Microbiome composition may differ according to menopause status, which may be partially mediated by diet (1). Peri- and post-menopausal symptom burden is associated with diet quality (2), however, knowledge on the association between menopause symptoms and gut microbiome composition is limited (3). This study investigates the associations between gut microbiome composition and menopause symptoms.

Data was analysed from 70,399 peri- (N = 27,926) and post-menopausal women (N = 42,473) from the PREDICT 3 cohort (NCT04735835), examining the gut microbiome composition (using metagenomic sequencing) and diet quality using Healthy Eating Index (HEI) scores derived from the PREDICT Food Frequency Questionnaire. Data was also collected on menopause symptoms, grouped into vasomotor, sexual, psychological and somatic domains. A Menopause Symptom Tracker Score (MSTS) (0-100) was used to capture symptom prevalence (out of 20 symptoms) and impact on quality of life (0-not at all, 1-a little, 3-quite a bit and 5-extremely), with higher score values reflecting greater symptom burden (4).

Using random forest machine learning (ML) models, we found that microbiome composition was predictive of the MSTS (AUCall = 0.70; AUCperi = 0.66; AUCpost = 0.65), as well as physical (e.g., fatigue, weight gain and slowed metabolism, thinning hair) and psychological (e.g., low mood or depression, anxiety and mood changes) domain scores (AUCall = 0.70; AUCperi = 0.66; AUCpost = 0.68 and AUCall = 0.70; AUCperi = 0.65; AUCpost = 0.66 respectively). Microbiome was also predictive of diet quality (HEI; AUCall = 0.77; AUCperi = 0.77; AUCpost = 0.75). Subsequently, we compared the top 50 species predictive for the HEI and MSTS respectively, and identified 32 common predictive species. Notably, the top predictive species for both HEI and MSTS was the not-yet-characterised Lachnospiraceae species-level genome bin SGB4964.

To the best of our knowledge, this is the first time associations between menopause symptoms and the gut microbiome have been identified. Further work is needed to unravel diet-microbiome-symptom interrelationships and investigate a potential causal role of microbiome in menopause symptom burden. This knowledge could ultimately lead to novel, microbiome-based strategies for improving the quality of life for women during and after the menopausal transition.

Psoriasis is an inflammatory skin disease, presenting as elevated and red cutaneous lesions, adversely impacting people’s quality of life. Given the link between diet and inflammation and the unclear role of diet quality in the onset of psoriasis (1), this study used the large-scale UK Biobank to explore the association between dietary patterns and psoriasis incidence.

The study included 121,584 UK Biobank participants who were initially free of psoriasis and followed for an average of 14 years. Participants in this analysis were free from chronic inflammatory infectious disease (HIV and chronic viral hepatitis) and had completed at least two 24-hour dietary recalls. Nine diet quality indices were computed, including the Low Carbohydrate Diet Score (LCDS), Alternative Mediterranean Diet (aMed) Score, Eatwell Score, Alternative Binary Eatwell Score, Alternative Graded Eatwell Score, Healthy Diet Index (HDI), Alternative Healthy Eating Index (aHEI), Dietary Approaches to Stop Hypertension Score (DASH), Dietary Inflammatory Index (DII), and Plant-Based Diet Index (PDI) with the addition of alcohol-excluded scores (aMed-nonalc, aHEI-nonalc) to account for the known link between alcohol and psoriasis risk (2). The primary outcome of this study was the incidence of psoriasis, determined through self-reported diagnosis, primary care (GP), and hospital admission data.

Of the 121,584 participants, 1,087 developed psoriasis, yielding an incidence rate of 0.89%. Participants who developed psoriasis reported significantly lower DASH (24.85 ± 4.53 vs. 25.19 ± 4.55, P = 0.017) and PDI (54.28 ± 5.51 vs. 54.82 ± 5.52, P = 0.001) scores, as well as less negative (pro-inflammatory) DII scores (-0.47 ± 1.78 vs. -0.58 ± 1.76, P = 0.039), compared to participants who did not develop psoriasis. Each increment in aMed (HR: 0.95, 95% CI: 0.92–0.99), aMed-nonalc (HR: 0.95, 95% CI: 0.92–0.98), DASH (HR: 0.98, 95% CI: 0.97–1.00), and PDI (HR: 0.98, 95% CI: 0.97–0.99) score was associated with lower psoriasis risk, while a higher DII (HR: 1.04, 95% CI: 1.00–1.07) was linked to an increased risk of psoriasis onset. After adjusting for age, sex, Townsend deprivation index, socioeconomic status, physical activity, smoking status, alcohol consumption, and comorbidities, each 1-point increment in the PDI score was associated with a modest 2% reduction in psoriasis risk. This association persisted after further adjustment for BMI. However, no significant associations were found for other dietary scores, both before and after BMI adjustment.

In this large cohort, greater adherence to the PDI was associated with a modestly lower risk of psoriasis, suggesting the potential benefits of plant-based diets in reducing psoriasis risk. Future research should prioritize randomized controlled trials to confirm this relationship.

Pulses (dry, edible, non-oil seeds of Leguminosae or Favaceae family) are considered beneficial for our health and environment due to their macro- and micronutrient profile, presence of bioactive compounds, long shelf life, affordability and low climate impact (1, 2). However, there is very little research on pulse consumption within the UK except a few studies using the national diet and nutrition survey data (2). Therefore, the aim of this study was to identify the knowledge, attitude and practice of purchasing pulses and explore specific drivers and barriers for the consumption of pulses within a sample of UK adult population.

Data was collected using an anonymous, online quantitative survey adapted from a European study (3). Survey questions were organised into sections to create distinct pathways depending on whether the respondent was a consumer or non-consumer. Question types were limited to checkbox grids, multiple choice, Likert scales and open text questions. Descriptive statistics was used for nominal data and presented as frequencies or percentages. Chi Squared or Fisher’s Exact test was used to determine statistically significant associations between demographic groups and data relating to knowledge (familiarly, frequency, variety), attitude (drivers or barriers) and practices (use of pulses). A Friedman Test was used for comparison of categorical data between different demographic groups.

Of the 61 participants, more were pulse consumers (n=59) than non-consumers (n=2). Majority of the pulse consumers were >40 years old, female, from White British background, not living alone, employed, with education status at postgraduate level or above and following an omnivorous diet. Majority of consumers had a high familiarity of pulses (94.6%), a high frequency of consumption (54.8%) with a medium variety of pulses (51.6%). Despite high familiarity and high frequency of consumption, a small variety of pulses (red kidney beans and chickpeas) were consumed. Health was the main driver for consuming pulses (39.7%), especially in the >40 years demographic. A statistically significant association was observed between frequency and variety of pulses (x2(4)=25.844, p<0.001); age and convenience (x2(2)=34.630, p=0.04); age and “being healthy” (x2(2)=10.106, p=0.001); ethnicity and “being filling” (x2(2)=8.078, p=0.001); dietary preference and foods replaced with pulses (x2(2)=6.357, p=0.042). Most participants who reported themselves as omnivores ate higher levels of pulses and used pulses as a replacement for meat. Preparation, sensory and digestion issues were the greatest barriers to consumption reported by non-consumers.

This study provides evidence for ‘linking health and pulse consumption’ when promoting pulses in the UK. Further research is required to understand the barriers and drivers for the consumption of pulses from a larger sample with greater socio-demographic diversity. Innovative solutions are needed to address the consumption of a small variety of pulses in the UK.

Psoriasis is a chronic, inflammatory skin condition characterized by red, scaly patches that can cause substantial discomfort and social stigma (1). Psoriasis significantly impairs the quality of life of those affected, particularly when co-existing with other conditions (1-2). Although diet has been linked to many psoriasis-associated conditions, including cardiovascular disease, obesity and type 2 diabetes (3), evidence-based dietary guidance for psoriasis is currently lacking, and the research supporting dietary interventions for psoriasis management remains limited. This study aimed to characterize dietary intake in individuals with psoriasis and assess associations with psoriasis severity and the risk of psoriasis-related comorbidities.

This study included the baseline data from the UK Biobank cohort, a prospective study with 502,000 adults aged 40-69 years at baseline (2006-2010). Participants with psoriasis at baseline were identified by self-reports or linked health records. Participants without psoriasis at baseline who remained free of the condition during follow-up were included as controls. Individuals with chronic infectious inflammatory disease such as HIV or chronic viral hepatitis were excluded from both groups. Diet was assessed using a touchscreen food frequency questionnaire (FFQ), covering 16 major food groups. Associations between frequency or amount of food intake and psoriasis severity (assumed from self-reported medication use: systemic treatment > topical treatment only > no related medication), risk of 13 common psoriasis comorbidities were evaluated using multivariable regression models, adjusted for confounders including age, sex, Townsend deprivation index, physical activity level, smoking, alcohol, supplement use and the reporting source of psoriasis.

Compared to those living without psoriasis (N=485,201), participants living with psoriasis (N=10,920) were more likely to report consuming processed meat (adjusted odds ratio (aOR)=1.28, 95% confidence interval: 1.15-1.42, P<0.001) and bread (aOR=1.20, 1.13-1.27, P<0.001). Psoriasis was associated with a lower likelihood of breakfast cereal use (aOR=0.82, 0.77-0.88, P<0.001). Moreover, higher weekly cheese intake and daily tea intake were associated with a reduced likelihood of more severe psoriasis (aOR= 0.97, 0.94-0.99, P=0.018; aOR=0.98, 0.96-1.00, P=0.011, respectively). Regarding comorbidities, frequent intakes of meat products were associated with higher odds of psoriasis-related comorbidities, such as chronic kidney disease (aOR=1.11, 1.02-1.21, P=0.021), type 2 diabetes (aOR=1.10, 1.02-1.19, P=0.010),), obesity (aOR= 1.05, 1.00-1.10, P=0.048), osteoporosis (aOR=1.14, 1.04-1.26, P=0.007) or depression (aOR=1.07, 1.001.15, P=0.040).

Our findings suggest that specific food groups are associated with the severity of psoriasis and its comorbidities, highlighting the importance of dietary management in mid-adulthood years. Further longitudinal and interventional studies are needed to confirm these associations and establish dietary guidelines for psoriasis management.

Globally, the burden of skin diseases is considerable, being the fourth largest cause of disability (1). Diet is a modifiable risk factor for many dermatological conditions and one of the mechanisms by which nutrition influences skin health is via the gut microbiome. Oral probiotics, prebiotics and synbiotics may have the potential to improve functional indicators of skin health and delay skin ageing (2).

This scoping review aimed to map the body of literature on the role of oral probiotics, prebiotics and synbiotics in maintaining and optimising skin health and function, and preventing and managing skin conditions, through the life course. The first stage of the scoping review, reported here, was the mapping of systematic reviews. The ongoing second stage involves the mapping of experimental and observational studies.

The scoping review was conducted in accordance with the JBI methodology for scoping reviews (3). Six electronic databases (MEDLINE, EMBASE, CENTRAL, CINAHL, Scopus and Web of Science) were systematically searched without limits on language or date, along with sources of grey literature. All sources were considered for inclusion by two reviewers based on previously established criteria using the participants, concept and context framework.

The titles and abstracts of 8,972 studies were screened and subsequently 1,034 full texts were retrieved. Finally, 521 studies were included in the scoping review of which 72 were systematic reviews and are analysed here.

Most reviews analysed the efficacy of oral probiotics (93%), with 13% and 18% of reviews considering oral prebiotics and oral synbiotics respectively. These interventions were most reviewed in infants aged 0-12 months (78%), pregnant mothers (47%), and/or younger children (43%) inclusively. Only 28% and 19% of reviews considered adults up to, and above, 60 years respectively. Most systematic reviews included participants who were either diagnosed with (42%), or at risk of a skin disease (28%) with just 4% reviewing effects in primarily healthy populations (24% did not confirm the included populations).

Outcomes related to preventing and managing a skin condition were studied by 97% of reviews; just 2 reviews examined optimising skin health and function (namely skin hydration, and epidermal thickness) in healthy populations. Atopic dermatitis (AD) was the most studied skin disease; 33 of 36 meta-analyses indicated a positive effect on its prevention, compared to 19 of 26 meta-analyses on AD severity. The remaining reviews investigated psoriasis (n=2), urticaria (n=2), and acne (n=2).

This review has identified a plethora of evidence synthesis on oral probiotics, prebiotics and synbiotics in AD, particularly in infants and children, and a paucity of evidence synthesis in healthy populations. The second stage of the review considering the underlying experimental and observational evidence will determine the scope for further evidence synthesis or confirm gaps in the experimental data to inform future research.

The average age of menopause (cessation of menstruation for minimum 12 months) is 51 years, accounting for over one-third of a woman’s lifespan (1, 2). The transitional period known as perimenopause, characterised by menstrual irregularities due to female sex hormone deficiency, occurs from around 45 years. Menopausal changes significantly impact health, increasing prevalence of metabolic syndrome, cardiovascular risk factors, cognitive decline, and cause wide-ranging burdensome symptoms such as mood changes and sleep disturbances (1). Considering the recognised influence of nutrition on these health variables, a specific, reliable tool to assess menopausal symptoms would enable further research into potential lifestyle interventions, such as diet, for effective symptom management. The Kupperman Index, Menopause Rating Scale, Menopause Specific Quality of Life questionnaire and the Greene Climacteric Scale are the most widely recognised instruments for assessing menopausal symptoms (3). However, these scales were published between 1950 and 1996, when large-scale studies of menopausal experiences were lacking. This study examined menopause symptoms using the new MenoScale questionnaire, completed by peri- and postmenopausal women within two weeks of its launch on 4th September 2024, at https://zoe.com/menoscale.

The MenoScale, developed with support from the British Menopause Society, considers 20 symptoms across four domains (vasomotor, sexual, psychological, somatic) and subjective impact on quality of life (QoL). The MenoScale score ranges from 0 to 100. It improves on existing tools by uniquely combining prevalence-informed symptoms, modern language, assessing QoL, and offering open online access. Descriptive statistical analysis was performed on the collected responses.

The questionnaire was completed by 61,866 individuals. Average scores were 35.8 (95% CI 35.6, 36.0) for perimenopausal (N = 21,695) and 35.2 (95% CI 35.0, 35.4) for postmenopausal (N = 20,228) respondents. Nearly all (99.9%) peri- and post-menopausal women reported experiencing at least one symptom, with most reporting up to 10 symptoms (89.5% peri-, 87.0% postmenopausal). Furthermore, 8.6% of peri- and 9.5% of postmenopausal women reported all 20 symptoms. Most common symptoms for perimenopausal women were “tiredness and fatigue” (93.3%), “irritability” (88.4%), and “memory problems” (87.2%), and for postmenopausal women “tiredness and fatigue” (89.5%), “loss of interest in sex” (87.5%) and “sleep problems” (87.2%).

As all stages of menopause involve various fluctuating symptoms and subjective experiences, reliable and accessible monitoring methods are essential for establishing dietary, lifestyle and pharmacological interventions that alleviate symptom burden. This open-access and online questionnaire allows real-time symptom monitoring and periodic reassessment to increase understanding of menopause, empowering women to track and manage their menopause experience, and facilitate data-backed conversations with healthcare providers. Investigations into the validity and reliability of the MenoScale in comparison to existing widely used tools is currently underway. Future research should include collecting dietary data alongside the MenoScale to investigate how adherence to dietary guidelines is related to menopausal symptom experiences.

This study investigates how children aged 4 to 12 years participate in /u/-fronting, a phonetically conditioned change in Ontario English in which the high back vowel /u/ is initially more fronted after coronal consonants than in other contexts. A picture naming task was used to elicit vowel tokens from children and their parents, and F1 and F2 measurements were extracted using FAVE. Children in all three age groups (4-6, 7-9, 10-12 years) were found to have significantly higher F2 values for /u/ (indicating more fronting) than adults in the non-coronal environment. This pattern does not appear to follow the predicted pattern of incrementation of sound change by older children. Instead, the findings may reflect overgeneralization of /u/-fronting, with young children extending the change to a new phonetic context during acquisition, or an earlier start to the incrementation of this variable in this population.

The modal auxiliary form must plus perfect aspect (must have +V-en) has recently acquired the meaning of direct evidentiality in Multicultural London English, the new London dialect. Because the new meaning is a recent innovation we have a rare opportunity to witness its development at first hand, unlike earlier changes in the history of must. Our analysis supports the view that the classic definition of evidentiality in terms of information source is too narrow to explain the expression of evidentiality in spoken interaction, and that a broader definition in terms of epistemic authority is more appropriate. We argue that the direct evidential meaning is a coherent further step in the semantic changes undergone by must during its history. It represents a previously undocumented pathway in the grammaticalisation of evidentiality. It also supports the view that evidentiality is not a purely lexical phenomenon in English.

As the population ages, the provision of adult long-term care (LTC) is one of the major challenges facing the UK and other developed nations. LTC funding for the elderly is complex, reflecting the range and level of services provided, with the total cost depending on the duration of LTC required. Institutional care settings (e.g., nursing/residential care homes) represent the most expensive form of LTC. Planning and funding for institutional LTC requires an understanding of the factors affecting the mortality (and hence duration and cost of care) of such LTC recipients. Using data provided by Bupa, one of the largest LTC providers in Britain, this paper investigates factors affecting the mortality of residents of institutional LTC facilities over the period 2016-2019. Consistent with existing research, most residents were female and had a higher average age profile compared with male residents. For those residents who died during the investigation period, the average length of stay was approximately 1.6 times longer for females relative to males. For both males and females, new residents experienced higher mortality in the first-year post admission compared to existing residents. Variations in the mortality of the residents were analysed by condition, funding status and care type on admission.

Aims: Catatonia is a complex neuropsychiatric syndrome of disturbed psychomotor function, abnormal behaviours and withdrawal. It remains under-recognised and under-diagnosed, especially within the acute hospital setting.

While often associated with primary mental illness, it can also occur secondary to systemic medical conditions such as systemic lupus erythematosus (SLE), an autoimmune disease in which neuropsychiatric manifestations are commonly described.

We present a case which highlights the diagnostic challenge and importance of recognising catatonia in the context of lupus.

Methods: A 34-year-old female with a three-year history of SLE presented with decline in functioning accompanied by malar rash, joint pains, paucity of speech and altered mental state. She had previously experienced command hallucinations in the context of lupus flares and though the psychotic component resolved between episodes, she was prescribed a daily maintenance dose of olanzapine 2.5 mg.

Assessment revealed an agitated, distracted patient with suspected auditory and visual hallucinations, profound paucity of speech and incoherent mumbling. She required assistance with personal care, displayed rigid posturing, and had stopped eating and drinking. Laboratory results were consistent with an acute SLE flare, and it was proposed that her presentation was SLE-related psychosis, initially addressed by increasing olanzapine dose with minimal effect.

Further clinical deterioration prompted a lumbar puncture after which the patient began to talk and regain some normal functioning. Thorough examination of notes revealed midazolam had been administered so it was proposed that this was catatonia and therefore partially resolved with a benzodiazepine. Further examination revealed waxy flexibility, catalepsy, stupor and mutism. Regular lorazepam was added to the schedule of cyclophosphamide and high-dose prednisolone and led to prompt substantial clinical improvement.

Results: Data suggests neuropsychiatric symptoms are common in SLE and though there are some reports in literature of lupus-associated catatonia, its precise prevalence is uncertain.

It is proposed that the diversity of symptoms can arise due to various pathophysiological mechanisms in lupus, which include autoimmune inflammation of the central nervous system, metabolic disturbances or adverse effects of medication. While treatment of the underlying cause is key, timely recognition of catatonia and pharmacological therapy can result in rapid clinical improvement.

Conclusion: Catatonia is associated with significant morbidity and mortality if untreated. It should be considered as a differential in patients with lupus, particularly those with concurrent neuropsychiatric symptoms, thus resulting in improved patient outcomes.

Aims: Timely initiation of assessment for Autism Spectrum Disorder (ASD) is crucial as delays can significantly impact development of children and family well-being. This audit aimed to assess the adherence to National Institute for Health and Care Excellence (NICE) guideline recommendations of timely initiation of ASD assessment and follow-up care in the Greater Preston Area.

Methods: A retrospective observational study was conducted, using electronic patient records of patients referred to the ASD diagnostic pathway and listed for further investigation in 2022 in the Greater Preston area. Data on wait times between referral and first appointment and times between diagnosis and follow-up appointment were collected and analysed. Patients eligible for this study were under 18 years of age, living in the Preston area and had been referred to the ASD diagnostic pathway and listed for further investigation in 2022. 37 school-age and 48 preschool-age children were included in this study.

Results: It was found that 18.9% of school-age and 16.7% of preschool-age children were seen within the 13-week window between referral and first appointment recommended by NICE guidelines. This study also showed that 18.9% of school-age children and 20.8% of preschool-age children received a follow-up appointment within the 6-week guideline.

Conclusion: This study found significant delays in accessing the ASD diagnostic pathway and follow-up care which indicates the Greater Preston area is not in adherence with NICE guidelines. Changes are necessary to address these gaps and ensure timely support for children affected by ASD.

Aims: This project aims to assess staff awareness of the Physician Associate (PA) role and the impact of PAs on an acute male psychiatric ward and a male psychiatric intensive care unit (PICU) in Kent and Medway NHS and Social Care Partnership Trust (KMPT).

PAs are integral to supporting the effective functioning of inpatient psychiatric wards and contributing to service development. At KMPT, there are currently five PAs working across 5 inpatient wards with 880 combined admissions last year. Bed pressures have increased annually, making consistent medical support essential. PAs, due to the nature of their role, can provide continuity and act as a key point of contact for staff.

Hypothesis: We hypothesize that staff may have limited awareness of the PA role due to its recent introduction in the trust, but that PAs will have a positive impact on patient care in mental health settings.

Methods: Data was collected through a survey to assess staff understanding of the PA role and its impact on patient care, collaboration, and team dynamics. Staff across various multidisciplinary team (MDT) roles, including the medical, nursing, occupational therapy, and psychology teams in the male PICU and a male acute ward were surveyed.

Results: A total of 32 responses were received.

Staff Awareness: 81.2% reported working closely with PAs daily. While 65.6% were very familiar with the PA role, 31.2% were somewhat familiar. Notably, 17.15% mistakenly believed PAs can prescribe medication and order ionizing radiation investigations.

Impact on Patient Care: 81.25% reported PAs made a significant impact in assessing and diagnosing physical health conditions, compared with 50% for mental health conditions. 64% said PAs significantly improved patient communication and engagement with carers.

Collaboration and Team Dynamics: 65.6% found PAs to be “very effective” in collaborating with the MDT. 58.3% agreed that PAs significantly reduced workload and administrative burden, improved continuity of care, and provided a consistent point of contact for ongoing care.

Overall Impact: 71.8% of staff reported a “very positive” impact of PAs; 28.1% felt it was “positive”; and 93.7% recommended expanding the role to other mental health services.

Conclusion: This survey shows most staff have daily contact with PAs; are familiar with their role; and believe PAs have a significant positive impact on patient care, collaboration, and continuity of care in inpatient mental health settings. However, there are knowledge gaps about specific limitations of the PA role, suggesting a need for further education to enhance staff understanding.

Aims: More than half of new recruits in the NHS are International Medical Graduates (IMGs). It is recognised that IMG need additional support, however to offer this their supervisors need to be aware of the landscape and resources to effectively support them. We developed a training for supervisors of IMGs using a mix of didactic, group work and simulation training.

Methods: The Faculty Development and IMG tutors surveyed and worked with several IMGs to identify topics for the training learning from their recent lived experiences. They also looked at guidance for IMG induction as published by General Medical Council (GMC) and British Medical Association (BMA). We identified that challenges of IMGs evolve through their journey and developed 3 simulation scenarios targeted at early, mid and later stages of the IMG pathway.

The one day face-to-face course included:

An introduction into current IMG landscape including the identified challenges. AS offered lived experience of IMG journey. This allowed for a discussion among the supervisors to reflect on their role.

This was followed by the 3 SIM scenarios:

An IMG doctor who had just moved to the UK and introduced to the supervisor the various practical hurdles that this entails around immigration and joining the NHS.

An IMG had been living in the UK for a few months and was starting a training job, with the focus on fleshing out the differences in healthcare systems.

Managing feedback about communication skills in an IMG who had significant clinical experience in their home country before moving to the UK a few years ago.

We gathered quantitative and qualitative feedback from the participants.

Results: 6 of the 7 candidates offered feedback which was unanimously positive. All found the content useful, most found the course extremely helpful to manage IMGs and an overall rating of excellent by 83% (5 out of 6). We received qualitative feedback as well, ‘It was amazing’ & ‘so grateful especially simulation rather than only theory’.

Conclusion: As IMGs enter the workforce through different pathways and at different times, organising focused IMG induction can be challenging. Moreover the needs of IMGs evolve over time. In psychiatry we have a structure of regular supervision which offers an opportunity of ongoing support to IMGs through the supervisors. However we believe supervisors are not always up to date with the IMG landscape or resources and would benefit from upskilling and updating in this field.