Safety Monitoring of mRNA COVID-19 Vaccine Third Doses Among Children Aged 6 Months-5 Years - United States, June 17, 2022-May 7, 2023.

As of May 7, 2023, CDC's Advisory Committee on Immunization Practices (ACIP) recommends that all children aged 6 months-5 years receive at least 1 age-appropriate bivalent mRNA COVID-19 vaccine dose. Depending on their COVID-19 vaccination history and history of immunocompromise, these children might also need additional doses* (1-3). Initial vaccine safety findings after primary series vaccination among children aged 6 months-5 years showed that transient local and systemic reactions were common whereas serious adverse events were rare (4). To characterize the safety of a third mRNA COVID-19 vaccine dose among children aged 6 months-5 years, CDC reviewed adverse events and health surveys reported to v-safe, a voluntary smartphone-based U.S. safety surveillance system established by CDC to monitor health after COVID-19 vaccination (https://vsafe.cdc.gov/en/) and the Vaccine Adverse Event Reporting System (VAERS), a U.S. passive vaccine safety surveillance system co-managed by CDC and the Food and Drug Administration (FDA) (https://vaers.hhs.gov/) (5). During June 17, 2022-May 7, 2023, approximately 495,576 children aged 6 months-4 years received a third dose (monovalent or bivalent) of Pfizer-BioNTech vaccine and 63,919 children aged 6 months-5 years received a third dose of Moderna vaccine.† A third mRNA COVID-19 vaccination was recorded for 2,969 children in v-safe; approximately 37.7% had no reported reactions, and among those for whom reactions were reported, most reactions were mild and transient. VAERS received 536 reports after a third dose of mRNA COVID-19 vaccine for children in these age groups; 98.5% of reports were nonserious and most (78.4%) were classified as a vaccination error.§ No new safety concerns were identified. Preliminary safety findings after a third dose of COVID-19 vaccine for children aged 6 months-5 years are similar to those after other doses. Health care providers can counsel parents and guardians of young children that most reactions reported after vaccination with Pfizer-BioNTech or Moderna vaccine were mild and transient and that serious adverse events are rare.

The impact of drug palatability on prescribing and dispensing of antibiotic formulations for paediatric patients: a cross-sectional survey of general practitioners and pharmacists.

BACKGROUND: Palatability is a key element of paediatric acceptability for medicines. Many patient and drug factors are considered when choosing an antibiotic for a child. Pharmacists report that they receive questions about the palatability of oral liquid antibiotics for children. This study aimed to explore the experiences of GPs and pharmacists concerning palatability of oral liquid antibiotics for children. METHODS: A questionnaire about the impact of palatability on the choice of antibiotic formulation for children was emailed to all community pharmacists in Ireland and to GPs and trainee GPs in the Cork region and posted on social media. Survey items were not compulsory; therefore, percentage responses were calculated based on the number of responses to that item. GP and pharmacist responses were analysed independently. RESULTS: Responses were received from 244 participants (59 GPs, 185 pharmacists). Clinical guidelines and availability of supply were the most important factors considered when choosing an oral liquid antibiotic formulation for children by GP (79.7%) and pharmacist (66.5%) respondents respectively. Forty GP respondents (76.9%) reported ensuring adherence was the most common palatability-related reason leading to deviation from guidelines. Pharmacist respondents (52%) reported advising a parent/caregiver to manipulate the required antibiotic dose to improve acceptability. The least palatable oral liquid antibiotics reported were flucloxacillin (16% GPs, 18% pharmacists) and clarithromycin (17% of each profession). CONCLUSION: This study identified palatability issues associated with oral liquid antibiotics for children reported by GPs and pharmacists. Pharmaceutical approaches to adapting oral liquid antibiotic formulations must be developed to improve palatability and thus paediatric acceptability.

Facilitators and barriers to the introduction of atrial fibrillation screening in primary care: a qualitative descriptive study of general practitioners in primary care.

INTRODUCTION: Atrial fibrillation (AF), the most common cardiac arrhythmia, is a major risk factor for stroke. AF is often asymptomatic and, if identified, treatment can be offered that can reduce stroke risk by up to two thirds. AF screening meets many of the Wilson Jungner criteria for screening. While AF screening is recommended in clinical practice and internationally, the optimal mode and location for AF screening remains under investigation. Primary care has been identified as a potential setting. This study aimed to identify facilitators and barriers to AF screening from the perspective of GPs. METHODS: The study adopted a qualitative descriptive design conducted in the south of Ireland. 58 GPs were invited from the north Cork region to participate in individual interviews at their practices, rural and urban, with a view to recruiting a purposive sample of up to 12 GPs. The interviews were audio-recorded, transcribed verbatim and analysed using a framework analysis. RESULTS: Eight GPs (four male, four female) from five practices participated. Five GPs were from urban practices and three were from rural practices. Facilitators and barriers were sub-categorised into patient facilitators, practice facilitators, GP facilitators, patient barriers, practice barriers, GP barriers, attitudes to AF screening, willingness to facilitate and priority ranking. All eight participants expressed a willingness to engage in AF screening. Time was the barrier discussed most frequently by all participants along with the need for additional staff. Programme structure was the most discussed facilitator by all participants and patient awareness campaigns. DISCUSSION: Despite barriers to AF screening identified by GPs, there was a significant willingness to engage and identify potential facilitators to support such screening.

Supporting safe and gradual reduction of long-term benzodiazepine receptor agonist use: Development of the SAFEGUARDING-BZRAs toolkit using a codesign approach.

INTRODUCTION: Long-term benzodiazepine receptor agonist (BZRA) use persists in healthcare settings worldwide and poses risks of patient harm. OBJECTIVE: This study aimed to develop an intervention to support discontinuation of long-term BZRA use among willing individuals. METHODS: The intervention development process aligned with the UK Medical Research Council's complex intervention framework. This involved a previous systematic review of brief interventions targeting long-term BZRA use in primary care and qualitative interviews based on the Theoretical Domains Framework that explored barriers and facilitators to discontinuing long-term BZRA use. A codesign approach was used involving an active partnership between experts by experience, researchers and clinicians. Intervention content was specified in terms of behaviour change techniques (BCTs). RESULTS: The SAFEGUARDING-BZRAs (Supporting sAFE and GradUAl ReDuctIon of loNG-term BenZodiazepine Receptor Agonist uSe) toolkit comprises 24 BCTs and includes recommendations targeted at primary care-based clinicians for operationalizing each BCT to support individuals with BZRA discontinuation. CONCLUSION: The SAFEGUARDING-BZRAs toolkit has been developed using a systematic and theory-based approach that addresses identified limitations of previous research. Further research is needed to assess its usability and acceptability by service users and clinicians, as well as its potential to effectively support safe and gradual reduction of long-term BZRA use. PATIENT OR PUBLIC CONTRIBUTION: The qualitative interview phase included patients as participants. The codesign process included 'experts by experience' with either current or previous experience of long-term BZRA use as collaborators.

Impact of changes in controlled drugs legislation on benzodiazepine receptor agonist prescribing in Ireland: a repeated cross-sectional study.

PURPOSE: To examine the impact of new controlled drugs legislation introduced in May 2017 on benzodiazepine receptor agonist (BZRA) prescribing in Ireland. METHODS: A repeated cross-sectional analysis was conducted using publically available monthly pharmacy claims data from the General Medical Services (GMS) database. The study population comprised all GMS-eligible individuals aged ≥ 16 years from January 2016 to September 2019. Monthly prevalence rates of individuals receiving BZRA prescriptions per 10,000 eligible population were calculated and trends examined over time. Segmented linear regression of prevalence rates was used to examine changes before and after introduction of the legislation stratified by gender and age groups. Regression coefficients (ß) and 95% confidence intervals (CIs) for monthly change were calculated. RESULTS: Pre-legislation (January 2016 to April 2017), there was a significant monthly decline in benzodiazepine prevalence rate (ß = - 1.18; 95% CI - 1.84, - 0.51; p < 0.001) but no significant change in Z-drug prescribing. Post-legislation (May 2017 to September 2019), increases in prevalence rates were observed for benzodiazepines (ß = 1.04; 95% CI 0.17, 1.92; p = 0.021) and Z-drugs (ß = 1.04; 95% CI 0.26, 1.83; p = 0.010). Post-legislation trends showed increases in BZRA prevalence rates among the youngest subgroup (16-44 years), with variable changes in the middle-aged subgroup (45-64 years) and no changes in the oldest subgroup (≥ 65 years). CONCLUSIONS: This study indicates that introduction of new legislation had limited impact on BZRA prescribing on the main public health scheme in Ireland. Interventions targeting specific population subgroups may be required to achieve sustained reductions in prescribing.

Hollow-Core Photonic Crystal Fiber Mach-Zehnder Interferometer for Gas Sensing.

A novel and compact interferometric refractive index (RI) point sensor is developed using hollow-core photonic crystal fiber (HC-PCF) and experimentally demonstrated for high sensitivity detection and measurement of pure gases. To construct the device, the sensing element fiber (HC-PCF) was placed between two single-mode fibers with airgaps at each side. Great measurement repeatability was shown in the cyclic test for the detection of various gases. The RI sensitivity of 4629 nm/RIU was demonstrated in the RI range of 1.0000347-1.000436 for the sensor with an HC-PCF length of 3.3 mm. The sensitivity of the proposed Mach-Zehnder interferometer (MZI) sensor increases when the length of the sensing element decreases. It is shown that response and recovery times of the proposed sensor inversely change with the length of HC-PCF. Besides, spatial frequency analysis for a wide range of air-gaps revealed information on the number and power distribution of modes. It is shown that the power is mainly carried by two dominant modes in the proposed structure. The proposed sensors have the potential to improve current technology's ability to detect and quantify pure gases.

Searching for Ultralight Dark Matter with Optical Cavities.

We discuss the use of optical cavities as tools to search for dark matter (DM) composed of virialized ultralight fields (VULFs). Such fields could lead to oscillating fundamental constants, resulting in oscillations of the length of rigid bodies. We propose searching for these effects via differential strain measurement of rigid and suspended-mirror cavities. We estimate that more than 2 orders of magnitude of unexplored phase space for VULF DM couplings can be probed at VULF Compton frequencies in the audible range of 0.1-10 kHz.

Medication reconciliation: time to save? A cross-sectional study from one acute hospital.

PURPOSE: Medication errors during transitional care are an important patient safety issue. Medication reconciliation is an established intervention to reduce such errors. Current evidence has not demonstrated an associated reduction in healthcare costs, however, with complexity and resource intensity being identified as issues. The aims of this study were to examine an existing process of medication reconciliation in terms of time taken, to identify factors associated with additional time, and to determine if additional time is associated with detecting errors of clinical significance. METHODS: A cross-sectional study was conducted. Issues arising during medication reconciliation incurring a time burden additional to the usual process were logged and quantified by pharmacists. Regression analyses investigated associations between patient characteristics and clinically significant errors and additional time. Cost for additional time in terms of hospital pharmacist salary was calculated. RESULTS: Eighty-nine patients were included. Having a personal record of medication at admission (OR 3.30, 95% CI: (1.05 to 10.42), p = 0.004) was a significant predictor of additional time. No significant associations were found between the occurrence of clinically significant error and additional time (p > 0.05). The most common reason for additional time was clarifying issues pertaining to primary care medication information. Projected annual 5-year costs for the mean additional time of 3.75 min were €1.8-1.9 million. CONCLUSIONS: Spending additional time on medication reconciliation is associated with economic burden and may not yield benefit in terms of capturing clinically significant errors. There is a need to improve communication of medication information between primary and secondary care.

Tapered Fiber-Optic Mach-Zehnder Interferometer for Ultra-High Sensitivity Measurement of Refractive Index.

A Mach-Zehnder interferometer (MZI) based fiberoptic refractive index (RI) sensor is constructed by uniformly tapering standard single mode fiber (SMF) for RI measurement. A custom flame-based tapering machine is used to fabricate microfiber MZI sensors directly from SMFs. The fabricated MZI device does not require any splicing of fibers and shows excellent RI sensitivity. The sensor with a cladding diameter of 35.5 µm and length of 20 mm exhibits RI sensitivity of 415 nm/RIU for RI range of 1.332 to 1.384, 1103 nm/RIU for RI range of 1.384 to 1.4204 and 4234 nm/RIU for RI range of 1.4204 to 1.4408, respectively. The sensor reveals a temperature sensitivity of 0.0097 nm/°C, which is relatively low in comparison to its ultra-high RI sensitivity. The proposed inexpensive and highly sensitive optical fiber RI sensors have numerous applications in chemical and biochemical sensing fields.

Monitoring of Carbon Dioxide Using Hollow-Core Photonic Crystal Fiber Mach-Zehnder Interferometer.

Monitoring of greenhouse gases is essential to understand the present state and predict the future behavior of greenhouse gas emissions. Carbon dioxide (CO2) is the greenhouse gas of most immediate concern, because of its high atmospheric concentration and long lifetime. A fiber-optic Mach-Zehnder interferometer (MZI) is proposed and demonstrated for the laboratory-scale monitoring of carbon dioxide concentration. The interferometric sensor was constructed using a small stub of hollow-core photonic crystal fiber between a lead-in and lead-out standard single mode fiber, with air-gaps at both interfaces. At room temperature and atmospheric pressure, the sensor shows the sensitivity of 4.3 pm/% CO2. The device was packaged to demonstrate the laboratory-scale leakage detection and measurement of CO2 concentration in both subsurface and aqueous environments. The experimental study of this work reveals the great potential of the fiber-optic approach for environmental monitoring of CO2.

Benzodiazepine and Z-drug prescribing in Ireland: analysis of national prescribing trends from 2005 to 2015.

AIMS: The aim of this study was to examine prescribing trends for benzodiazepines and Z-drugs to General Medical Services (GMS) patients in Ireland. METHODS: A repeated cross-sectional analysis of the national pharmacy claims database was conducted for GMS patients aged ≥16 years from 2005 to 2015. Prescribing rates per 1000 eligible GMS population were calculated with 95% confidence intervals (CIs). Negative binomial regression was used to determine longitudinal trends and compare prescribing rates across years, gender and age groups. Duration of supply and rates of concomitant benzodiazepine and Z-drug prescribing were determined. Age (16-44, 45-64, ≥65 years) and gender trends were investigated. RESULTS: Benzodiazepine prescribing rates decreased significantly from 225.92/1000 population (95% CI 224.94-226.89) in 2005 to 166.07/1000 population (95% CI 165.38-166.75) in 2015 (P < 0.0001). Z-drug prescribing rates increased significantly from 95.36/1000 population (95% CI 94.73-96.00) in 2005 to 109.11/1000 population (95% CI 108.56-109.67) in 2015 (P = 0.048). Approximately one-third of individuals dispensed either benzodiazepines or Z-drugs were receiving long-term prescriptions (>90 days). The proportion of those receiving >1 benzodiazepine and/or Z-drug concomitantly increased from 11.9% in 2005 to 15.3% in 2015. Benzodiazepine and Z-drug prescribing rates were highest for older women (≥65 years) throughout the study period. CONCLUSIONS: Benzodiazepine prescribing to the GMS population in Ireland decreased significantly from 2005 to 2015, and was coupled with significant increases in Z-drug prescribing. The study shows that benzodiazepine and Z-drug prescribing is common in this population, with high proportions of individuals receiving long-term prescriptions. Targeted interventions are needed to reduce potentially inappropriate long-term prescribing and use of these medications in Ireland.

General practitioners' knowledge, attitudes, and experiences of managing behavioural and psychological symptoms of dementia: A mixed-methods systematic review.

OBJECTIVES: To synthesise the existing published literature on general practitioners (GP)'s knowledge, attitudes, and experiences of managing behavioural and psychological symptoms of dementia (BPSD) with a view to informing future interventions. METHODS: We conducted a systematic review and synthesis of quantitative and qualitative studies that explored GPs' experiences of managing BPSD (PROSPERO protocol registration CRD42017054916). Seven electronic databases were searched from inception to October 2017. Each stage of the review process involved at least 2 authors working independently. The meta-ethnographic approach was used to synthesise the findings of the included studies while preserving the context of the primary data. The Confidence in the Evidence from Reviews of Qualitative research (CERQual) was used to assess the confidence in our individual review findings. RESULTS: Of the 1638 articles identified, 76 full texts were reviewed and 11 were included. Three main concepts specific to GPs' experiences of managing BPSD emerged: unmet primary care resource needs, justification of antipsychotic prescribing, and the pivotal role of families. A "line of argument" was drawn, which described how in the context of resource limitations a therapeutic void was created. This resulted in GPs being over reliant on antipsychotics and family caregivers. These factors appeared to culminate in a reactive response to BPSD whereby behaviours and symptoms could escalate until a crisis point was reached. CONCLUSION: This systematic review offers new insights into GPs' perspectives on the management of BPSD and will help to inform the design and development of interventions to support GPs managing BPSD.

'Working away in that Grey Area ' A qualitative exploration of the challenges general practitioners experience when managing behavioural and psychological symptoms of dementia.

Background: general practitioners (GPs) have identified the management of behavioural and psychological symptoms of dementia (BPSD) as a particularly challenging aspect of dementia care. However, there is a paucity of research on why GPs find BPSD challenging and how this influences the care they offer to their patients with dementia. Objectives: to establish the challenges GPs experience when managing BPSD; to explore how these challenges influence GPs' management decisions; and to identify strategies for overcoming these challenges. Design: qualitative study of GPs experiences of managing BPSD. Methods: semi-structured interviews were conducted with 16 GPs in the Republic of Ireland. GPs were purposively recruited to include participants with differing levels of experience caring for people with BPSD in nursing homes and in community settings to provide maximum diversity of views. Interviews were analysed thematically. Results: three main challenges of managing BPSD were identified; lack of clinical guidance, stretched resources and difficulties managing expectations. The lack of relevant clinical guidance available affected GPs' confidence when managing BPSD. In the absence of appropriate resources GPs felt reliant upon sedative medications. GPs believed their advocacy role was further compromised by the difficulties they experienced managing expectations of family caregivers and nursing home staff. Conclusions: this study helps to explain the apparent discrepancy between best practice recommendations in BPSD and real-life practice. It will be used to inform the design of an intervention to support the management of BPSD in general practice.

Physician and practice characteristics associated with immunoglobulin test ordering.

Background: Primary care test requests for serum immunoglobulins are rising rapidly, with concerns that many requests may be unnecessary. Evidence suggests some characteristics of general practitioners (GPs) and practices are associated with higher test ordering. Objective: To identify the physician and practice characteristics associated with immunoglobulin test ordering. Methods: Retrospective, cross-sectional study using routine laboratory data on primary care serum immunoglobulin requests. Data were linked with GP patient list size data. The primary outcome measure was the count of test requests per GP. Predictor variables were physician gender, years experience, practice region and type (number of GPs), GP patient list size and composition. Mixed-effects multilevel regression models were used to calculate incidence rate ratios (IRRs) with 95% confidence intervals (CIs) for the associations between physician and practice characteristics and GP requesting. Sensitivity analysis was performed by limiting the model to the more than 70 years age category. Results: In total, 5990 immunoglobulin tests were ordered by 481 GPs in the South of Ireland during 2013. The number of tests ordered by individual GPs varied from one to 377. In the final fully adjusted Poisson regression analysis, female gender (IRR: 1.81; 95% CI: 1.45-2.26) and less experience (IRR: 2.27; 95% CI: 1.47-3.51) were associated with higher requesting (P < 0.001). None of the practice factors were associated with test ordering. Sensitivity analysis on the 70 years or more age category found similar results. Conclusion: Further research is required to explore the potential reasons for higher requesting among GPs with fewer years of experience and also among female GPs.

Economic impact of medication error: a systematic review.

PURPOSE: Medication error is a significant source of morbidity and mortality among patients. Clinical and cost-effectiveness evidence are required for the implementation of quality of care interventions. Reduction of error-related cost is a key potential benefit of interventions addressing medication error. The aim of this review was to describe and quantify the economic burden associated with medication error. METHODS: PubMed, Cochrane, Embase, CINAHL, EconLit, ABI/INFORM, Business Source Complete were searched. Studies published 2004-2016 assessing the economic impact of medication error were included. Cost values were expressed in Euro 2015. A narrative synthesis was performed. RESULTS: A total of 4572 articles were identified from database searching, and 16 were included in the review. One study met all applicable quality criteria. Fifteen studies expressed economic impact in monetary terms. Mean cost per error per study ranged from €2.58 to €111 727.08. Healthcare costs were used to measure economic impact in 15 of the included studies with one study measuring litigation costs. Four studies included costs incurred in primary care with the remaining 12 measuring hospital costs. Five studies looked at general medication error in a general population with 11 studies reporting the economic impact of an individual type of medication error or error within a specific patient population. CONCLUSIONS: Considerable variability existed between studies in terms of financial cost, patients, settings and errors included. Many were of poor quality. Assessment of economic impact was conducted predominantly in the hospital setting with little assessment of primary care impact. Limited parameters were used to establish economic impact. Copyright © 2017 John Wiley & Sons, Ltd.

A scoping review of the potential for chart stimulated recall as a clinical research method.

BACKGROUND: Chart-stimulated recall (CSR) is a case-based interviewing technique, which is used in the assessment of clinical decision-making in medical education and professional certification. Increasingly, clinical decision-making is a concern for clinical research in primary care. In this study, we review the prior application and utility of CSR as a technique for research interviews in primary care. METHODS: Following Arksey & O'Malley's method for scoping reviews, we searched seven databases, grey literature, reference lists, and contacted experts in the field. We excluded studies on medical education or competence assessment. Retrieved citations were screened by one reviewer and full texts were ordered for all potentially relevant abstracts. Two researchers independently reviewed full texts and performed data extraction and quality appraisal if inclusion criteria were met. Data were collated and summarised using a published framework on the reporting of qualitative interview techniques, which was chosen a priori. The preferred reporting items for systematic reviews and meta-analyses (PRISMA) guidelines informed the review report. RESULTS: From an initial list of 789 citations, eight studies using CSR in research interviews were included in the review: six from North America, one from the Netherlands, and one from Ireland. The most common purpose of included studies was to examine the influence of guidelines on physicians' decisions. The number of interviewees ranged from seven to twenty nine, while the number of charts discussed per interview ranged from one to twelve. CSR gave insights into physicians' reasoning for actions taken or not taken; the unrecorded social and clinical influences on decisions; and discrepancies between physicians' real and perceived practice. Ethical concerns and the training and influence of the researcher were poorly discussed in most of the studies. Potential pitfalls included the risk of recall, selection and observation biases. CONCLUSIONS: Despite the proven validity, reliability and acceptability of CSR in assessment interviews in medical education, its use in clinical research is limited. Application of CSR in qualitative research brings interview data closer to the reality of practice. Although further development of the approach is required, we recommend a role for CSR in research interviews on decision-making in clinical practice.

Transitional care interventions: Relevance for nursing in the community.

OBJECTIVES: The coordination and integration of health care is compromised by complex challenges related to transitions between care settings, greater prevalence of chronic health conditions, and older individuals with increasing levels of dependency. Transitional care incorporates a broad range of services designed to provide care continuity. This systematic review aims to synthesize and present findings regarding the relevance of transitional care interventions to community nursing. DESIGN AND SAMPLE: A systematic search of electronic databases was conducted as part of a larger review to identify evidence-based interventions to support a model to guide nursing and midwifery in the community in Ireland. All relevant empirical studies published in English between 2010 and 2015 were included. MEASURES: Studies were assessed based on inclusion criteria. The Cochrane Risk of Bias and AMSTAR tools were used to assess the methodological quality of studies. Key themes and concepts were extracted and synthesized. RESULTS: Transitional care interventions had significant positive effects in reducing all-cause readmissions, mortality, and heart failure-related rehospitalizations. CONCLUSION: Effective transitional care requires excellent communication between acute and primary care providers. This has implications for integration and organization of care across settings and nursing competence.

Conceptualising a model to guide nursing and midwifery in the community guided by an evidence review.

BACKGROUND: Successful models of nursing and midwifery in the community delivering healthcare throughout the lifespan and across a health and illness continuum are limited, yet necessary to guide global health services. Primary and community health services are the typical points of access for most people and the location where most care is delivered. The scope of primary healthcare is complex and multifaceted and therefore requires a practice framework with sound conceptual and theoretical underpinnings. The aim of this paper is to present a conceptual model informed by a scoping evidence review of the literature. METHODS: A scoping evidence review of the literature was conducted using the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) statement. Databases included CINAHL, MEDLINE, PsycINFO and SocINDEX using the EBSCO platform and the Cochrane Library using the keywords: model, nursing, midwifery, community, primary care. Grey literature for selected countries was searched using the Google 'advanced' search interface. Data extraction and quality appraisal for both empirical and grey literature were conducted independently by two reviewers. From 127 empirical and 24 non-empirical papers, data extraction parameters, in addition to the usual methodological features, included: the nature of nursing and midwifery; the population group; interventions and main outcomes; components of effective nursing and midwifery outcomes. RESULTS: The evidence was categorised into six broad areas and subsequently synthesised into four themes. These were not mutually exclusive: (1) Integrated and Collaborative Care; (2) Organisation and Delivery of Nursing and Midwifery Care in the Community; (3) Adjuncts to Nursing Care and (4) Overarching Conceptual Model. It is the latter theme that is the focus of this paper. In essence, the model depicts a person/client on a lifespan and preventative-curative trajectory. The health related needs of the client, commensurate with their point position, relative to both trajectories, determines the nurse or midwife intervention. Consequently, it is this need, that determines the discipline or speciality of the nurse or midwife with the most appropriate competencies. CONCLUSION: Use of a conceptual model of nursing and midwifery to inform decision-making in primary/community based care ensures clinical outcomes are meaningful and more sustainable. Operationalising this model for nursing and midwifery in the community demands strong leadership and effective clinical governance.

Multi time-step wavefront reconstruction for tomographic adaptive-optics systems.

In tomographic adaptive-optics (AO) systems, errors due to tomographic wavefront reconstruction limit the performance and angular size of the scientific field of view (FoV), where AO correction is effective. We propose a multi time-step tomographic wavefront reconstruction method to reduce the tomographic error by using measurements from both the current and previous time steps simultaneously. We further outline the method to feed the reconstructor with both wind speed and direction of each turbulence layer. An end-to-end numerical simulation, assuming a multi-object AO (MOAO) system on a 30 m aperture telescope, shows that the multi time-step reconstruction increases the Strehl ratio (SR) over a scientific FoV of 10 arc min in diameter by a factor of 1.5-1.8 when compared to the classical tomographic reconstructor, depending on the guide star asterism and with perfect knowledge of wind speeds and directions. We also evaluate the multi time-step reconstruction method and the wind estimation method on the RAVEN demonstrator under laboratory setting conditions. The wind speeds and directions at multiple atmospheric layers are measured successfully in the laboratory experiment by our wind estimation method with errors below 2 ms-1. With these wind estimates, the multi time-step reconstructor increases the SR value by a factor of 1.2-1.5, which is consistent with a prediction from the end-to-end numerical simulation.

Linear prediction of atmospheric wave-fronts for tomographic adaptive optics systems: modelling and robustness assessment.

We use a theoretical framework to analytically assess temporal prediction error functions on von-Kármán turbulence when a zonal representation of wavefronts is assumed. The linear prediction models analyzed include auto-regressive of an order up to three, bilinear interpolation functions, and a minimum mean square error predictor. This is an extension of the authors' previously published work Correia et al. [J. Opt. Soc. Am. A31, 101 (2014)JOAOD61084-752910.1364/JOSAA.31.000101], in which the efficacy of various temporal prediction models was established. Here we examine the tolerance of these algorithms to specific forms of model errors, thus defining the expected change in behavior of the previous results under less ideal conditions. Results show that ±100% wind speed error and ±50 deg are tolerable before the best linear predictor delivers poorer performance than the no-prediction case.