ex vivo models stand to be a unique tool in clinicians’ hands. With the integration of the biopsy into the cancer staging process, PDO or OIC response can only add information for treatment guidance.Of the oncologic subspecialties—radiation oncology is uniquely situated to benefit from patient-derived modeling. Progress in the field of radiation oncology has chiefly focused on anatomical precision to reduce these acute side effects. MRI-guided radiotherapy in gynecologic cancers can reduce exposure to adjacent organs by up to 59% . Proton Equally important to predicting an individual’s tumor response and their normal tissue radiotoxicity. Unplanned breaks in radiotherapy treatment due to toxicity can have significant negative effect on treatment outcomes ,120. DifThis constellation of data draws a picture of two sectors of medicine that stand to gain from translational science: Drug development and personalized medicine. The data offered by a patient’s own tissue is invaluable both in the lab and clinic and should be leveraged as such. Working smarter—not harder—to make preclinical drug development more efficient and making therapeutic choices more accurate stands to make oncology more affordable and more effective.


Though these studies provide a valuable foundation to the cell-substrate adhesion field, the evolution of cell-substrate adhesion machinery across evolutionary space and the role of focal adhesions in vivo are largely understudied within the field. Furthering investigation in these areas is necessary to bolster our understanding of the role cell-substrate adhesion machinery across Eukaryotes plays during cell migration in physiological contexts such as cancer and pathogenesis. In this review, we review studies of cell-substrate adhesion machinery in organisms evolutionary distant from Metazoa and cover the current understanding and ongoing work on how focal adhesions function in single and collective cell migration in an in vivo environment, with an emphasis on work that directly visualizes cell-substrate adhesions. Finally, we discuss nuances that ought to be considered moving forward and the importance of future investigation in these emerging fields for application in other fields pertinent to adhesion-based processes.Cell-substrate adhesion is a critical aspect of many forms of cell migration. Cell adhesion to an extracellular matrix (ECM) generates traction forces necessary for efficient migration. One of the most well-studied structures cells use to adhere to the ECM is focal adhesions, which are composed of a multilayered protein complex physically linking the ECM to the intracellular actin cytoskeleton. Much of our understanding of focal adhesions, however, is primarily derived from  VinA is associated with cytokinesis B and has been shown to localize to ventral surface punctae  has been shown to localize to ventral surface punctae  family, SibA is expressed at the cell ventral surface and possesses multiple extracellular domains associated with cell-substrate adhesions in Metazoan β-integrins such as a von Willebrand factor type A (VWA) domain and cysteine rich domain  demonstrated that these proteins form distinct cell ventral surface punctae that co-localize with actin at filopodia . Additioilopodia . BlockinY motifs .Capsaspora integrin and scaffolding molecules for cell-substrate adhesion, further work suggests a potential role for tyrosine kinases at cell-substrate adhesion sites. In Metazoan focal adhesions, tyrosine kinases such as Src and FAK are pivotal for regulating focal adhesion formation and assembly dynamics as well as cell migration -mediated regulatory system  primordium is a group of cells known to migrate collectively between the overlying skin and the underlying muscle layer in a coordinated fashion. This migration is required to deposit a cluster of cells that eventually differentiate into mechanosensory organs  localizes to the interface where superficial primordium cells make contact with the skin, providing evidence that focal adhesions form and are activated during primordium migration . Live imin vivo VASP-positive structures is comparable to the lifetime of in vitro focal adhesions, suggesting focal adhesion lifetime in vivo might be similar to the lifetime that measured in vitro. These results suggest the presence of focal adhesion structures in leader cells during several forms of collective cell migration.While the formation of the pLL primordium is a well-studied process for revealing mechanisms of collective cell migration, other forms of collective migration in zebrafish have been shown to also require focal adhesions. Work highlighting collectively migrating endocardial cells during zebrafish heart valve morphogenesis using immunostaining approaches showed that various focal adhesion proteins, including integrin β1, integrin α5, Talin, Vinculin, and activated Paxillin, localize to the leading edge of migrating leader endocardial cells . Focal aDrosophila and zebrafish are a promising starting point for investigating focal adhesion formation in vivo, these efforts have not been replicated in mammalian systems. To our knowledge, there are no studies visualizing focal adhesions via live intravital imaging in mammalian models, with most work focused on immunostaining of fixed samples instead. For example, antibody staining of mouse lung sections with cancer metastases showed the co-localization of actin and integrin α5 in lung-colonized breast cancer cells (Though work in er cells . Furtherer cells .Drosophila, it is clear that focal adhesion formation and interaction with the ECM is a pivotal component of in vivo collective cell migration. Genomic analyses of model organisms such as Drosophila and zebrafish suggest these species possess highly conserved focal adhesion toolkits (in vivo processes, make these organisms ideal to research focal adhesion structures in a relevant in vivo environment. Initial characterization of focal adhesion components Talin and integrin β has shown that in vivo structures positive for these components appear to be smaller in size and possess faster turnover dynamics than their in vitro counterparts. Indeed, unlike in vitro focal adhesions that can be categorized into newly formed nascent adhesions and more mature adhesions, in vivo focal adhesions are largely reminiscent of nascent adhesions, suggesting effective focal adhesion-based cell migration may rely on more transient adhesion formation rather than mature and prolonged cell-matrix interactions.In summary, thanks to initial work focused on the developmental processes of Metazoan model organisms such as zebrafish and toolkits . This noin vivo focal adhesions for collective cell migration are growing, work into the role of focal adhesions during in vivo single cell migration is largely lacking. Although there has been work focusing on cell-matrix adhesion during single cells adopting cell shape changes in vivo (in vivo focal adhesion dynamics during single cell migration. This work, using a transgenic zebrafish model, focused on characterizing Paxillin localization in actively migrating single cells (in vivo single cell migration.While studies into  in vivo , to the le cells . Transiele cells . These ple cells . Work frle cells . Taken tin vivo collective cell migration, research into focal adhesions during in vivo single cell migration is still in an early stage. The only conclusions that can be established with current research into focal adhesions during in vivo single cell migration is Paxillin is present at adhesion contact sites with the ECM and is dynamically regulated. Similar to the trend seen in collective cell migration, in vivo focal adhesions are smaller during single cell migration and have a morphology reminiscent of nascent adhesions in cells under in vitro cell culture conditions.Compared to in vivo single cell migration. Although we anticipate that the function and composition of focal adhesion machinery will not differ drastically between collective and single cell migration in vivo, it is still crucial to investigate these questions. Furthermore, most of the mechanistic insight of focal adhesion biology generated in vitro has been from studies focused on single cell migration. Given this, focal adhesion-based in vivo single cell migration holds promise as serving as a direct way to compare focal adhesion mechanics, formation, and dynamics between an in vivo native environment and an in vitro cell culture system. Insights gained from this research will go a long way to understand the mechanistic basis of leukocyte and cancer cell migration, which can then be applied for targeting disease-associated processes such as cancer dissemination.One factor that may limit research is a lack of physiological processes involving in vivo focal adhesions in cell migration, there are still multiple challenges moving forward. One of the largest obstacles to further research in both in vivo collective and single cell migration is the difficulty of imaging cells in a non-invasive fashion while retaining high spatial-temporal resolution. It is important to note that most published in vivo studies take advantage of a superficial imaging plane to visualize focal adhesions such as the zebrafish pLL primordium just underneath the skin, and the follicle cell migration at the surface of the Drosophila egg. While identification of superficial tissue environments for collective cell migration can provide ideal imaging conditions, this is often not the case for single cell migration. Single cells such as cancer cells and macrophages often migrate in deeper tissue throughout the body, likely introducing ECM variability not as observed in collective cell migration. These observations provide plenty of unanswered questions for researchers to further consider when identifying relevant tissue environments. Will different types of ECM substrate within different microenvironments differentially dictate the formation of focal adhesions? Will focal adhesions adopt differential spatial-temporal dynamics in response to these different environmental substrates? Given the current limitations of non-invasive imaging techniques, it is likely that visualizing focal adhesions during cell migration in vivo will continue to require the identification of superficial imaging planes to help answer these questions and many more.Despite this initial work into the role of in vivo focal adhesion research is quantifying protein localization and dynamics at the single cell level, especially in the context of collective migration where cells are physically connected to one another during this process. Given the cell-cell contact during collective cell migration, it can be difficult to distinguish the spatial regulation of focal adhesion structures at single cell resolution, as adhesions localizing at or near membrane contact sites between trailing and leading edges of individual cells become difficult to resolve. A method to potentially overcome this challenge is mosaic labelling of cells, which will reduce fluorescence from neighboring cells and enable better spatial resolution at the single cell scale.Another challenge associated with Drosophila. In this example, it was shown that focal adhesion components localize to punctate structures at the ectodermal-mesodermal tissue interface and that disassembly of these structures enables macrophage infiltration, which was further confirmed via RNA interference of focal adhesion components talin, vinculin and integrin β (Additionally, single cell migration through a complex tissue or environment is another process where quantifying protein localization and dynamics can present challenges. Though one advantage of single cell migration is the lack of neighboring cells within a collective that can muddle the signal to noise ratio of cells of interest, there are still scenarios such as migration through tissues interfaces where confounding factors could arise. One key example is research looking at the role of focal adhesions in dividing ectodermal cells during macrophage infiltration in tegrin β . This woin vivo focal adhesion structures in both collective and single cell migration is promising. This includes investigating the presence, interactions, and dynamics of individual focal adhesion components, elucidating the overall focal adhesion architecture, and teasing out the spatial organization of these structures in both single cells and collective cell groups.As researchers develop techniques to overcome these challenges, future work on in vivo can elucidate physiologically relevant dynamics and functions that these structures possess during processes such as migration or proliferation in a physiologically-relevant environment. These insights can then be applied into disease contexts such as cancer with the assurance that physiological nuances and complexities are largely accounted for, providing a more accurate picture when considering potential disease therapies or interventions focused around cell-substrate adhesion machinery.Decades after the discovery of focal adhesions and the initial studies characterizing their basic functions and components, , the fieThe advent of these new avenues of investigation, as well as other future directions not covered in this review, are fields full of promise for researchers interested in pushing the boundaries of cell-substrate adhesion machinery. These new findings will help contribute to a more holistic understanding of the field of cell-substrate adhesions machinery, which will go a long way when applying this understanding to other areas of study such as cell migration, proliferation, survival, and pathogenesis.


Staff reported feeling empowered to query antibiotic appropriateness with prescribing clinicians. The TARGET Antibiotic Checklist was completed with 2043 patients. Topics patients identified as requiring advice from the pharmacy team included symptom duration, alcohol and food consumption guidance, antibiotic side-effects, and returning unused antibiotics to pharmacies. Pharmacy staff acknowledged the need for improved communication across the primary care pathway to optimise antimicrobial use, and PAMSI has potential to support this ambition if implemented nationally. To support patients not attending a pharmacy in person, an online information tool will be developed.The community pharmacy antimicrobial stewardship intervention (PAMSI) is multi-faceted and underpinned by behavioural science, consisting of the TARGET Antibiotic Checklist, staff e-Learning, and patient-facing materials. This mixed-method study evaluated the effect of PAMSI on community pharmacy staffs’ self-reported antimicrobial stewardship (AMS) behaviours. Data collection included staff pre- and post-intervention questionnaires, qualitative interviews, and TARGET Antibiotic Checklists. Quantitative data were analysed by a multivariate ordinal linear mixed effect model; qualitative data were analysed thematically. A total of 101 staff participated from 66 pharmacies, and six completed semi-structured interviews. The statistical model indicated very strong evidence ( Antimicrobial resistance (AMR) is exacerbated by the use of antimicrobials . The UK’There is evidence of antibiotic non-adherence behaviours of patients in the community, such as not completing the prescribed course, and using leftover or non-prescribed antibiotics ,10,11,12Community pharmacy staff believe that providing antibiotic and infection self-care advice is a key responsibility; however, lack of time, resources, and awareness of their role in AMS often prevents this ,16,17. TThe effectiveness of PAMSI was measured pragmatically in everyday community pharmacy practice. Quantitative and qualitative data were collected via pre- and post-intervention questionnaires, semi-structured interviews with community pharmacy staff, and a follow-up questionnaire with participating patients . ParticiA pilot, using all questionnaires and interview schedules planned for the main evaluation, was completed with six purposively recruited community pharmacies (varied size and type) in South-West England in August 2020, to identify if the study design was still appropriate during COVID-19 restrictions. Staff implemented the PAMSI for two weeks and participated in a semi-structured telephone interview. The pilot supported the commencement of the full evaluation if the antibiotic prescription was being collected in person at the pharmacy, and if staff utilised local COVID-19 guideline measures or supported patients in completing the TARGET Antibiotic Checklist.A total of 105 Boots UK community pharmacies located in England were purposively selected to include different regions, areas , and type of pharmacy . The number and range of pharmacies invited were based on practicality, available resources, and the goal to maximise diversity in participants. Pharmacies were invited via a centrally disseminated communication from Boots UK, followed by email correspondence from researchers. One staff member from each pharmacy provided informed consent and acted as the pharmacy representative; they were asked to return completed TARGET Antibiotic Checklists and encourage colleague involvement. Participating staff were asked to complete the AMS e-Learning and then use the resources for four to six weeks from October to December 2020.(a)TARGET Antibiotic ChecklistsIn October 2020, pharmacies received a package comprising printed TARGET Antibiotic Checklists, patient-facing leaflets and resources (available via the TARGET toolkit ), and pr(b)Staff questionnairesThe pre (October 2020) and post (December–January 2021) staff intervention questionnaires  were hos(c)Staff interviewsPharmacy staff were able to express interest in participating in interviews at the end of the post-intervention questionnaire; 16 of the 81 staff (20%) expressed interest and were invited in February 2021; six pharmacists agreed. Interviews were conducted by two female researchers (AT and FP) experienced in qualitative research who encouraged pharmacists to speak openly about their experiences. These researchers were not involved in the first part of the evaluation and therefore were not known to participants. The interview schedule  was alig(d)Patient questionnaireIn addition to the main data collected, a questionnaire was sent to patients who provided their contact details (email address or telephone) on the TARGET Antibiotic Checklist. Checklist data were returned on a weekly basis, and researchers followed up all patients who provided contact details, with a link to an online questionnaire. As this was not a primary outcome, the results are provided in the Microsoft Excel was used for descriptive analysis and visual presentation of the quantitative data. A statistical model was applied to staff pre- and post-intervention questionnaire primary and secondary outcomes. The aim of the multivariate ordinal linear mixed effect modelling was to detect evidence of improvements in the primary (staff checking of antibiotic appropriateness) and secondary outcomes (provision of advice to patients) at post- versus pre-intervention. The linear predictor included individual random (latent) effects to consider extra variation that was not explained by the intervention. The linear predictor included additional variables collected from participants in addition to the intervention: participant professional role; pharmacy region; rural or urban area; whether the pharmacy had taken part in previous infection-related interventions; and participants’ previous training in infections or antibiotics. All statistical analysis was completed in the generalised latent linear and mixed model (GLLAMM) in Stata 17.Analysis of qualitative interview transcripts followed a six-stage inductive thematic analysis consisting of: familiarisation with the data; coding the meaning of data in the transcripts; searching for themes; naming, reviewing, and revising themes; and reporting themes . NVivo pThis service evaluation was internally reviewed and approved by the UKHSA Research Ethics and Governance Group (REGG) (Reference: R&D NR0176). All participants providing data via questionnaires or interview were provided with information and consent forms before consenting to participate and were aware of the study aims. Questionnaires were hosted on a secure SnapSurvey platform, and all files were handled in accordance with the Data Protection Act 2018 and General Data Protection Regulations (GDPR).A total of 101 pharmacy staff from 66 of 105 (62.9%) invited community pharmacies participated; 91 and 81 pharmacy staff completed the pre- and post-intervention questionnaires, respectively, and eight pharmacies were lost to follow up. Most staff identified as a pharmacist (59%) or dispenser (18%); see Pharmacy staff used the TARGET Antibiotic Checklists with 2043 patients over the data collection period; 884 patients provided contact details, and 89 (10%) responded to a follow up questionnaire after their pharmacy visit .Of the TARGET Antibiotic Checklists completed by participating pharmacy staff, 1944/2043 (95%) of patients named the infection they were being treated for, and 1846/2043 (90%) patients reflected on their knowledge upon arrival at the community pharmacy . While pPharmacy staff also used the TARGET Antibiotic Checklist to audit antibiotic safety and appropriateness checks against each prescription. Staff indicated that they checked for: allergies and risk factors (84%); the correct dosage (86%); the correct duration (84%); antibiotic appropriateness (86%); and that they checked against local prescribing guidance (73%). The most common antibiotics dispensed were amoxicillin (31%), nitrofurantoin (16%), and flucloxacillin (15%).Antibiotic Appropriatenessp < 0.001) of increased antibiotic appropriateness checks. Post-intervention, fewer staff reported ‘never’ querying an antibiotic prescription with a prescribing clinician; however, statistical modelling found no significant evidence of this.Most staff members  completing the pre-intervention questionnaire reported that checking appropriateness of antibiotic prescriptions was part of their role, and 41% reported that they always or very often checked antibiotic appropriateness ; this inp ≤ 0.01) for an increase in provision of advice across six of the seven topics, at post-intervention, except for ‘how and when to take the antibiotic’, likely due to the high response at pre-intervention.A total of 90/91 staff responding to the pre-intervention questionnaire and 70/81 staff responding to the post-intervention questionnaire indicated they had a role in providing advice to patients. The percentage of staff self-reporting how often they provided advice to patients increased across the seven topics . The prop < 0.001).Staff were asked about communication methods for providing infection and antibiotic advice , which iPost-intervention, staff estimated that the extra time to provide tailored advice to patients with the TARGET Antibiotic Checklist was an average of 5 min per patient. Most staff agreed that this extra time was feasible  and justified by the benefits of keeping antibiotics working .Six community pharmacists participated in semi-structured interviews to share their experience of implementing PAMSI. Three of the six had additional roles as pharmacy managers. See Staff reported the TARGET Antibiotic Checklist and patient information leaflets fitted into their working day, and the extra time required was feasible as it was necessary information. Incorporation into routine was facilitated by embedding the materials in the everyday environment (placing leaflets on the counter) and involving the whole pharmacy team . Staff felt that PAMSI fitted into wider priorities, including the 2020/2021 PQS, and that it improved team motivation. The TARGET information leaflets were useful for patients attending the pharmacy with minor ailments without an antibiotic prescription, particularly urinary tract infections (UTIs). Staff reported that the e-Learning improved their knowledge of AMR and AMS and helped their team to understand the importance of their role in reducing AMR.Overall, staff felt their team were more confident in querying prescriptions with a prescriber when necessary, and that the TARGET Antibiotic Checklist was useful to engage the prescriber in conversation. Staff believed communication with patients had improved and they felt more aware of areas where patients lacked knowledge, which helped them initiate conversations that would not have occurred otherwise. All interviewees said they would continue to use PAMSI, as they felt they increased patient engagement and improved the safety and effectiveness of their medicine.COVID-19 affected implementation of the PAMSI tool through changes in general practice (GP) and dental prescribing and fluctuating patient attendance throughout the pandemic. Some staff felt there was a lack of AMS continuity across the patient pathway, and that more shared working was needed between pharmacies, GPs, and dentists. In some cases, it was necessary for staff to complete the patient checklist sections on behalf of the patients by asking questions verbally. Some staff felt this was more effective, as it was helpful to explain the purpose of the questions, while others felt patients might not be honest about where they lacked knowledge if this verbal approach was used. There were also concerns about some patients who did not fully complete the TARGET Antibiotic Checklist. Staff reported a lack of time to use the resources for every patient collecting an antibiotic, and many prescriptions were collected by representatives or delivered directly to the home. Although information was given to the representative or leaflets were included in the delivery, staff were unsure if patients had engaged with the information as there was lack of follow up. A minority of staff reported language barriers but was able to overcome these through members of staff who could speak the language; however, translated resources would be useful.PAMSI supported community pharmacy staff to significantly improve AMS behaviours around assessing appropriateness of antibiotics and providing antibiotic and infection advice to patients. This was facilitated by whole team involvement and embedding the intervention into routine. Staff believed PAMSI supported essential roles, and therefore the extra time to provide tailored advice to patients was feasible and justified. Qualitative themes were that staff felt motivated in their AMS role through improved knowledge of AMR, felt more capable to query decisions by other prescribers, and had greater opportunity to provide tailored information through understanding patient knowledge gaps. Supplementary findings from follow up with 89 patients suggest positive impacts, as the majority was able to recall the advice provided to them at the pharmacy and reported good knowledge of their antibiotics; however, further research is needed to ascertain impacts of PAMSI on patients.Similarly to the feasibility study of PAMSI, staff reported that the intervention fitted into their operational practice and led to more meaningful conversations . Our finAlthough the TARGET Antibiotic Checklist can act as an audit to ensure the relevant checks have been carried out on all prescriptions, we found that these were not done for 15–25% of the 2043 Antibiotic Checklists completed with patients, suggesting environmental barriers preventing implementation. Interview participants in our study commented on the impact of time pressures and patients not being physically present (heightened by the COVID-19 pandemic), as well as lack of continuity along the patient pathway. Access to local antibiotic prescribing guidelines may be a factor, and therefore commissioners should ensure these are disseminated locally and easily available. The lack of easy communication between pharmacy and general practices has been previously highlighted, and staff have suggested the need for better referral pathways . When trMinor ailment schemes encourage patients to visit the pharmacy for common infections rather than general practice and could save £12 million per year if implemented across England . The TARThis mixed-method design informed by behavioural science allowed us to capture data on the effect of PAMSI on community pharmacy AMS, as well as understand behavioural insights into implementation. Collaborating with a central pharmacy chain allowed streamlined communication with pharmacy staff and helped to recruit a large sample; although we had some loss to follow up, this was limited considering the COVID-19 pandemic. A potential bias is that staff in other chains or independents may have experienced PAMSI differently; this effect was minimised by selecting a range of pharmacy types; however, other variables such as organisational culture may have influenced findings. Pharmacies were recruited centrally to avoid bias, i.e., recruiting pharmacies with an interest in AMS, and this is supported through the pre-intervention data showing low baseline AMS activity and low previous experience of interventions and training on AMS. As semi-structured interviews were an opportunity that participants could opt-in for, we were restricted to a smaller sample, and it is possible these participants may have had a biased interest in AMS; therefore, findings may not represent the views of all the staff who participated in the study; however, the interview themes are valuable as they support and give context to the quantitative findings.Strengths and weaknesses of the development of PAMSI have been published elsewhere ; a possiSince this study, the English PQS has included the AMS e-Learning and TARGET Antibiotic Checklist as criteria in 2020/21 and 2021/22, respectively. This will support embedding PAMSI into community pharmacies in England, and future work should evaluate the effect nationally. Guidance and training for staff and future policy considerations could promote the use of information leaflets and webpages, such as the TARGET toolkit , in faciOur study has highlighted that community pharmacy staff feel there is a lack of continuity and communication around AMS within the primary care pathway. There is a need for further research and policy considerations on how community pharmacy teams can be further integrated across the primary care pathway, including GP, dentistry, and out of hours.The Pharmacy Antimicrobial Stewardship Intervention provides a model for community pharmacy AMS and facilitates tailoring information on antibiotics and common infections to patients’ needs. Pharmacy staff acknowledge a need for improved communication and integration across the primary care pathway to optimise prescribing and use of antimicrobials.