Exploring the value, enablers and barriers of being a clinician-coach: A qualitative pilot study of clinician-coaches in emergency medicine.

OBJECTIVE: To explore how clinicians understand coaching and their clinician-coach practice in emergency medicine. METHODS: Participants were surveyed about the value of coaching and their beliefs about the enablers of, and barriers to, being a clinician-coach. RESULTS: Three themes were developed for the value of coaching: empowerment and growth; enhanced interpersonal dynamics; and reflective transformation. Key enablers were supportive infrastructure, self-driven development and recognition of value. Key barriers were time constraints and scheduling conflicts, cultural challenges and financial and structural obstacles. CONCLUSIONS: Fostering a supportive environment for coaching could significantly enhance clinician competence and well-being, healthcare delivery and professional development.

The genome sequences of the marine diatom Epithemia pelagica strain UHM3201 (Schvarcz, Stancheva & Steward, 2022) and its nitrogen-fixing, endosymbiotic cyanobacterium.

We present the genome assembly of the pennate diatom Epithemia pelagica strain UHM3201 (Ochrophyta; Bacillariophyceae; Rhopalodiales; Rhopalodiaceae) and that of its cyanobacterial endosymbiont (Chroococcales: Aphanothecaceae). The genome sequence of the diatom is 60.3 megabases in span, and the cyanobacterial genome has a length of 2.48 megabases. Most of the diatom nuclear genome assembly is scaffolded into 15 chromosomal pseudomolecules. The organelle genomes have also been assembled, with the mitochondrial genome 40.08 kilobases and the plastid genome 130.75 kilobases in length. A number of other prokaryote MAGs were also assembled.

Leadership conceptions of nurses and physicians in emergency care: A scoping review.

BACKGROUND: The Emergency Department (ED) is a setting where teamwork and leadership is imperative, however, the literature to date is mostly discipline (nursing or medical) specific. This scoping review aimed to map what is known about nurses' and physicians' conceptions of leadership in the ED to understand similarities, differences, and opportunities for leadership development and research. METHOD: Guided by the Joanna Briggs Institute approach, and Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR) Guidelines, a systematic search of three electronic databases was performed. The Mixed Methods Assessment Tool was used for quality appraisal of included articles. RESULTS: In total, 37 articles were included. Four key findings emerged: 1) leadership was rarely explicitly defined; 2) nurse leaders tended to be characterised as agents of continuity whilst physician leaders tended to be characterised as agents of change and continuity; 3) the clarification of expectations from nurse leaders was more evident than expectations from physician leaders; and 4) leadership discourse tended to be traditional rather than contemporary. CONCLUSION: Despite the proliferation of studies into ED nurse, physician and interprofessional leadership, opportunities exist to integrate learnings from other sectors to strengthen the development of current and next generation of ED leaders.

Disentangling top-down drivers of mortality underlying diel population dynamics of Prochlorococcus in the North Pacific Subtropical Gyre.

Photosynthesis fuels primary production at the base of marine food webs. Yet, in many surface ocean ecosystems, diel-driven primary production is tightly coupled to daily loss. This tight coupling raises the question: which top-down drivers predominate in maintaining persistently stable picocyanobacterial populations over longer time scales? Motivated by high-frequency surface water measurements taken in the North Pacific Subtropical Gyre (NPSG), we developed multitrophic models to investigate bottom-up and top-down mechanisms underlying the balanced control of Prochlorococcus populations. We find that incorporating photosynthetic growth with viral- and predator-induced mortality is sufficient to recapitulate daily oscillations of Prochlorococcus abundances with baseline community abundances. In doing so, we infer that grazers in this environment function as the predominant top-down factor despite high standing viral particle densities. The model-data fits also reveal the ecological relevance of light-dependent viral traits and non-canonical factors to cellular loss. Finally, we leverage sensitivity analyses to demonstrate how variation in life history traits across distinct oceanic contexts, including variation in viral adsorption and grazer clearance rates, can transform the quantitative and even qualitative importance of top-down controls in shaping Prochlorococcus population dynamics.

Nocturnal hypoxaemia is common in adults with sickle cell anaemia.

The symptoms and sequelae of sickle cell anaemia (SCA) are caused by the polymerization of deoxygenated sickle haemoglobin, and people with SCA may be uniquely susceptible to adverse outcomes from hypoxia and haemoglobin desaturation. We examined by oximetry adults (aged 18-45 years) with SCA presenting symptoms indicative of polysomnography, at a single institution, irrespective of treatment, for nocturnal hypoxaemia. Clinical labs and blood for in vitro assessments were taken upon enrolment and after 8-12 weeks of oxygen therapy or observation. Of 21 screened participants, nine (43%) had sufficient nocturnal hypoxaemia to warrant oxygen therapy (≥5 min at SpO2 ≤ 88%). Time spent at SpO2 ≤ 88% associated with age (p = 0.0092), annual hospitalizations (p = 0.0018) and anaemia (p = 0.0139), as well as plasma levels of TNFα (p = 0.0019) and IL-4 (p = 0.0147). Longitudinal analysis showed that WBC significantly decreased during the follow-up period in hypoxic individuals but not in non-hypoxic individuals (p = 0.0361 and p = 0.6969 respectively). Plasma levels of CCL2 and IL-1ra tended to increase, while levels of red blood cell reactive oxygen species tended to decrease with oxygen therapy. Overall, nocturnal hypoxaemia was common in this pilot study population and associated with plausible clinical comorbidities; oxygen therapy may decrease inflammation and oxidative damage in hypoxic individuals.

The Prehabilitation Radiotherapy Exercise, smoking Habit cessation and Balanced diet Study (PREHABS) protocol to explore the feasibility of embedding behavioural modifications into the clinical pathway for patients undergoing radical radiotherapy for lung cancer.

Patients with curable non-surgical lung cancer are often current smokers, have co-existing medical comorbidities and are treated with curative radiotherapy. To maximise the benefits of modern radiotherapy, there is an urgent need to optimise the patient's health to improve survival and quality of life. METHODS AND ANALYSIS: The Yorkshire Cancer Research-funded Prehabilitation Radiotherapy Exercise, smoking Habit cessation and Balanced diet Study (PREHABS) (L426) is a single-centre prospective feasibility study to assess embedding behavioural changes into the radical radiotherapy pathway of patients with lung cancer. Feasibility will be assessed by measuring acceptability, demand and implementation. The duration of the study is 24 months. PREHABS has two workstreams: the intervention study and the theory of change (ToC) study.Intervention study: PREHABS will commence at the R-IDEAL phase 2 trial (exploratory) based on existing evidence and includes support for smoking cessation, increasing activity and dietary well-being. Patients undergoing radical radiotherapy for lung cancer will be recruited from the oncology department at Leeds Teaching Hospitals NHS Trust (LTHT). ToC study: to maximise the acceptability and adherence to the PREHABS, we will use a ToC approach to qualitatively explore the key barriers and enablers of implementing a tailored programme of 'prehabilitation'. The PREHABS ToC study participants will be recruited from patients with lung cancer undergoing radical radiotherapy and staff from the LTHT oncology department. ANALYSIS: The primary endpoint analysis will report the number of participants and adherence to the study interventions. Secondary endpoints include continued engagement with study interventions post-treatment. The analysis will focus on descriptive statistics. Thematic analysis of the qualitative data from the ToC study will identify consensus on intervention optimisation and delivery. ETHICS AND DISSEMINATION: On 12 May 2021, the Cambridge East Ethics Committee granted ethical approval (21/EE/0048). The study is registered in the National Institute for Health and Care Research (NIHR) portfolio. The results will be disseminated through publication in peer-reviewed scientific journals and presented at conferences. TRIAL REGISTRATION NUMBER: NIHR portfolio 48420.

A search for commonalities in defining the common good: Using folk theories to unlock shared conceptions.

Throughout the course of scholarly history, some concepts have been notoriously hard to define. The 'common good' is one such concept. While the common good has a long and contested scholarly history, social psychology research on folk theories - lay beliefs that represent an individual's informal and subjective understanding of the world - may provide a key for unlocking this nebulous concept. In the current paper, we analysed lay definitions of the common good using the linguistic inquiry and word count's meaning extraction method. From a nationally representative Australian sample of open-ended text responses (n = 14,303), we uncovered a consistent conceptual structure, with nine themes corresponding to three core aspects: (i) outcomes and objects, (ii) principles and processes and (iii) stakeholders and beneficiaries. From this, we developed a working definition of the folk concept of the common good: 'achieving the best possible outcome for the largest number of people, which is underpinned by decision-making that is ethically and morally sound and varies by the context in which the decisions are made'. A working definition benefits the academic community and society more broadly, particularly when diverse stakeholders come together to act for the common good to address shared challenges.

Evidence behind the exhortation? A rapid review of servant leadership's influence and claims in healthcare over the last decade.

Servant leadership is an other-oriented approach to leadership with multiple positive outcomes. However, its influence in the context of medicine, particularly on healthcare leaders, is less clear. We conducted a rapid review to examine the impact of servant leadership in healthcare over the last decade. We included a total of 28 articles, 26 of which described beneficial organisational, relational and personal outcomes of servant leadership. However, most of these were either conceptual or opinion-based articles. Moreover, most quantitative studies were cross-sectional, precluding causal inferences. Our review demonstrates that the purported positive association between servant leadership and healthcare outcomes lacks a strong evidence base. We conclude by calling for more rigorous empirical research to examine the effects and potential challenges of implementing servant leadership in healthcare contexts.

Are emergency departments leader identity workspaces? A qualitative study of emergency physicians.

OBJECTIVE: Emergency medicine is a discipline with complex leadership demands, which are experienced by junior and senior emergency physicians alike. In this environment, emergency physicians can struggle to work out what it means to be a leader and develop professional identities as leaders, necessitating a leader identity workspace. The aim of the present study is to explore whether emergency physicians view their work environment as leader identity workspaces. METHODS: An online qualitative survey was used that included open-ended questions about emergency physicians' experience of their workplace as a 'space' to craft their leadership identity. Participants' responses were analysed using reflexive thematic analysis. RESULTS: Three themes, comprising several subthemes, were identified that related to emergency physicians' ideal leader selves (leader dreams and desired leader selves), their experience of the community of clinicians in hospitals (confrontational sentient communities) and the types of rituals emergency physicians yearn for to support and legitimate their leadership (seeking vital leadership rites of passage). CONCLUSION: Our results suggest that neither EDs nor hospitals more generally exhibit the properties of, or are experienced by emergency physicians, as leader identity workspaces.

Test Characteristics of Emergency Medicine-Performed Point-of-Care Ultrasound for the Diagnosis of Acute Cholecystitis: A Systematic Review and Meta-analysis.

Acute cholecystitis accounts for up to 9% of hospital admissions for acute abdominal pain, and best practice entails early surgical management. Ultrasound is the standard modality used to confirm diagnosis. Our objective was to perform a systematic review and meta-analysis to determine the diagnostic accuracy of emergency physician-performed point-of-care ultrasound for the diagnosis of acute cholecystitis when compared with a reference standard of final diagnosis (informed by available surgical pathology, discharge diagnosis, and radiology-performed ultrasound). We completed a systematic review and meta-analysis, registered in PROSPERO, in adherence to Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. We searched 7 databases as well as gray literature in the form of select conference abstracts from inception to February 8, 2023. Two independent reviewers completed study selection, data extraction, and risk of bias (QUADAS-2) assessment. Disagreements were resolved by consensus with a third reviewer. Data were extracted from eligible studies to create 2 × 2 tables for diagnostic accuracy meta-analysis. Hierarchical Summary Receiver Operating Characteristic models were constructed. Of 1855 titles/abstracts, 40 were selected for full-text review. Ten studies (n=2356) were included. Emergency physician-performed point-of-care ultrasound with final diagnosis as the reference standard (7 studies, n=1,772) had a pooled sensitivity of 70.9% (95% confidence interval [CI] 62.3 to 78.2), specificity of 94.4% (95% CI 88.2 to 97.5), positive likelihood ratio of 12.7 (5.8 to 27.5), and negative likelihood ratio of 0.31 (0.23 to 0.41) for the diagnosis of acute cholecystitis. Emergency physician-performed point-of-care ultrasound has high specificity and moderate sensitivity for the diagnosis of acute cholecystitis in patients with clinical suspicion. This review supports the use of emergency physician-performed point-of-care ultrasound to rule in a diagnosis of acute cholecystitis in the emergency department, which may help expedite definitive management.

Biopsychosocial Factors Associated With Pain and Pain-Related Outcomes in Adults and Children With Sickle Cell Disease: A Multivariable Analysis of the GRNDaD Multicenter Registry.

Pain is the primary symptomatic manifestation of sickle cell disease (SCD), an inherited hemoglobinopathy. The characteristics that influence pain experiences and outcomes in SCD are not fully understood. The primary objective of this study was to use multivariable modeling to examine associations of biopsychosocial variables with a disease-specific measure of pain interference known as pain impact. We conducted a secondary analysis of data from the Global Research Network for Data and Discovery national SCD registry. A total of 657 children and adults with SCD were included in the analysis. This sample was 60% female with a median age of 34 (interquartile range 26-42 years) and a chronic pain prevalence of 64%. The model accounted for 58% of the variance in pain impact. Low social (P < .001) and emotional (P < .001) functioning, increasing age (P = .004), low income (P < .001), and high acute painful episodes (P = .007) were most strongly associated with high pain impact in our multivariable model. Additionally, multivariable modeling of pain severity and physical function in 2 comparable samples of registry participants revealed that increasing age and low social functioning were also strongly associated with higher pain severity and low physical functioning. Overall, the results suggest that social and emotional functioning are more strongly associated with pain impact in individuals with SCD than previously studied biological modifiers such as SCD genotype, hemoglobin, and percentage fetal hemoglobin. Future research using longitudinally collected data is needed to confirm these findings. PERSPECTIVE: This study reveals that psychosocial (ie, social and emotional functioning) and demographic (ie, age) variables may play an important role in predicting pain and pain-related outcomes in SCD. Our findings can inform future multicenter prospective longitudinal studies aimed at identifying modifiable psychosocial predictors of adverse pain outcomes in SCD.

Power and politics of leading change in emergency departments: A qualitative study of Australasian emergency physicians.

OBJECTIVE: The ability to lead change is well recognised as a core leadership competency for clinicians, including emergency physicians. However, little is known about how emergency physicians' think about change leadership. The present study explores Australasian emergency physicians' beliefs about the factors that help and hinder efforts to lead change in Australasian EDs. METHODS: An online modified Delphi study was conducted with 19 Fellows of the Australasian College for Emergency Medicine. To structure the process, participants were sorted into four panels. Using a three-phase Delphi process, participants were guided through a process of brainstorming, narrowing down and ranking the factors that help and hinder attempts to lead change. Reflexive thematic analysis was used to code and interpret the qualitative data set emerging from participants' responses through the final ranking phase. RESULTS: A wide array of self-, ED- and hospital-related enablers and barriers of leading change were identified, the relative importance of which varied as a function of panel. Five core themes characterised emergency physicians' conceptions of change leadership in hospitals: challenging environments of competing interests and tribalism; need for trust and psychological safety to sustain collaboration; challenges of navigating complex hierarchies; need to garner executive leadership support and; need to maintain a growth mindset and motivation to practice change leadership. CONCLUSION: The findings of our study provide new insight into emergency physicians' conceptions of the nature, barriers to and enablers of change and point to new directions in leadership development to support emergency physicians' aspirations in the context of quality, organisation and health systems improvement.

The impact on passenger car emissions associated with the promotion and demise of diesel fuel.

The promotion and growth in the use of diesel fuel in passenger cars in the UK and Europe over the past two decades led to considerable adverse air quality impacts in urban areas and more widely. In this work, we construct a multi-decade analysis of passenger car emissions in the UK based on real driving emissions data. An important part of the study is the use of extensive vehicle emission remote sensing data covering multiple measurement locations, time periods, environmental conditions and consisting of over 600,000 measurements. These data are used to consider two scenarios: first, that diesel fuel use was not promoted in the early 2000s for climate mitigation reasons, and second, that there was not a dramatic decline in diesel fuel use following the Dieselgate scandal. The strong growth of diesel fuel use coincided with a time when diesel NOx emissions were high and, conversely, the strong decrease of diesel fuel use coincided with a time when diesel vehicle after-treatment systems for NOx control were effective. We estimate that the growth in diesel car use in the UK results in excess NOx emissions of 721 kt over a three decade period; equivalent to over 7 times total annual passenger car NOx emissions and greater than total UK NOx emissions of 681.8 kt in 2021 and with an associated damage cost of £5.875 billion. However, the sharp move away from diesel fuel post-Dieselgate only reduced NOx emissions by 41 kt owing to the effectiveness of modern diesel aftertreatment systems.

Pain Frequency and Health Care Utilization Patterns in Women with Sickle Cell Disease Experiencing Menstruation-Associated Pain Crises.

Background: Pain crises in sickle cell disease (SCD) lead to high rates of health care utilization. Historically, women have reported higher pain burdens than men, with recent studies showing a temporal association between pain crisis and menstruation. However, health care utilization patterns of SCD women with menstruation-associated pain crises have not been reported. We studied the frequency, severity, and health care utilization of menstruation-associated pain crises in SCD women. Materials and Methods: A multinational, cross-sectional cohort study of the SCD phenotype was executed using a validated questionnaire and medical chart review from the Consortium for the Advancement of Sickle Cell Research (CASiRe) cohort. Total number of pain crises, emergency room/day hospital visits, and hospitalizations were collected from a subcohort of 178 SCD women within the past 6 months and previous year. Results: Thirty-nine percent of women reported menstruation-associated pain crises in their lifetime. These women were significantly more likely to be hospitalized compared with those who did not (mean 1.70 vs. 0.67, p = 0.0005). Women reporting menstruation-associated pain crises in the past 6 months also experienced increased hospitalizations compared with those who did not (mean 1.71 vs. 0.75, p = 0.0016). Forty percent of women reported at least four menstruation-associated pain crises in the past 6 months. Conclusions: Nearly 40% of SCD women have menstruation-associated pain crises. Menstruation-associated pain crises are associated with high pain burden and increased rates of hospitalization. Strategies are needed to address health care disparities within gynecologic care in SCD.

Non-clinical intuitions and adaptive heuristics in emergency care: A scoping review.

BACKGROUND: Across a range of fields, including healthcare, heuristics are typically conceived as a source of bias and systematic error. However, research across the psychological and management sciences shows that intuition and heuristics are also vital sources of adaptive decision strategies, especially in complex, uncertain environments. The complexity of the emergency care environment marks this environment as one in which non-clinical intuitions and heuristics are likely to emerge and function as adaptive decision strategies. The aim of this study was to map and contextualize what is known about leadership and non-clinical intuitions and heuristics in emergency care. METHODS: Based on a systematic search of the Pubmed, Scopus, Web of Science, MEDLINE and CINAHL electronic databases, we conducted a scoping review to map what is known about leadership and non-clinical intuitions and adaptive heuristics in emergency care. RESULTS: Of the 1219 articles retrieved, 9 met the inclusion criteria. Our review revealed four key findings. First, intuitions are used to make judgments about patients, caring for patients, and coordinating with colleagues. Second, although non-clinical intuitions are documented, non-clinical heuristics are rarely studied. Third, the literature is focused on nurses and silent on the use of non-clinical intuition and heuristics among medical doctors. Finally, professional cultures influence clinicians' use of intuitive sense- and decision-making. CONCLUSION: This review highlights the dearth of research into non-clinical intuitions and heuristics in emergency care. Understood in the context of insights from the psychological and management sciences about intuitions and 'smart' heuristics as adaptive decision strategies, our findings point to new frontiers of research into leadership in emergency care.

Advanced practice provider-led clinic for care transitions in newly diagnosed venous thromboembolism: establishment and utilization.

Background: Patients with suspected or newly diagnosed venous thromboembolism (VTE) are often referred to the emergency department (ED) for management, where anticoagulation is initiated. However, when the patient is judged to be suitable for outpatient management, counseling and follow-up specialty care are frequently suboptimal. Objectives: To establish an advanced practice provider (APP)-led rapid follow-up clinic to improve transitions of care for patients with newly diagnosed deep vein thrombosis or low-risk pulmonary embolism and to provide continued specialty care and support, including management of complications and medication access issues. Methods: In order to address this gap in transition of care, we developed an APP-led clinic with a mandate to improve quality and safety in the outpatient setting for patients with acute VTE. Results: In the first 2 years, a total of 234 patients were evaluated, of whom data were standardized and reviewed for 229. Utilization steadily increased over time, with at least 10% of patients requiring financial medication assistance over both years. Seventy-two percent of patients were referred from the ED in the first year and 59% in the second year, and referrals from non-ED outpatient specialties increased. Data on deviations from standard care identified in referred patients were collected in the second year and found in 19 (12.7%) of cases. These included unnecessarily prescribed or changed anticoagulants, dosing errors, misclassification of thrombosis, and other deviations. Patient demographic data also demonstrated increasing diversity of the patient population over time, with increased utilization by Hispanic and African American patients in the second year. This highlighted the need for better patient education material translations into Spanish, which is a future aim. Conclusion: In summary, the APP-led VTE Transition Clinic was feasible and grew quickly in utilization, diversity of referrals, and diversity of patients served.

Five ways to get a grip on designing medical student clerkship clinical rotations during a pandemic.

During the COVID-19 pandemic, the task of preparing students for workplace-based clerkship and supporting learners' ongoing professional identity formation became incrementally more challenging. The former design of clerkship rotations was re-challenged and revolutionized going forward, as COVID-19 accelerated the development and implementation of e-Health and technology-enhanced learning (TEL). However, the practical integration of learning and teaching activities, and the application of well-thought-out first principles in pedagogy in higher education, remain difficult to implement in today's pandemic era. In this paper, using the transition-to-clerkship (T2C) course as an example, we outline the steps taken to implement our clerkship rotation, discussing various curricular challenges from the lenses of various stakeholders, and practical lessons learned.

Pendant la pandémie de la COVID-19, la tâche de préparer les étudiants aux stages d'externat et de soutenir la construction de leur identité professionnelle est devenue plus difficile. La structure traditionnelle de l'externat a été remise en question et révolutionnée, car la COVID-19 a accéléré le développement et la mise en œuvre de la technologie des soins en santé et de l'apprentissage assisté par la technologie. Cependant, l'intégration des activités d'apprentissage et d'enseignement, et l'application de principes pédagogiques éprouvés dans l'enseignement supérieur restent difficiles à mettre en pratique dans le contexte actuel de pandémie. Dans cet article, prenant le cours de transition vers l'externat comme exemple, nous décrivons les étapes que nous avons suivies pour organiser notre stage d'externat et les défis rencontrés sur le plan du cursus par les diverses parties prenantes, et nous présentons les leçons pratiques que nous en avons tirées.