How can wellbeing for all be improved while reducing risks of destabilising the biosphere? This ambition underlies the 2030 Agenda but analysing whether it is possible in the long-term requires linking global socioeconomic developments with life-supporting Earth systems and incorporating feedbacks between them. The Earth4All initiative explores integrated developments of human wellbeing and environmental pressures up to 2100 based on expert elicitation and an integrated global systems model. The relatively simple Earth4All model focuses on quantifying and capturing some high-level feedback between socioeconomic and environmental domains. It analyses economic transformations to increase wellbeing worldwide and increase social cohesion to create conditions that are more likely to reduce pressures on planetary boundaries. The model includes two key novelties: a social tension index and a wellbeing index, to track societal progress this century. The scenarios suggest that today's dominant economic policies are likely to lead to rising social tensions, worsening environmental pressures, and declining wellbeing. In the coming decades, unchecked rising social tensions, we hypothesise, will make it more difficult to build a large consensus around long-term industrial policy and behavioural changes needed to respect planetary boundaries. We propose five extraordinary turnarounds around poverty, inequality, empowerment, energy and food that in the model world can shift the economy off the current trajectory, improve human wellbeing at a global scale, reduce social tensions and ease environmental pressures. The model, the five (exogenous) turnarounds and the resulting two scenarios can be used as science-policy boundary objects in discussions on future trajectories.

Our world is facing a convergence of environmental, health, security, and social crises. These issues demand urgent, systemic solutions now that address not only environmental but also social dimensions. Weak political responses have stalled progress on the Sustainable Development Goals and the Paris Agreement. We have developed scenarios that explore interconnections between possible climate futures, rising living costs, and increasing inequalities that fuel populism and undermine democracy to the year 2100. We propose five turnaround solutions – energy, food and land systems, inequality, poverty, and gender equality – that if enacted are likely to provide wellbeing for a majority of people plus greater social cohesion. This will support long-term industrial policies and behavioural change to reduce emissions and protect the biosphere toward a long-term goal of living on a relatively stable planet.

Our dominant economic model is destabilising societies and the planet. Earth4All found 5 turnarounds for real system change.

This study demonstrates a national programme which has been accepted in Wales as a mandatory part of the induction process for the rotating ENT SHO cohort.

The ENT Induction Bootcamp was established based on the learning needs of ENT SHOs. Pre- and post-course assessment of the subjective and objective benefit of the 1-day course was captured.

Between 2022 and 2024, 152 participants have attended the bootcamp; all of whom (100 per cent) found the course beneficial. The greatest improvements in participant confidence were observed in emergency tracheostomy management, flexible nasendoscopy and nasal examination (all p < 0.01). Based on objective assessment, participant knowledge improved from a mean of 68.5 per cent to 96.5 per cent.

This initiative highlights the value of a bootcamp approach to standardise junior doctors’ abilities to manage ENT emergencies. This bootcamp is now a mandatory component for all SHO entering ENT attachments in Wales, in an easily adoptable format.

Evidence for necrotising otitis externa (NOE) diagnosis and management is limited, and outcome reporting is heterogeneous. International best practice guidelines were used to develop consensus diagnostic criteria and a core outcome set (COS).

The study was pre-registered on the Core Outcome Measures in Effectiveness Trials (COMET) database. Systematic literature review identified candidate items. Patient-centred items were identified via a qualitative study. Items and their definitions were refined by multidisciplinary stakeholders in a two-round Delphi exercise and subsequent consensus meeting.

The final COS incorporates 36 items within 12 themes: Signs and symptoms; Pain; Advanced Disease Indicators; Complications; Survival; Antibiotic regimes and side effects; Patient comorbidities; Non-antibiotic treatments; Patient compliance; Duration and cessation of treatment; Relapse and readmission; Multidisciplinary team management.

Consensus diagnostic criteria include 12 items within 6 themes: Signs and symptoms (oedema, otorrhoea, granulation); Pain (otalgia, nocturnal otalgia); Investigations (microbiology [does not have to be positive], histology [malignancy excluded], positive CT and MRI); Persistent symptoms despite local and/or systemic treatment for at least two weeks; At least one risk factor for impaired immune response; Indicators of advanced disease (not obligatory but mut be reported when present at diagnosis). Stakeholders were unanimous that there is no role for secondary, graded, or optional diagnostic items. The consensus meeting identified themes for future research.

The adoption of consensus-defined diagnostic criteria and COS facilitates standardised research reporting and robust data synthesis. Inclusion of patient and professional perspectives ensures best practice stakeholder engagement.

Cardiometabolic disease risk factors are disproportionately prevalent in bipolar disorder (BD) and are associated with cognitive impairment. It is, however, unknown which health risk factors for cardiometabolic disease are relevant to cognition in BD. This study aimed to identify the cardiometabolic disease risk factors that are the most important correlates of cognitive impairment in BD; and to examine whether the nature of the relationships vary between mid and later life.

Data from the UK Biobank were available for 966 participants with BD, aged between 40 and 69 years. Individual cardiometabolic disease risk factors were initially regressed onto a global cognition score in separate models for the following risk factor domains; (1) health risk behaviors (physical activity, sedentary behavior, smoking, and sleep) and (2) physiological risk factors, stratified into (2a) anthropometric and clinical risk (handgrip strength, body composition, and blood pressure), and (2b) cardiometabolic disease risk biomarkers (CRP, lipid profile, and HbA1c). A final combined multivariate regression model for global cognition was then fitted, including only the predictor variables that were significantly associated with cognition in the previous models.

In the final combined model, lower mentally active and higher passive sedentary behavior, higher levels of physical activity, inadequate sleep duration, higher systolic and lower diastolic blood pressure, and lower handgrip strength were associated with worse global cognition.

Health risk behaviors, as well as blood pressure and muscular strength, are associated with cognitive function in BD, whereas other traditional physiological cardiometabolic disease risk factors are not.

There is concern that junior doctors are not prepared for their post-graduate attachments in ENT. The aims of this study were to capture the learning priorities of those in the ENT first on-call role and facilitate further educational opportunities to address these needs.

Semi-structured interviews were undertaken to explore the learning needs of junior doctors with seven junior and two senior ENT clinicians.

The thematic analysis generated three themes: the role of the ENT Junior; the perceived, expressed and prescribed learning needs; and attitudes towards future learning. These themes explored the misalignment between undergraduate training and post-graduate expectations, the lack of competence in ENT practical skills and the need for focused ENT training prior to commencing on-call shifts.

All interviewees identified the need for greater experience in practical interventional skills prior to their ENT attachments and expressed interest towards a standardised, bootcamp-style induction with simulated emergency experience.

Otoscopic skills are essential for ENT doctors. Early-stage doctors develop skills whilst treating patients, with minimal teaching, potentially increasing risk to patients. Simulation allows skill development without patient risk; however, simulation often requires subjective expert review of technique. This study compared enhanced low-fidelity simulation with performance feedback against standard simulation using a basic otoscopy skills simulator.

Two low-fidelity ear simulators were created: a basic model without feedback and an enhanced model which alarms when the aural instrument tip touches the canal wall. Participants were evaluated in a randomised crossover pilot study, using both models to assess whether objective feedback reduced tip touches.

The enhanced simulator reduced tip touches more than the control model, suggesting better and more sustained skill uptake. Participants reported that the enhanced model improved learning.

Enhanced low-fidelity models provide a low-cost opportunity to improve otoscopy skills without patient risk or the need for subjective expert feedback.

Neuroleptic Malignant Syndrome (NMS) is a rare, life-threatening complication of antipsychotic medication. There are no gold standard tests to diagnose NMS, however various diagnostic criteria have been suggested. NMS is typically reported in patients who have recently commenced an antipsychotic or had a change in dose. This case report describes an elderly female who developed NMS after being treated with the same dose of antipsychotic for 7 years. We aimed to establish whether similar cases are commonly reported, and what the key learning outcomes are.

This case presents an 82-year-old female taking the same dose of zuclopenthixol for 7 years. She was admitted with increased confusion and was initially prescribed antibiotics for a possible infection. She later became pyrexial and developed hypertonia, at which point NMS was suspected. Her creatinine kinase titre was significantly elevated, and her antipsychotic was discontinued. A potential trigger was a significant rectal bleed occurring a few weeks prior with no other obvious triggers noted. She was switched to quetiapine but developed NMS again when this dose was increased.

There are few reports of NMS occurring in patients taking a long-term and stable antipsychotic dose. One case describes NMS developing after 30 years on Clozapine with no clear trigger. Another reports NMS after 7 years on Olanzapine, however this was triggered by dehydration. This case is an example of NMS in an elderly patient with a complex medical history who was initially misdiagnosed with sepsis before NMS was suspected. This shows the importance of considering NMS not only in those who have recently commenced antipsychotics or recently changed dose, but also those who have been stable on medication for a number of years. In suspected NMS, we should aim to stop relevant medication immediately and commence conservative management. It is important to highlight these atypical presentations so that NMS can be recognised without delaying treatment, thereby reducing mortality and improving patient outcomes

This report highlights the importance of considering NMS in patients who have been prescribed the same dose of antipsychotic for an extended period. Awareness of potential risk factors such as medical comorbidity that may trigger an episode of NMS even in those on established antipsychotic treatment is vital. Symptoms may mimic infection and it is important to raise awareness of atypical presentations to effectively identify, and treat, NMS earlier to improve outcomes.