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Background: Trauma care represents a complex patient journey, requiring multi-disciplinary coordinated care. Team members are human, and as such, how they feel about their colleagues and their work affects performance. The challenge for health service leaders is enabling culture that supports high levels of collaboration, cooperation and coordination across diverse groups. Aim Statement: We aimed to define and set the agenda for improvement of the relational aspects of trauma care at a large tertiary care hospital. Measures & Design: We conducted a mixed-methods collaborative ethnography using the Relational Coordination survey – an established tool to analyze the relational dimensions of multidisciplinary teamwork – participant observation, interviews, and narrative surveys. Findings were presented to clinicians in working groups for further interpretation and to facilitate co-creation of targeted interventions designed to improve team relationships and performance. Evaluation/Results: We engaged a complex multidisciplinary network of ~500 care providers dispersed across seven core interdependent clinical disciplines. Initial findings highlighted the importance of relationships in trauma care and opportunities to improve. Narrative survey and ethnographic findings further highlighted the centrality of a translational simulation program in contributing positively to team culture and relational ties. A range of 16 interventions – focusing on structural, process and relational dimensions – were co-created with participants and are now being implemented and evaluated by various trauma care providers. Discussion/Impact: Through engagement of clinicians spanning organizational boundaries, relational aspects of care can be measured and directly targeted in a collaborative quality improvement process. We encourage health care leaders to consider relationship-based quality improvement strategies, including translational simulation and relational coordination processes, in their efforts to improve care for patients with complex, interdependent journeys.
Introduction: Patients frequently present to the Emergency Department (ED) with predictable complications associated with radiation and chemotherapy for active cancer. Care alternatives have been proposed to reduce ED visits; however, no systematic review related to ED presentations has been completed. The objective of this scoping review was to examine the effectiveness of interventions designed to reduce ED visits among patients receiving active cancer treatment. Methods: A comprehensive literature search involving nine electronic databases and the grey literature was completed. Inclusion criteria considered studies assessing the impact of any intervention to reduce ED utilization among patients with active cancer. Two reviewers independently assessed relevance and inclusion; disagreements were resolved through third party adjudication. Dichotomous and continuous outcomes were summarized as risk ratio (RR) or mean difference (MD) with 95% confidence intervals (CIs) using a random-effects model, wherever appropriate. Results: From 3303 citations, a total of 25 studies were included. Interventions identified in these studies comprised: routine and symptom-based patient follow-up, oncology outpatient clinics, early symptom detection, comprehensive inpatient management, hospital at home, and patient navigators. Six out of eight studies assessing oncology outpatient clinics reported a decrease in the proportion of patients presenting to the ED. A meta-analysis of three of these studies did not demonstrate reduction in ED utilization (RR 0.78; 95% CI: 0.56 to 1.08; I2 = 77%) when comparing oncology outpatient clinics to standard care; however, sensitivity analysis removing one study reporting rare events supported a decrease in ED visits (RR 0.86; 95% CI: 0.74 to 0.99; I2 = 47%). Three studies assessing patient follow-up interventions showed no difference in ED utilization (RR 0.69; 95% CI: 0.38 to 1.25; I2 = 86%). Conclusion: A variety of interventions designed to mitigate ED presentations by patients receiving active cancer treatment have been developed and evaluated. Limited evidence suggests that an oncology outpatient clinic may be an effective strategy to reduce ED utilization; however, additional high-quality studies are needed.
In Australia, free-range egg production pullets are typically reared indoors, but adult layers get outdoor access. This new environment may be challenging to adapt to, which could impair egg production and/or egg quality. Adaptation might be enhanced through rearing enrichments. We reared 1386 Hy-Line Brown® chicks indoors with three treatments across 16 weeks: (1) a control group with standard litter housing conditions, (2) a novelty group providing novel objects that changed weekly, and (3) a structural enrichment group with custom-designed structures to partially impair visibility across the pen and allow for vertical movement. Pullets were transferred to a free-range system at 16 weeks of age with daily outdoor access provided from 25 until 64 weeks. Daily egg production at different laying locations (large nests, small nests and floor), weekly egg weights and egg abnormalities were recorded from 18 to 64 weeks old. External and internal egg quality parameters of egg weight, shell reflectivity, albumen height, haugh unit, yolk colour score, shell weight and shell thickness were measured at 44, 52, 60 and 64 weeks. There was a significant interaction between rearing treatment and nest box use on hen-day production from weeks 18 to 25 (P < 0.0001) with the novelty hens laying the most eggs and the control hens the fewest eggs in the nest box. Similarly, from 26 to 64 weeks, the novelty hens laid more eggs in the large nest boxes and fewer eggs on the floor than both the structural and control hens (P < 0.0001). Egg weight and abnormalities increased with age (P < 0.0001), but rearing treatment had no effect on either measure (both P ≥ 0.19). Rearing treatment affected shell reflectivity and yolk colour with the control hens showing paler colours across time relative to the changes observed in the eggs from enriched hens. The novelty hens may have established nest box laying patterns as they were more accustomed to exploring new environments. The differences in egg quality could be related to stress adaptability or ranging behaviour. This study shows that enriching environments during rearing can have some impacts on production parameters in free-range hens.
Introduction: Atrial fibrillation (AF) is the most common arrhythmia treated in the emergency department (ED) and is associated with an increased risk of ischemic stroke. Studies have shown that only oral anticoagulant (OAC) therapy reduces risk of AF related stroke. Our objective was to measure the prescribing practices for OACs for new onset AF at a tertiary ED and two surrounding community EDs, and identify rates of adverse effects within 90 days. The findings of this study will provide quality assurance information for the management of patients with new onset AF. This information has the potential to promote adherence to prescribing guidelines for AF in the ED and the reduction of common adverse events such as ischemic stroke. Methods: We conducted a retrospective chart review of 385 patients with new onset AF who presented to the ED between November 2014 to Mach 2018. We defined new onset as symptoms <48 hours and had AF confirmed with electrocardiogram. We recorded the selected therapy choice of cardioversion and/or rate control, gender, age, and assessed CHADS-65 score. We recorded who was prescribed OAC and those who were referred to cardiology, family medicine, or did not have a documented follow up plan. Patients with a previous history of AF or current anticoagulant therapy were excluded. We recorded if any patients returned to the ED within 90 days with ischemic stroke, AF recurrence, myocardial infarction, other embolic disease or death. Results: 86 of 294 (29.5%) of patients who qualified under CHADS-65 received OACs appropriately. 64 of 66 (97.0%) of patients who did not qualify under CHADS-65 did not receive OACs appropriately. 5 patients overall returned within 90 days with ischemic stroke, 4 of those were not prescribed OACs, however this was not statistically significant (P = 0.999). Conclusion: This data suggests that physicians in the study are under-prescribing OACs relative to published guidelines. A larger study is necessary to elucidate the effect of ED OAC prescribing patterns on long-term patient outcome.
Approximately 70% of the 30 000 known bee (Hymenoptera) species and most flower-visiting, solitary wasps (Hymenoptera) nest in the ground. However, nesting behaviours of most ground-nesting bees and wasps are poorly understood. Habitat loss, including nesting habitat, threatens populations of ground-nesting bees and wasps. Most ground-nesting bee and wasp studies implement trapping methods that capture foraging individuals, but provide little insight into the nesting preferences of these taxa. Some researchers have suggested that emergence traps may provide a suitable means by which to determine ground-nesting bee and wasp abundance. We sought to evaluate nest-site selection of ground-nesting bees and wasps using emergence traps in two study systems: (1) planted wildflower enhancement plots and fallow control plots in agricultural land; and (2) upland pine and hammock habitat in forests. Over the course of three years (2015–2017), we collected 306 ground-nesting bees and wasps across all study sites from emergence traps. In one study, we compared captures per trap between coloured pan traps and emergence traps and found that coloured pan traps captured far more ground-nesting bees and wasps than did emergence traps. Based on our emergence trap data, our results also suggest ground-nesting bees and wasps are more apt to nest within wildflower enhancement plots than in fallow control plots, and in upland pine habitats than in hammock forests. In conclusion, emergence traps have potential to be a unique tool to gain understanding of ground-nesting bee and wasp habitat requirements.
In product design engineering (PDE), ideation involves the generation of technical behaviours and physical structures to address specific functional requirements. This differs from generic creative ideation tasks, which emphasise functional and technical considerations less. To advance knowledge about the neural basis of PDE ideation, we present the first fMRI study on professional product design engineers practising in industry. We aimed to explore brain activation during ideation, and compare activation in open-ended and constrained tasks. Imagery manipulation tasks were contrasted with ideation tasks in a sample of 29 PDE professionals. The key findings were: (1) PDE ideation is associated with greater activity in left cingulate gyrus; (2) there were no significant differences between open-ended and constrained tasks; and (3) a preliminary association with activity in the right superior temporal gyrus was also observed. The results are consistent with existing fMRI work on generic creative ideation, suggesting that PDE ideation may share a number of similarities at the neural level. Future work includes: functional connectivity analysis of open-ended and constrained ideation to further investigate potential differences; investigating the effects of aspects of design expertise/training on processing; and the use of novelty measures directly linked to the designer’s internal processing in fMRI analysis.
Nighttime eating is often associated with a negative impact on weight management and cardiometabolic health. However, data from recent acute metabolic studies have implicated a benefit of ingesting a bedtime snack for weight management. The present study compared the impact of ingesting a milk snack containing either 10 (BS10) or 30 g (BS30) protein with a non-energetic placebo (BS0) 30 min before bedtime on next morning metabolism, appetite and energy intake in mildly overweight males (age: 24·3 (sem 0·8) years; BMI: 27·4 (sem 1·1) kg/m2). Next morning measurements of RMR, appetite and energy intake were measured using indirect calorimetry, visual analogue scales and an ad libitum breakfast, respectively. Bedtime milk ingestion did not alter next morning RMR (BS0: 7822 (sem 276) kJ/d, BS10: 7482 (sem 262) kJ/d, BS30: 7851 (sem 261) kJ/d, P=0·19) or substrate utilisation as measured by RER (P=0·64). Bedtime milk ingestion reduced hunger (P=0·01) and increased fullness (P=0·04) during the evening immediately after snack ingestion, but elicited no effect the next morning. Next morning breakfast (BS0: 2187 (sem 365) kJ, BS10: 2070 (sem 336) kJ, BS30: 2582 (sem 384) kJ, P=0·21) and 24 h post-trial (P=0·95) energy intake was similar between conditions. To conclude, in mildly overweight adults, compared with a non-energetic placebo, a bedtime milk snack containing 10 or 30 g of protein does not confer changes in next morning whole-body metabolism and appetite that may favour weight management.
The effect of transportation and lairage on the faecal shedding and post-slaughter contamination of carcasses with Escherichia coli O157 and O26 in young calves (4–7-day-old) was assessed in a cohort study at a regional calf-processing plant in the North Island of New Zealand, following 60 calves as cohorts from six dairy farms to slaughter. Multiple samples from each animal at pre-slaughter (recto-anal mucosal swab) and carcass at post-slaughter (sponge swab) were collected and screened using real-time PCR and culture isolation methods for the presence of E. coli O157 and O26 (Shiga toxin-producing E. coli (STEC) and non-STEC). Genotype analysis of E. coli O157 and O26 isolates provided little evidence of faecal–oral transmission of infection between calves during transportation and lairage. Increased cross-contamination of hides and carcasses with E. coli O157 and O26 between co-transported calves was confirmed at pre-hide removal and post-evisceration stages but not at pre-boning (at the end of dressing prior to chilling), indicating that good hygiene practices and application of an approved intervention effectively controlled carcass contamination. This study was the first of its kind to assess the impact of transportation and lairage on the faecal carriage and post-harvest contamination of carcasses with E. coli O157 and O26 in very young calves.
Prevalence of skin sores and scabies in remote Australian Aboriginal communities remains unacceptably high, with Group A Streptococcus (GAS) the dominant pathogen. We aim to better understand the drivers of GAS transmission using mathematical models. To estimate the force of infection, we quantified the age of first skin sores and scabies infection by pooling historical data from three studies conducted across five remote Aboriginal communities for children born between 2001 and 2005. We estimated the age of the first infection using the Kaplan–Meier estimator; parametric exponential mixture model; and Cox proportional hazards. For skin sores, the mean age of the first infection was approximately 10 months and the median was 7 months, with some heterogeneity in median observed by the community. For scabies, the mean age of the first infection was approximately 9 months and the median was 8 months, with significant heterogeneity by the community and an enhanced risk for children born between October and December. The young age of the first infection with skin sores and scabies reflects the high disease burden in these communities.
The Molonglo Observatory Synthesis Telescope (MOST) is an 18000 m2 radio telescope located 40 km from Canberra, Australia. Its operating band (820–851 MHz) is partly allocated to telecommunications, making radio astronomy challenging. We describe how the deployment of new digital receivers, Field Programmable Gate Array-based filterbanks, and server-class computers equipped with 43 Graphics Processing Units, has transformed the telescope into a versatile new instrument (UTMOST) for studying the radio sky on millisecond timescales. UTMOST has 10 times the bandwidth and double the field of view compared to the MOST, and voltage record and playback capability has facilitated rapid implementaton of many new observing modes, most of which operate commensally. UTMOST can simultaneously excise interference, make maps, coherently dedisperse pulsars, and perform real-time searches of coherent fan-beams for dispersed single pulses. UTMOST operates as a robotic facility, deciding how to efficiently target pulsars and how long to stay on source via real-time pulsar folding, while searching for single pulse events. Regular timing of over 300 pulsars has yielded seven pulsar glitches and three Fast Radio Bursts during commissioning. UTMOST demonstrates that if sufficient signal processing is applied to voltage streams, innovative science remains possible even in hostile radio frequency environments.
The class of radio transients called Fast Radio Bursts (FRBs) encompasses enigmatic single pulses, each unique in its own way, hindering a consensus for their origin. The key to demystifying FRBs lies in discovering many of them in order to identity commonalities – and in real time, in order to find potential counterparts at other wavelengths. The recently upgraded UTMOST in Australia, is undergoing a backend transformation to rise as a fast transient detection machine. The first interferometric detections of FRBs with UTMOST, place their origin beyond the near-field region of the telescope thus ruling out local sources of interference as a possible origin. We have localised these bursts to much better than the ones discovered at the Parkes radio telescope and have plans to upgrade UTMOST to be capable of much better localisation still.
Free-range laying hen systems are increasing within Australia. The pullets for these systems are typically reared indoors before being provided first range access around 21 to 26 weeks of age. Thus, the rearing and laying environments are disparate and hens may not adapt well to free-range housing. In this study, we reared 290 Hy-Line® Brown day-old chicks divided into two rooms each with feed, water and litter. In the enriched room, multiple structural, manipulable, visual and auditory stimuli were also provided from 4 to 21 days, the non-enriched room had no additional objects or stimuli. Pullets were transferred to the laying facility at 12 weeks of age and divided into six pens (three enriched-reared, three non-enriched-reared) with identical indoor resources and outdoor range area. All birds were first provided range access at 21 weeks of age. Video observations of natural disturbance behaviours on the range at 22 to 23 and 33 to 34 weeks of age showed no differences in frequency of disturbance occurrences between treatment groups (P=0.09) but a decrease in disturbance occurrences over time (P<0.0001). Radio-frequency identification tracking of individually tagged birds from 21 to 37 weeks of age showed enriched birds on average, spent less time on the range each day (P<0.04) but with a higher number of range visits than non-enriched birds from 21 to 24 weeks of age (P=0.01). Enriched birds accessed the range on more days (P=0.03) but over time, most birds in both treatment groups accessed the range daily. Basic external health scoring showed minimal differences between treatment groups with most birds in visibly good condition. At 38 weeks of age all birds were locked inside for 2 days and from 40 to 42 weeks of age the outdoor range was reduced to 20% of its original size to simulate stressful events. The eggs from non-enriched birds had higher corticosterone concentrations following lock-in and 2 weeks following range reduction compared with the concentrations within eggs from enriched birds (P<0.0001). Correspondingly, the enriched hens showing a greater increase in the number of visits following range area reduction compared to non-enriched hens (P=0.02). Only one rearing room per treatment was used but these preliminary data indicate 3 weeks of early enrichment had some long-term effects on hen ranging behaviour and enhanced hen’s adaptability to environmental stressors.
Introduction: Effective trauma resuscitation requires a coordinated team approach, yet there is a significant risk for error. These errors can manifest from sequential system-, team- and knowledge based failures, defined as latent safety threats (LSTs). In situ simulation (ISS), a point-of-care training strategy, provides a novel prospective approach to identify factors that impact patient safety. This study quantified and formulated a hierarchy of LSTs during risk-informed ISS trauma resuscitations. Methods: At a Level 1 trauma centre, we conducted 12 multi-disciplinary, unannounced ISSs to prospectively identify trauma-related LSTs. Four, risk-informed scenarios were developed based on 5 recurring themes found within the trauma program’s morbidity and mortality process. The actual, on-call trauma team participated in the study. Simulations were video recorded with 4 cameras, each positioned at a different angle. Using a framework analysis methodology, human factors experts transcribed and coded the videos. Thematic structure was established deductively based on existing literature and inductively based on observed ISS events. All LSTs were prioritized for future patient safety, systems and ergonomic interventions using the Healthcare Failure Mode and Effect Analysis (HFMEA) matrix. Results: We identified 893 LSTs from 12 simulations. LST analysis resulted in 8 themes subcategorized into 43 codes. Themes were associated with team-, knowledge- or system-related issues. The following themes emerged: situational awareness, provider safety, mental model alignment, team/individual responsibility, team resources, equipment considerations, workplace environment and clinical protocols. The HFMEA hazard scoring process identified 13 high priority codes that required urgent attention and intervention to mitigate negative patient outcomes. Conclusion: A prospective, video-based framework analysis represents a novel and robust approach to LST identification within trauma care. Patterns of LSTs within and between simulations provide a high degree of transparency and traceability for an inter-professional trauma program review. Hazard matrix scoring facilitates the classification and prioritization of human factors interventions intended to improve patient safety.
Historically, community engagement (CE) in research has been implemented in the fields of public health, education and agricultural development. In recent years, international discussions on the ethical and practical goals of CE have been extended to human genomic research and biobanking, particularly in the African context. While there is some consensus on the goals and value of CE generally, questions remain about the effectiveness of CE practices and how to evaluate this. Under the auspices of the Human Heredity and Health in Africa Initiative (H3Africa), the H3Africa CE working group organized a workshop in Stellenbosch, South Africa in March 2016 to explore the extent to which communities should be involved in genomic research and biobanking and to examine various methods of evaluating the effectiveness of CE. In this paper, we present the key themes that emerged from the workshop and make a case for the development of a rigorous application, evaluation and learning around approaches for CE that promote a more systematic process of engaging relevant communities. We highlight the key ways in which CE should be embedded into genomic research and biobanking projects.
Free-range laying hen systems are increasing within Australia and research is needed to determine optimal outdoor stocking densities. Six small (n=150 hens) experimental flocks of ISA Brown laying hens were housed with access to ranges simulating one of three outdoor stocking densities with two pen replicates per density: 2000 hens/ha, 10 000 hens/ha or 20 000 hens/ha. Birds were provided daily range access from 21 to 36 weeks of age and the range usage of 50% of hens was tracked using radio-frequency identification technology. Throughout the study, basic external health assessments following a modified version of the Welfare Quality® protocol showed most birds were in visibly good condition (although keel damage was increasingly present with age) with few differences between stocking densities. Toenail length at 36 weeks of age was negatively correlated with hours spent ranging for all pens of birds (all r⩾−0.23, P⩽0.04). At 23 weeks of age, there were no differences between outdoor stocking densities in albumen corticosterone concentrations (P=0.44). At 35 weeks of age, density effects were significant (P<0.001) where the eggs from hens in the highest outdoor stocking density showed the highest albumen corticosterone concentrations, although eggs from hens in the 10 000 hens/ha density showed the lowest concentrations (P<0.017). Behavioural observations of hens both on the range and indoors showed more dust bathing and foraging (scratching followed by ground-pecking) was performed outdoors, but more resting indoors (all P<0.001). Hens from the 2000 hens/ha densities showed the least foraging on the range but the most resting outdoors, with hens from the 20 000 hens/ha densities showing the least amount of resting outdoors (all P<0.017). Proportions of dust bathing outdoors tended to differ between the stocking densities (P=0.08). For each of the health and behavioural measures there were differences between pen replicates within stocking densities. These data show outdoor stocking density has some effects on hen welfare, and it appears that consideration of both individual and group-level behaviour is necessary when developing optimal stocking density guidelines and free-range system management practices.
A small fraction of Tidal Disruption Events (TDE) produce relativistic jets, evidenced by their non-thermal X-ray spectra and transient radio emission. Here we present milliarcsecond-resolution imaging results on TDE J1644+5734 with the European VLBI Network (EVN). These provide a strong astrometric constraint on the average apparent jet velocity βapp < 0.27, that constrains the intrinsic jet velocity for a given viewing angle.
To examine the delivery and assessment of psychiatry at undergraduate level in the six medical schools in the Republic of Ireland offering a medical degree programme.
A narrative description of the delivery and assessment of psychiatry at undergraduate level by collaborative senior faculty members from all six universities in Ireland.
Psychiatry is integrated to varying degrees across all medical schools. Clinical experience in general adult psychiatry and sub-specialities is provided by each medical school; however, the duration of clinical attachment varies, and the provision of some sub-specialities (i.e. forensic psychiatry) is dependent on locally available resources. Five medical schools provide ‘live’ large group teaching sessions (lectures), and all medical schools provide an array of small group teaching sessions. Continuous assessment encompasses 10–35% of the total assessment marks, depending on the medical school. Only one medical school does not provide a clinical examination in the form of an Objective Structured Clinical Examination with viva examinations occurring at three medical schools.
Many similarities exist in relation to the delivery of psychiatry at undergraduate level in Ireland. Significant variability exists in relation to assessment with differences in continuous assessment, written and clinical exams and the use of vivas noted. The use of e-learning platforms has increased significantly in recent years, with their role envisaged to include cross-disciplinary teaching sessions and analysis of examinations and individual components within examinations which will help refine future examinations and enable greater sharing of resources between medical schools.
The number and size of free-range laying hen (Gallus gallus domesticus) production systems are increasing within Australia in response to consumer demand for perceived improvement in hen welfare. However, variation in outdoor stocking density has generated consumer dissatisfaction leading to the development of a national information standard on free-range egg labelling by the Australian Consumer Affairs Ministers. The current Australian Model Code of Practice for Domestic Poultry states a guideline of 1500 hens/ha, but no maximum density is set. Radio-frequency identification (RFID) tracking technology was used to measure daily range usage by individual ISA Brown hens housed in six small flocks (150 hens/flock – 50% of hens tagged), each with access to one of three outdoor stocking density treatments (two replicates per treatment: 2000, 10 000, 20 000 hens/ha), from 22 to 26, 27 to 31 and 32 to 36 weeks of age. There was some variation in range usage across the sampling periods and by weeks 32 to 36 individual hens from the lowest stocking density on average used the range for longer each day (P<0.001), with fewer visits and longer maximum durations per visit (P<0.001). Individual hens within all stocking densities varied in the percentage of days they accessed the range with 2% of tagged hens in each treatment never venturing outdoors and a large proportion that accessed the range daily (2000 hens/ha: 80.5%; 10 000 hens/ha: 66.5%; 20 000 hens/ha: 71.4%). On average, 38% to 48% of hens were seen on the range simultaneously and used all available areas of all ranges. These results of experimental-sized flocks have implications for determining optimal outdoor stocking densities for commercial free-range laying hens but further research would be needed to determine the effects of increased range usage on hen welfare.