5% versus 49.9%, respectively, p ≤ 0.0001. Five-year CSS varied within each stage and across age strata of less then 45, 45 - 59, and ≥60 years. Within each stage, females less then 45 had better CSS than all other sex/age groups (p  less then  0.0001). In multivariable analysis of stage II/III patients, female sex, younger age, and lower mitotic index retained favorable CSS prognostic significance (p  less then  0.001). Conclusions Sex-based differences in melanoma survival persist in a contemporary patient cohort staged with the latest prognostic system. These data may guide decision marking regarding adjuvant therapy, highlight the importance of including sex as a pre-specified clinical trial variable, and suggest that investigation of underlying biologic mechanisms may drive discovery of biomarkers and therapeutic targets to improve patient care.Agricultural workers are exposed to heat stress due to spending significant amount of time outdoors. Risk information from mobile apps is more readily available for timely advice on risk management that is crucial in preventing severe acute illnesses and deaths, but its reliability is unknown. The purpose of this study was to determine the reliability of the OSHA-NIOSH Heat Safety Tool mobile app in providing accurate risk information to prevent heat-related illnesses among agricultural workers in eastern North Carolina. Wet bulb globe temperature (WBGT) indices were datalogged at two agricultural sites using heat stress monitors from April-August 2019 and were assigned to risk levels (minimal, low, moderate, high, extreme) by workload (light, moderate, heavy, very heavy) based on the ACGIH® Threshold Limit Values (TLVs®). Hourly heat index (HI) and its corresponding risk level were obtained using the app. Hourly HI-based risk level assignments were time-matched to their corresponding WBGT-based risk level asssment of occupational heat stress risk in agricultural settings is not recommended.Porphyromonas gingivalis, like other bacteria belonging to the phylum Bacteroidetes, synthesizes sphingolipids (SLs). However, their exact roles in microbial physiology and their potential role in mediating interactions with their eukaryotic host are unclear. Our working hypothesis for this study was that synthesis of SLs (host-like lipids) affords a mechanism that allows P. gingivalis to persist in homeostasis with its host. In a previous study, we deleted a gene (PG1780 in strain W83) predicted to encode a serine palmitoyl transferase (SPT)-the enzyme that catalyzes the first conserved step in the synthesis of SLs-and we determined that the mutant was unable to synthesize SLs. Here, we characterized the SPT enzyme encoded by PG1780, analyzed the impact of SPT deletion on P. gingivalis gene expression (RNA-Seq analysis), and began to define the impact of SL synthesis on its interactions with host cells. Enzymatic analysis verified that the protein encoded by PG1780 is indeed an SPT. RNA-Seq analysis determined that a lack of SL synthesis results in differential expression of extracytoplasmic function sigma factors, components of the type IX secretion system (T9SS), and CRISPR and cas genes. Our data demonstrate that when human THP1 macrophage-like cells were challenged with the wild type (W83) and the SL-null mutant (W83 ΔSPT), the SL-null strain elicited a robust inflammatory response (elevated IL-1β, IL-6, IL-10, IL-8, RANTES, and TNFα) while the response to the parent strain W83 was negligible. Interestingly, we also discovered that SLs produced by P. gingivalis can be delivered to host cells independent of cell-to-cell contact. Overall, our results support our working hypothesis that synthesis of SLs by P. gingivalis is central to its ability to manipulate the host inflammatory response, and they demonstrate the integral importance of SLs in the physiology of P. gingivalis.BACKGROUND Patients with lymphoedema referred to a lymphoedema service from care homes in one health board area in Wales were often complex cases, with repeated cellulitis, a history of falls and other complications. A pilot project was initiated to develop education and raise awareness of lymphoedema among care home staff. AIMS To enable care staff to identify residents with lymphoedema, promote prompt referrals, raise the importance of skin care and exercise in the management of lymphoedema and estimate the likely costs from complications associated with lymphoedema. METHODS An education tool was developed and 47 care homes were asked to participate. A lymphoedema therapist carried out a scoping review of the residents. RESULTS Forty-four care homes agreed to participate in the project with 1216 education packs being issued to care home staff. Initial findings suggest that of the 960 residents reviewed, 262 had lymphoedema (27%); 4% suffered with frequent falls, 1% had wounds and 3% had recurrent cellulitis. Only 13% (35/262) of residents with lymphoedema were known to the local lymphoedema service. Of the 31 residents reporting cellulitis, 81% had lymphoedema; of the 11 residents identified with a wound, 100% had lymphoedema and of the 40 residents reporting falls, 70% had lymphoedema. CONCLUSION This educational project has identified the value of raising awareness of lymphoedema within care homes.John Fowler, Educational Consultant, explores how to survive your nursing career.BACKGROUND Young people with mental illness are at high risk of physical health complications. Physical healthcare on a general adolescent inpatient unit is complex. AIM To establish a wellbeing clinic to improve efficiency and quality of the physical healthcare offered and increase health promotion. METHODS Plan, Do, Study, Act (PDSA) cycles were used to drive this quality-improvement project. The authors audited 12 records before establishing the clinic and 12 at three further time points (6, 18 and 30 months post-intervention) to guide changes. RESULTS Results progressively improved over PDSA cycles. Time taken for initial investigations dropped. Compliance with medication monitoring and management of important physical health domains rose from zero in some cases to 100% in all but one area. CONCLUSIONS Establishing a dedicated physical health clinic in this setting is feasible and leads to improved performance against local and national standards. Mental health teams need to ensure physical health is prioritised.John Tingle, Lecturer in Law, Birmingham Law School, University of Birmingham, discusses some recent patient reports and crisis events.Emeritus Professor Alan Glasper, from the University of Southampton, discusses the ongoing NHS Employers initiative which is designed to support the NHS employees’ emotional health.A child presenting with decreased level of conscious (dLOC) is of great concern due to the wide range of possible causes, and potential for death or serious long-term sequelae. It is therefore vital that health professionals can recognise a child with dLOC quickly, intervene appropriately and escalate for senior review as a matter of urgency. This article provides an explanation for the mechanisms of decreased consciousness, outlines the different causative pathologies, and provides a simple and logical approach to the first-line recognition and management that a health professional may apply when faced with such a patient. Illustrative case studies have been included, to demonstrate how children with dLOC may present in clinical practice.Sam Foster, Chief Nurse, Oxford University Hospitals, considers how the complaints from patients and staff have changed over the years and how a decision-making tool has helped her consider the issues.Postoperative pain remains poorly managed for many patients. Effective pain management begins with accurate pain assessment, with patient self-reporting considered the most accurate measure of pain. This literature review aimed to identify how congruent nurses’ assessments of pain were with patients’ self-reporting. A search identified six observational studies and one quasi-experimental study that met the inclusion criteria. The findings from these studies were summarised under two themes nurses’ underestimation of patients’ pain and nurses’ knowledge and understanding of pain assessment. Some nurses’ pain management knowledge was deemed inadequate, with evidence of negative attitudes towards managing pain in certain groups of patients. Educational interventions have so far had limited impact on correcting the ethical and professional problem of inadequate pain relief in many patients postoperatively. Randomised controlled trials are required to identify effective education interventions that can contribute to ending this avoidable suffering.BACKGROUND A culture of patient safety is one of the cornerstones of good-quality healthcare, and its provision is one of the significant challenges in healthcare environments. AIM The purpose of this study was to evaluate the effect of a surgical safety educational programme on the attitudes of nurses to patient safety in operating rooms (OR). DESIGN An interventional one-group pre-/post-test design, which sought to measure changes in OR nurses’ attitudes toward patient safety culture. METHODS A simple random sampling technique was used to recruit 66 OR nurses working at six Royal Medical Service hospitals in Amman, Jordan. All participants took part in a 4-hour educational workshop. Pre-tests and post-tests were done. RESULTS The results of this study showed that OR nurses’ attitudes towards a culture of patient safety was originally negative; significant improvement after attending the programme was found (3.3 ± 0.20 versus 3.8 ± 0.30). There was a negative correlation between years of experience and nurses’ attitudes towards patient safety. CONCLUSIONS Incorporating courses about safety culture into continuing education programmes may improve nurses’ attitudes towards patient safety. Nurses should be qualified to play an important role in creating a culture of patient safety.Introduction The zinc finger homeobox 4 (ZFHX4) protein is a crucial molecular regulator of tumor-initiating stem cell-like functions. Objective This study aimed to determine the role of ZFHX4 in the progression of ovarian serous cystadenocarcinoma (OSC). Methods Differential gene expression ZFHX4 among low-stage (stages I and II), high-stage (stages III and IV), low-grade (grades I and II), and high-grade (grades III and IV) OSC patients was identified using four independent cohorts from the Cancer Genome Atlas (TCGA) and the Gene Expression Omnibus (GEO). We compared ZFHX4 expression as a prognostic factor using Kaplan-Meier survival curves, multivariate analysis, the time-dependent area under the curve (AUC) of Uno’s C-index, and the AUC of the receiver operating characteristics at 4 years post diagnosis. Results ZFHX4 gene expression in high-stage tumors is significantly higher than in low-stage tumors (TCGA, p = 0.007; GSE9891, p = 0.001). A Kaplan-Meier analysis revealed that elevated expression of ZFHX4 was associated with a poor prognosis in OSC patients for all cohorts, regardless of stage and grade (TCGA, p = 1e-04; GSE9891, p = 0.0044; GSE13876, p = 0.00078; GSE26712, p = 0.039). Analysis of C-indices and the area under the receiver operating characteristic curve further supported this result (C-index TCGA, 0.599; GSE9891, 0.642; GSE13876, 0.585; GSE26712, 0.597). Moreover, univariate and multivariate Cox hazards analyses confirmed the prognostic significance of ZFHX4 levels. Conclusion Collectively, these findings suggest that ZFHX4 is a prognostic factor for OSC.