Elemental fingerprinting of mineral species in iron-fortified milk: anomalous small-angle X-ray scattering and resonant soft X-ray scattering studies.

Anomalous small-angle X-ray scattering (ASAXS) and resonant soft X-ray scattering (RSoXS) are two related techniques that can enable element-specific structural information to be obtained. The development of iron-fortified milk products can greatly benefit from such techniques, allowing the structure of iron and other minerals (such as native calcium) within the casein micelle to be determined. Each method has advantages and disadvantages: for ASAXS, the sample preparation is straightforward, but the signal is relatively low and information about the structure of Ca is difficult to access. RSoXS can be used to study both Ca and Fe, and the element-specific signals observed are proportionally much higher; however, the measurements are challenging due to the difficulty of precise control of the solution thickness using currently available vacuum-compatible liquid cells. Nevertheless, complementary results from both techniques indicate Fe is co-located with Ca, i.e. within the colloidal calcium phosphate nanoclusters that are present within native casein micelles in milk.

UK Paramedics Confidence in Identifying Child Sexual Abuse: A Mixed-Methods Investigation.

United Kingdom (UK) paramedics are in a prime position to identify children and young people who are victims or at risk of sexual abuse. Paramedics have access, by phone, or in person, to unprepared homes and communities which other health professionals such as social workers may not. Little research exists however, investigating UK paramedic confidence in identifying child sexual abuse. This mixed-method explanatory sequential investigation used the self-reported confidence levels of 276 UK paramedics to inform the design of seven semi-structured focus groups with 25 UK paramedics from a large ambulance service with operating models similar to all UK services. Multiple factors contribute to a lack of confidence in identifying child sexual abuse, child sexual exploitation, and female genital mutilation, including a perceived lack of exposure to sexual abuse, the perceived hidden nature of sexual abuse, and the lack of physical symptoms and examination. An overarching lack of knowledge is the most significant contributor to a lack of confidence which in turn perpetuates misinformation surrounding prevalence, location, and the signs and symptoms of sexual abuse. These findings suggest a lack of sufficient training and a need for further research evaluating the content of current training and its method of delivery.

Remote clinical decision-making: a clinician's definition.

Aims Remote clinical decision-making (RCDM), commonly known as 'telephone triage' or 'hear and treat', describes clinicians' non-face-to-face involvement with patient care, and is an established strategy in UK ambulance services for managing increasing demand. However, there is no suitable definition of RCDM that fully explains the roles undertaken by clinicians in 999 hubs, or for its use as an ambulance quality indicator (AQI). The aim of this study, which is part of a larger evaluation of a new RCDM module in higher education, is to determine how clinicians define RCDM. Methods Three participants were asked, during semi-structured interviews, to define RCDM. The interviews were recorded, transcribed and thematically analysed. Results Clinicians do not focus on outcomes when defining RCDM, but on the efficacy of the process and the appropriateness of the determined outcome. Conclusion There is no precise description of the role of healthcare professionals in 999 clinical hubs, but there is a need for role clarity, for employees and organisations. The study questions the suitability of the definition of hear and treat as an AQI, as it does not appear to represent fully the various duties undertaken by 999 clinical hub healthcare professionals. More research is needed to consider the definition of RCDM in all its forms.

Death anxiety among emergency care workers.

Death anxiety, or 'thanatophobia', is a state in which people experience negative emotional reactions in recognition of their own mortality. Emergency and unscheduled healthcare workers, such as emergency nurses and paramedics, are constantly reminded of death and therefore of their own mortality, and this makes them susceptible to death anxiety. This article introduces the concept of death anxiety, and highlights the need for staff, employers and universities to recognise its signs and symptoms. It also suggests some interventions that could prevent the debilitating effects of death anxiety, to improve staff's mental health and the care they provide to patients.

Challenges UK paramedics currently face in providing fully effective end-of-life care.

Paramedics play an integral part in community end-of-life care (EoLC) in the UK, especially given the lack of out-of-hours cover by palliative care specialists. Despite this, there remain multiple barriers to their fully effective provision of such care. This article provides a brief historical overview of paramedic practice, before highlighting some of the barriers to effective paramedic EoLC provision and introducing examples of collaborative work in the UK that aim to overcome these. The author hopes this will support improvements in paramedic-led EoLC. Given the similarities in the international evolution of paramedic education, readers from other countries will be able to relate to these findings.

Behind the screen: exploring the effects of home working on 999 telephone clinicians during the COVID-19 pandemic.

Introduction: The COVID-19 pandemic has significantly stretched global healthcare provisions since its commencement in 2019. From the outset, ambulance services in the UK had to adapt and change their working practices to meet distancing requirements, to increase staff numbers and to ease the effects of staff becoming unavailable for work due to self-isolation and illness. One strategy was moving clinicians from emergency operation centres (EOCs) to working from home. Like many international services, UK ambulance services use paramedics and nurses to undertake telephone and video assessments of patients calling the 999 emergency services line in a model known as virtual care or remote clinical decision making. Virtual care is any interaction between a patient and a clinician or clinicians, occurring remotely via information technologies.Increasing evidence is becoming available to suggest that the pandemic caused harm to the well-being of healthcare workers, primarily due to the severe stress of regular exposure to death and human suffering. However, there remains a dearth of literature focusing on the well-being of remote and virtual clinicians, especially those who moved from working in EOCs to working at home during the COVID-19 pandemic. Therefore, this study reports the findings of a qualitative analysis of these effects from the clinician's perspective. The authors hope that the findings from this study will inform the operating, well-being and leadership practices of those delivering such services. Methods: A convenience sample of telephone nurses and paramedics from one UK ambulance service where home working had been implemented were contacted. Fifteen clinicians with recent home-working experience responded to the invitation to participate out of a possible 31 (48%). All participants had previously practised remote assessment from within an EOC. Semi-structured interviews took place via video-conferencing software and were recorded, transcribed and thematically analysed. An inductive approach was taken to generating codes, and both researchers separately read the transcripts before re-reading them, assigning initial themes and determining frequency. Results: Five main themes were discovered, with further associated sub-themes. The main themes were: safety; financial implications; working relationships; home-working environment; and anxiety. Conclusions: Few studies explore remote clinicians' health and well-being. This study identified that home-working clinicians felt that there had been no detrimental impact on their health and well-being because of working from home during the initial phase of the COVID-19 pandemic. While some concerns were raised, these were mitigated through the support that clinicians received at home from family members, as well as from colleagues, some of whom had developed new working relationships. Financial implications appeared to have contributed to some concerns for participants initially, but these had been alleviated quickly despite requiring further exploration of the true financial impact of working from home.

How to improve patient care by learning from mistakes.

Mistakes made in healthcare settings and the challenges to staff that arise from them can harm service users, consume time and money, and often receive bad publicity. However, by learning from these mistakes and meeting these challenges, practitioners can improve the quality of the care they provide. This article explores what is meant by mistakes and challenges in the context of health care. It suggests that front line managers are best placed to prevent and learn from mistakes, and thereby improve care for patients.

The nature of health and social care partnerships.

Partnership, often wrongly used interchangeably with 'collaboration' and 'inter-agency working', features regularly in government publications, and is often high on health and social care managers' agendas. With an increasing emphasis on partnership in politics, society and health care, managers need to understand the concept in relation to their practice, its challenges and the most effective ways of implementing it. This article discusses the multifaceted nature of partnership, explores the benefits and obstacles to achieving successful partnerships and looks at how these can be overcome.

Benefits of a collaborative approach to service evaluation in urgent care.

Collaboration and service evaluation are essential enablers for improving models of health and social care. Significant benefits can be achieved when they are combined to form a collaborative service evaluation, particularly when such collaboration involves different clinical professions. This article uses the NHS 111 Wales service to explore a simple example of collaborative service evaluation and to discuss the benefits and challenges identified. While the tabletop exercises described were expected to focus solely on compliance data and the reasons for non-compliance, broader learning was identified for all parties involved. It became clear that there was a lack of shared understanding of each service, and that there were opportunities for education and opportunities to develop new national pathways. It is hoped that readers may be able to compare, learn and possibly replicate the collaborative approach used in their practice settings to achieve similar outcomes.

Development and validation of clinical prediction models for breast cancer incidence and mortality: a protocol for a dual cohort study.

INTRODUCTION: Breast cancer is the most common cancer and the leading cause of cancer-related death in women worldwide. Risk prediction models may be useful to guide risk-reducing interventions (such as pharmacological agents) in women at increased risk or inform screening strategies for early detection methods such as screening. METHODS AND ANALYSIS: The study will use data for women aged 20-90 years between 2000 and 2020 from QResearch linked at the individual level to hospital episodes, cancer registry and death registry data. It will evaluate a set of modelling approaches to predict the risk of developing breast cancer within the next 10 years, the 'combined' risk of developing a breast cancer and then dying from it within 10 years, and the risk of breast cancer mortality within 10 years of diagnosis. Cox proportional hazards, competing risks, random survival forest, deep learning and XGBoost models will be explored. Models will be developed on the entire dataset, with 'apparent' performance reported, and internal-external cross-validation used to assess performance and geographical and temporal transportability (two 10-year time periods). Random effects meta-analysis will pool discrimination and calibration metric estimates from individual geographical units obtained from internal-external cross-validation. We will then externally validate the models in an independent dataset. Evaluation of performance heterogeneity will be conducted throughout, such as exploring performance across ethnic groups. ETHICS AND DISSEMINATION: Ethics approval was granted by the QResearch scientific committee (reference number REC 18/EM/0400: OX129). The results will be written up for submission to peer-reviewed journals.

Call volume, triage outcomes, and protocols during the first wave of the COVID-19 pandemic in the United Kingdom: Results of a national survey.

OBJECTIVES: During the first wave of the COVID-19 pandemic in the United Kingdom (UK), to describe volume and pattern of calls to emergency ambulance services, proportion of calls where an ambulance was dispatched, proportion conveyed to hospital, and features of triage used. METHODS: Semistructured electronic survey of all UK ambulance services (n = 13) and a request for routine service data on weekly call volumes for 22 weeks (February 1-July 3, 2020). Questionnaires and data request were emailed to chief executives and research leads followed by email and telephone reminders. The routine data were analyzed using descriptive statistics, and questionnaire data using thematic analysis. RESULTS: Completed questionnaires were received from 12 services. Call volume varied widely between services, with a UK peak at week 7 at 13.1% above baseline (service range -0.5% to +31.4%). All services ended the study period with a lower call volume than at baseline (service range -3.7% to -25.5%). Suspected COVID-19 calls across the UK totaled 604,146 (13.5% of all calls), with wide variation between services (service range 3.7% to 25.7%), and in service peaks of 11.4% to 44.5%. Ambulances were dispatched to 478,638 (79.2%) of these calls (service range 59.0% to 100.0%), with 262,547 (43.5%) resulting in conveyance to hospital (service range 32.0% to 53.9%). Triage models varied between services and over time. Two primary call triage systems were in use across the UK. There were a large number of products and arrangements used for secondary triage, with services using paramedics, nurses, and doctors to support decision making in the call center and on scene. Frequent changes to triage processes took place. CONCLUSIONS: Call volumes were highly variable. Case mix and workload changed significantly as COVID-19 calls displaced other calls. Triage models and prehospital outcomes varied between services. We urgently need to understand safety and effectiveness of triage models to inform care during further waves and pandemics.

Beating the odds--nothing is impossible, its just a road less traveled.

By contrasting students with learning disabilities and students with schizophrenia, it becomes conspicuously clear that they face many of the same hurdles. I know through personal experience because I have both. Postsecondary institutions are making great strides in balancing the scales for disabled students. Special education for learning-disabled students is more a hindrance than a benefit; mainstreaming many learning-disabled students seems a more appropriate option. Students need to take advantage of the services that are most beneficial to them. The least restrictive environment is predominantly, if not always, the correct choice.

Estimating the mesorectal fascia in MRI.

Apart from chemoradiotherapy, surgery by total mesorectal resection is currently the only curative therapy for colorectal cancer. However, this often has a poor outcome, especially if there are affected lymph nodes too close to the resection boundary. The circumferential resection margin (CRM) is defined as the shortest distance from an affected region to the mesorectal fascia (MF), and should be at least 1 mm. However, this 3D distance is normally estimated in 2D (from image slices) and takes no account of uncertainty of the position of the MF. We describe a system able to estimate the location of the MF with a measure at each point along it of the uncertainty in location, and which then estimates the CRM in three dimensions. The MF localisation algorithm combines anatomical knowledge with a level set method based on: a non-parametric representation of the distribution of intensities, and the use of the monogenic signal to detect portions of the boundary.