Sounding out maerl sediment thickness: an integrated data approach.

Maerl beds are listed as a priority marine feature in Scotland. They are noted for creating suitable benthic habitat for diverse communities of fauna and flora and in supporting a wide array of ecosystem services. Within the context of climate change, they are also recognised as a potential blue carbon habitat through sequestration of carbon in living biomass and underlying sediment. There are, however, significant data gaps on the potential of maerl carbon sequestration which impede inclusion in blue carbon policy frameworks. Key data gaps include sediment thickness, from which carbon content is extrapolated. There are additional logistical and financial barriers associated with quantification methods that aim to address these data gaps. This study investigates the use of sub-bottom profiling (SBP) to lessen financial and logistical constraints of maerl bed sediment thickness estimation and regional blue carbon quantification. SBP data were cross validated with cores, other SBP data on blue carbon sediments, and analysed with expert input. Combining SBP data with estimates of habitat health (as % cover) from drop-down video (DDV) data, and regional abiotic data, this study also elucidates links between abiotic and biotic factors in determining maerl habitat health and maerl sediment thickness through pathway analysis in structural equation modelling (SEM). SBP data were proved to be sufficiently robust for identification of maerl sediments when corroborated with core data. SBP and DDV data of maerl bed habitats in Orkney exhibited some positive correlations of sediment thickness with maerl % cover. The average maerl bed sediment thickness was 1.08 m across all ranges of habitat health. SEM analysis revealed maerl bed habitat health was strongly determined by abiotic factors. Maerl habitat health had a separate positive effect on maerl bed sediment thickness.

Atrio-Ventricular Block by Legionella Disease.

Although Legionnaires' disease mainly affects the lungs, it can also present with other systemic involvement, including rare cardiac manifestations. Recognised presentations are endocarditis, myocarditis, pericarditis, and pericardial effusion. A 72-year-old British man presented with a six-day history of dry cough and a four-day history of fever during the peak of the COVID-19 pandemic. His electrocardiogram showed Mobitz type II atrio-ventricular block. Although all the cultures were negative, the chest X-ray demonstrated COVID-19 infection-like features. With high clinical suspicions and chest X-ray features, the polymerase chain reaction of the COVID tests was repeated three times and all were negative. He had a positive urinary Legionella antigen, and his bradycardia and heart block improved after treatment with amoxicillin/clavulanic acid, and clarithromycin. As the electrocardiogram showed Mobitz type II, a permanent pacemaker was implanted. The follow-up pacemaker check showed that he still required active pacing.

The value of all-payer claims databases to states.

All-payer claims databases are being developed in states across the nation to fill gaps in information about the health care system. The value of such databases is becoming more apparent as these databases mature and are used more frequently to help states better understand their health care utilization and costs.

Attitudes, implementation and practice of family presence during resuscitation (FPDR): a quantitative literature review.

AIM: To undertake a review of the quantitative research literature, to determine emergency staff and public attitudes, to support the implementation and practice of family presence during resuscitation in the emergency department. BACKGROUND: FPDR although endorsed by numerous resuscitation councils, cardiac, trauma and emergency associations, continues to be topical, the extent to which it is implemented and practiced remains unclear. REVIEW METHODS: A review of the quantitative studies published between 1992 and October 2011 was undertaken using the following databases: CINAHL, Ovid Medline, PSYCHINFO, Pro-Quest, Theses Database, Cochrane, and Google Scholar search engine. The primary search terms were 'family presence', and 'resuscitation'. The final studies included in this paper were appraised using the Critical Appraisal Skills Programme criteria. RESULTS: Fourteen studies were included in this literature review. These included quantitative descriptive designs, pre and post-test designs and one randomized controlled trial (RCT). The studies were divided into three main research areas; investigation of emergency staff attitudes and opinions, family and general public attitudes, and four papers evaluating family presence programs in the emergency department. Studies published prior to 2000 were included in the background. CONCLUSION: FPDR in the emergency department is well recognised and documented among policy makers, the extent in which it is implemented and practiced remains unclear. Further research is needed to assess how emergency staff are educated and trained in order to facilitate family presence during resuscitation attempts.

Managing patient deterioration: assessing teamwork and individual performance.

OBJECTIVE: To assess the ability of rural Australian nurse teams to manage deteriorating patients. METHODS: This quasi-experimental design used pre- and post-intervention assessments and observation to evaluate nurses' simulated clinical performance. Registered nurses (n=44) from two hospital wards completed a formative knowledge assessment and three team-based video recorded scenarios (Objective Structured Clinical Examinations (OSCE)). Trained patient actors simulated deteriorating patients. Skill performance and situation awareness were measured and team performance was rated using the Team Emergency Assessment Measure. RESULTS: Knowledge in relation to patient deterioration management varied (mean 63%, range 27-100%) with a median score of 64%. Younger nurses with a greater number of working hours scored the highest (p=0.001). OSCE performance was generally low with a mean performance of 54%, but performance was maintained despite the increasing complexity of the scenarios. Situation awareness was generally low (median 50%, mean 47%, range 17-83%, SD 14.03) with significantly higher levels in younger participants (r=-0.346, p=0.021). Teamwork ratings averaged 57% with significant associations between the subscales (Leadership, Teamwork and Task Management) (p<0.006), the global rating scale (p<0.001) and two of the OSCE measures (p<0.049). Feedback from participants following the programme indicated significant improvements in knowledge, confidence and competence (p<0.001). CONCLUSION: Despite a satisfactory knowledge base, the application of knowledge was low with notable performance deficits in these demanding and stressful situations. The identification and management of patient deterioration needs to be taught in professional development programmes incorporating high fidelity simulation techniques. The Team Emergency assessment tool proved to be a valid measure of team performance in patient deterioration scenarios.

Managing patient deterioration: a protocol for enhancing undergraduate nursing students' competence through web-based simulation and feedback techniques.

AIMS: To describe a funded proposal for the development of an on-line evidence based educational program for the management of deteriorating patients. BACKGROUND: There are international concerns regarding the management of deteriorating patients with issues around the 'failure to rescue'. The primary response to these issues has been the development of medical emergency teams with little focus on the education of primary first responders. DESIGN/METHODS: A mixed methods triangulated convergent design.In this four phase proposal we plan to 1. examine nursing student team ability to manage deteriorating patients and based upon these findings 2. develop web based educational material, including interactive scenarios. This educational material will be tested and refined in the third Phase 3, prior to evaluation and dissemination in the final phase. CONCLUSION: This project aims to enhance knowledge development for the management of deteriorating patients through rigorous assessment of team performance and to produce a contemporary evidence-based online training program.

The FIRST²ACT simulation program improves nursing practice in a rural Australian hospital.

OBJECTIVE: To measure the impact of the Feedback Incorporating Review and Simulation Techniques to Act on Clinical Trends (FIRST(2) ACT) simulation program on nursing observations and practice relevant to patient deterioration in a rural Australian hospital. DESIGN: Interrupted time series analysis. SETTING: A rural Australian hospital. PARTICIPANTS: All registered nurses (Division 1) employed on an acute medical/surgical ward. INTERVENTION: The FIRST(2) ACT simulation program. OUTCOME MEASURES: Appropriate frequency of a range of observations and administration of oxygen therapy. RESULTS: Thirty-four nurses participated (83% of eligible nurses) in the FIRST(2) ACT program, and 258 records were audited before the program and 242 records after. There were statistically significant reductions in less than satisfactory frequency of observations (P = 0.009) and pain score charting (P = 0.003). There was no measurable improvement in the administration of oxygen therapy (P = 0.143), while the incidence of inappropriate nursing practice for other measures both before and after the intervention was too low to warrant analysis. CONCLUSION: FIRST(2) ACT was associated with measurable improvements in nursing practice.

Simulation based learning in midwifery education: a systematic review.

AIM: To critically examine the evidence for simulation based learning in midwifery education. BACKGROUND: Simulated Learning Programs (SLPs) using low to high fidelity techniques are common in obstetric professionals' education and focus on the development of team work, labour and obstetric emergencies. REVIEW METHODS: A systematic review incorporating critical appraisal approaches, setting clear objectives and a defined search and analysis strategy. Evidence from obstetrics, neonatology, technical and non-technical skills (teamwork) was included where it informed the development of midwifery curricula. Studies in English from 2000 to 2010 were included searching CINAHL Plus, OVID Medline, Cochrane, SCOPUS and ProQuest and Google Scholar. RESULTS: Twenty-four papers were identified that met the inclusion criteria. All were quantitative reports; outcomes and levels of evidence varied with two notable papers indicating that simulation had an impact on clinical practice. Benefits of SLP over didactic formats were apparent, as were the development of non-technical skills confidence and competence. The study outcomes were limited by the range of evidence and context of the reports which focussed on obstetric emergency training using a number of simulation techniques. CONCLUSION: There is evidence that simulated learning of midwifery skills is beneficial. Simulation learning has an educational and clinical impact and advantages over didactic approaches. Where clinical practice is infrequent i.e. obstetric emergencies, simulation is an essential component of curricula. Simulation enhances practice and therefore may reduce the time taken to achieve competence; however there is no evidence from the literature that simulation should replace clinical practice.

Identifying patient deterioration: using simulation and reflective interviewing to examine decision making skills in a rural hospital.

OBJECTIVES: The study aim was to examine how Registered Nurses identify and respond to deteriorating patients during in-hospital simulation exercises. DESIGN: Mixed methods study using simulated actors. SETTING: A rural hospital in Victoria, Australia. PARTICIPANTS: Thirty-four Registered Nurses each completed two simulation exercises. METHODS: Data were obtained from the following sources: (a) Objective Structured Clinical Examination (OSCE) rating to assess performance of Registered Nurses during two simulation exercises (chest pain and respiratory distress); (b) video footage of the simulation exercises; (c) reflective interview during participants' review of video footage. Qualitative thematic analysis of video and interview data was undertaken. RESULTS: Themes generated from the data were: (1) exhausting autonomous decision-making; (2) misinterpreting the evidence; (3) conditioned response; and (4) missed cues. Assessment steps were more likely to be omitted in the chest pain simulation, for which there was a hospital protocol in place. CONCLUSIONS: Video review revealed additional insights into nurses' decision-making that were not evident from OSCE scoring alone. Feedback during video review was a highly valued component of the simulation exercises.

Mixed methods research: a design for emergency care research?

This paper follows previous publications on generic qualitative approaches, qualitative designs and action research in emergency care by this group of authors. Contemporary views on mixed methods approaches are considered, with a particular focus on the design choice and the amalgamation of qualitative and quantitative data emphasising the timing of data collection for each approach, their relative 'weight' and how they will be mixed. Mixed methods studies in emergency care are reviewed before the variety of methodological approaches and best practice considerations are presented. The use of mixed methods in clinical studies is increasing, aiming to answer questions such as 'how many' and 'why' in the same study, and as such are an important and useful approach to many key questions in emergency care.

Managing deteriorating patients: registered nurses' performance in a simulated setting.

AIM: To examine, in a simulated environment, rural nurses' ability to assess and manage patient deterioration using measures of knowledge, situation awareness and skill performance. BACKGROUND: Nurses' ability to manage deterioration and 'failure to rescue' are of significant concern with questions over knowledge and clinical skills. Simulated emergencies may help to identify and develop core skills. METHODS: An exploratory quantitative performance review. Thirty five nurses from a single ward completed a knowledge questionnaire and two video recorded simulated scenarios in a rural hospital setting. Patient actors simulated deteriorating patients with an Acute Myocardial Infarction (AMI) and Chronic Obstructive Pulmonary Disease (COPD) as the primary diagnosis. How aware individuals were of the situation (levels of situation awareness) were measured at the end of each scenario. RESULTS: KNOWLEDGE OF DETERIORATION MANAGEMENT VARIED CONSIDERABLY (RANGE: 27%-91%) with a mean score of 67%. Average situation awareness scores and skill scores across the two scenarios (AMI and COPD) were low (50%) with many important observations and actions missed. Participants did identify that 'patients' were deteriorating but as each patient deteriorated staff performance declined with a reduction in all observational records and actions. In many cases, performance decrements appeared to be related to high anxiety levels. Participants tended to focus on single signs and symptoms and failed to use a systematic approach to patient assessment. CONCLUSION: Knowledge and skills were generally low in this rural hospital sample with notable performance decrements as patients acutely declined. Educational models that incorporate high fidelity simulation and feedback techniques are likely to have a significant positive impact on performance.

Outcome after acute myocardial infarction: a comparison of patients seen by cardiologists and general physicians.

BACKGROUND: The management of acute myocardial infarction (AMI) has improved over the last 50 years with the more frequent use of effective medicines and procedures. The clinical benefit of the specialty of the attending physician is less clear. The United Kingdom National Service Framework for coronary heart disease (CHD) suggested that patients with CHD are likely to benefit from cardiological supervision. We set out to assess the effect of access to cardiologists on survival among AMI patients admitted in two UK hospitals. METHODS: The study was conducted in a university hospital and a district general hospital in England. Information was obtained on age, sex, ethnicity, Carstairs socioeconomic deprivation category derived from postcode of residence, comorbidity, distance from hospital and medication from all patients admitted with acute myocardial infarction in two acute trusts between July 1999 and June 2000. Record linkage to subsequent Hospital Episode Statistics and Registrar General's death records provided follow up information on procedures and mortality up to eighteen months after admission. Cox proportional hazard models were used to investigate the main hypothesis controlling for confounding. The main outcome measure was 18-month survival after myocardial infarction. RESULTS: Access to a cardiologist was univariately associated with improved survival (hazard ratio 0.16, 95% CI 0.10 to 0.25). This effect remained after controlling for the effect of patient characteristics (hazard ratio 0.22, 95% CI 0.14 to 0.25). The effect disappeared after controlling for access to effective medication (hazard ratio 0.70, 95% CI 0.33 to 1.46). CONCLUSIONS: Access to a cardiologist is associated with better survival compared to no access to a cardiologist among a cohort of patients already admitted with AMI. This effect is mainly due to the more frequent use of effective medicines by the group referred to cardiologists. Hospitals may improve survival by improving access to effective medicines and by coordinating care between cardiologists and general physicians.

Further studies on the anticancer activity of citrus limonoids.

Research in this laboratory has shown that some citrus limonoids can inhibit the development of 7,12-dimethylbenz[a]anthracene-induced oral tumors. The data from these studies have suggested that certain rings in the limonoid nucleus may be critical to antineoplastic activity. Using the hamster cheek pouch model, three new limonoids (ichangensin, deoxylimonin, and obacunone) have now been tested for cancer chemopreventive activity. In the first experiment, it was found that the treatments with ichangensin had no effect on tumor number or burden. In the second experiment, obacunone reduced tumor number and burden by 25 and 40%, respectively, whereas deoxylimonin reduced tumor number and burden by 30 and 50%, respectively. The results with deoxylimonin were significant, p < 0.05. Overall, the data indicated that changes in the A ring of the limonoid nucleus can lead to a loss of anticancer activity, whereas changes in the D ring can be tolerated without any apparent loss of biological activity.