Implementing human factors in anaesthesia: guidance for clinicians, departments and hospitals: Guidelines from the Difficult Airway Society and the Association of Anaesthetists: Guidelines from the Difficult Airway Society and the Association of Anaesthetists.

Human factors is an evidence-based scientific discipline used in safety critical industries to improve safety and worker well-being. The implementation of human factors strategies in anaesthesia has the potential to reduce the reliance on exceptional personal and team performance to provide safe and high-quality patient care. To encourage the adoption of human factors science in anaesthesia, the Difficult Airway Society and the Association of Anaesthetists established a Working Party, including anaesthetists and operating theatre team members with human factors expertise and/or interest, plus a human factors scientist, an industrial psychologist and an experimental psychologist/implementation scientist. A three-stage Delphi process was used to formulate a set of 12 recommendations: these are described using a 'hierarchy of controls' model and classified into design, barriers, mitigations and education and training strategies. Although most anaesthetic knowledge of human factors concerns non-technical skills, such as teamwork and communication, human factors is a broad-based scientific discipline with many other additional aspects that are just as important. Indeed, the human factors strategies most likely to have the greatest impact are those related to the design of safe working environments, equipment and systems. While our recommendations are primarily provided for anaesthetists and the teams they work with, there are likely to be lessons for others working in healthcare beyond the speciality of anaesthesia.

Human factors in anaesthesia: a narrative review.

Healthcare relies on high levels of human performance, as described by the 'human as the hero' concept. However, human performance varies and is recognised to fall in high-pressure situations, meaning that it is not a reliable method of ensuring safety. Other safety-critical industries embed human factors principles into all aspects of their organisations to improve safety and reduce reliance on exceptional human performance; there is potential to do the same in anaesthesia. Human factors is a broad-based scientific discipline which aims to make it as easy as possible for workers to do things correctly. The human factors strategies most likely to be effective are those which 'design out' the chance of an error or adverse event occurring. When errors or adverse events do happen, barriers are in place to trap them and reduce the risk of progression to patient and/or worker harm. If errors or adverse events are not trapped by these barriers, mitigations are in place to minimise the consequences. Non-technical skills form an important part of human factors barriers and mitigation strategies and include: situation awareness; decision-making; task management; and team working. Human factors principles are not a substitute for proper investment and appropriate staffing levels. Although applying human factors science has the potential to save money in the long term, its proper implementation may require investment before reward can be reaped. This narrative review describes what is known about human factors in anaesthesia to date.

Making remote measurement technology work in multiple sclerosis, epilepsy and depression: survey of healthcare professionals.

BACKGROUND: Epilepsy, multiple sclerosis (MS) and depression are long term, central nervous system disorders which have a significant impact on everyday life. Evaluating symptoms of these conditions is problematic and typically involves repeated visits to a clinic. Remote measurement technology (RMT), consisting of smartphone apps and wearables, may offer a way to improve upon existing methods of managing these conditions. The present study aimed to establish the practical requirements that would enable clinical integration of data from patients' RMT, according to healthcare professionals. METHODS: This paper reports findings from an online survey of 1006 healthcare professionals currently working in the care of people with epilepsy, MS or depression. The survey included questions on types of data considered useful, how often data should be collected, the value of RMT data, preferred methods of accessing the data, benefits and challenges to RMT implementation, impact of RMT data on clinical practice, and requirement for technical support. The survey was presented on the JISC online surveys platform. RESULTS: Among this sample of 1006 healthcare professionals, respondents were positive about the benefits of RMT, with 73.2% indicating their service would be likely or highly likely to benefit from the implementation of RMT in patient care plans. The data from patients' RMT devices should be made available to all nursing and medical team members and could be reviewed between consultations where flagged by the system. However, results suggest it is also likely that RMT data would be reviewed in preparation for and during a consultation with a patient. Time to review information is likely to be one of the greatest barriers to successful implementation of RMT in clinical practice. CONCLUSIONS: While further work would be required to quantify the benefits of RMT in clinical practice, the findings from this survey suggest that a wide array of clinical team members treating epilepsy, MS and depression would find benefit from RMT data in the care of their patients. Findings presented could inform the implementation of RMT and other digital interventions in the clinical management of a range of neurological and mental health conditions.

The impact of data from remote measurement technology on the clinical practice of healthcare professionals in depression, epilepsy and multiple sclerosis: survey.

BACKGROUND: A variety of smartphone apps and wearables are available both to help patients monitor their health and to support health care professionals (HCPs) in providing clinical care. As part of the RADAR-CNS consortium, we have conducted research into the application of wearables and smartphone apps in the care of people with multiple sclerosis, epilepsy, or depression. METHODS: We conducted a large online survey study to explore the experiences of HCPs working with patients who have one or more of these conditions. The survey covered smartphone apps and wearables used by clinicians and their patients, and how data from these technologies impacted on the respondents' clinical practice. The survey was conducted between February 2019 and March 2020 via a web-based platform. Detailed statistical analysis was performed on the answers. RESULTS: Of 1009 survey responses from HCPs, 1006 were included in the analysis after data cleaning. Smartphone apps are used by more than half of responding HCPs and more than three quarters of their patients use smartphone apps or wearable devices for health-related purposes. HCPs widely believe the data that patients collect using these devices impacts their clinical practice. Subgroup analyses show that views on the impact of this data on different aspects of clinical work varies according to whether respondents use apps themselves, and, to a lesser extent, according to their clinical setting and job role. CONCLUSIONS: Use of smartphone apps is widespread among HCPs participating in this large European survey and caring for people with epilepsy, multiple sclerosis and depression. The majority of respondents indicate that they treat patients who use wearables and other devices for health-related purposes and that data from these devices has an impact on clinical practice.

Genetic variation in blue whales in the eastern pacific: implication for taxonomy and use of common wintering grounds.

Many aspects of blue whale biology are poorly understood. Some of the gaps in our knowledge, such as those regarding their basic taxonomy and seasonal movements, directly affect our ability to monitor and manage blue whale populations. As a step towards filling in some of these gaps, microsatellite and mtDNA sequence analyses were conducted on blue whale samples from the Southern Hemisphere, the eastern tropical Pacific (ETP) and the northeast Pacific. The results indicate that the ETP is differentially used by blue whales from the northern and southern eastern Pacific, with the former showing stronger affinity to the region off Central America known as the Costa Rican Dome, and the latter favouring the waters of Peru and Ecuador. Although the pattern of genetic variation throughout the Southern Hemisphere is compatible with the recently proposed subspecies status of Chilean blue whales, some discrepancies remain between catch lengths and lengths from aerial photography, and not all blue whales in Chilean waters can be assumed to be of this type. Also, the range of the proposed Chilean subspecies, which extends to the Galapagos region of the ETP, at least seasonally, perhaps should include the Costa Rican Dome and the eastern North Pacific as well.

Beyond stress and arousal: a reconceptualization of alcohol-emotion relations with reference to psychophysiological methods.

In this review, the authors examine how psychophysiological research might better contribute to understanding the effects of alcohol on human emotion. They propose that future studies would benefit from greater use of contemporary theories of emotion that emphasize a dimensional structure of affective expression, incorporating the parameters of emotional arousal and emotional valence. Evidence suggests that, although alcohol exerts an overall dampening effect on arousal, it appears to modulate emotional response through its effects on higher order associative processes rather than at the level of primary brain motivational systems. They discuss methodological implications of this multidimensional, multilevel approach and suggest that alcohol-induced physiological changes need to be investigated as dynamic response patterns rather than isolated events tied to solitary measures.

Levels of adult alcohol consumption induced by interactions with child confederates exhibiting normal versus externalizing behaviors.

Investigated levels of distress and alcohol consumption in Ss interacting with problematic vs non-problematic child confederates. Social drinkers were randomly assigned to interact with boys trained to enact behaviors characteristic of either normal or attention-deficit disorder/conduct disorder (ADD/CD) children. Mood data were collected before and after the interaction. Ss engaged in ad lib beer consumption for 20 min, while anticipating another interaction with the same boy. Children in the ADD/CD role produced comparably distressed moods for both male and female Ss. However, only men drank to higher blood-alcohol levels in the ADD/CD vs. normal child condition. Results suggest that higher rates of drinking observed in fathers of ADD/CD children may be partly a function of their particular response to the distress associated with interactions with such children.

Alcohol and human emotion: a multidimensional analysis incorporating startle-probe methodology.

The effect of alcohol intoxication on emotional response was investigated using a model of emotion that includes both arousal and valence dimensions. Thirty-six university students were exposed to multiple presentations of photographic slides selected to elicit distinctive emotional reactions ranging from very pleasant to very unpleasant; half of them received a moderate (approximately .75 ml/kg) dose of ethanol. The students' psychophysiological responses indicated that both general startle reactivity and autonomic indices specific to emotional arousal were diminished by alcohol. However, the affective modulation of startle, occurring with emotional states manipulated by slides with distinct valences, remained intact. These findings suggest that "stress-response dampening" by alcohol may involve a nonspecific attenuation of arousal reactions evident for positive as well as negative stimuli and that theories of motivation for drinking that are based on mood alteration may need refinement.

Alcohol and fear-potentiated startle: the role of competing cognitive demands in the stress-reducing effects of intoxication.

Effects of alcohol and cognitive demands on reactions to threat were examined using startle response potentiation to index negative emotion. Men and women received nonalcoholic or alcoholic beverages prior to a series of trial blocks, signaled by light cues indicating that shocks might be delivered ("threat" blocks) or that none would occur ("safe" blocks). Within half of the blocks, participants intermittently viewed pleasant photographic slides. Alcohol attenuated overall startle reactivity, but robust fear potentiation (larger startle magnitudes and shorter latencies during threat versus safe blocks) did not differ by beverage condition. Decomposition of the Beverage x Threat x Slide interaction revealed significant fear potentiation in all conditions, except the one in which alcohol was combined with slides. Thus, dampening of stress response by alcohol may depend on diminished ability to process competing cognitive demands.

Person perception as a function of drinking behavior, gender and sex role stereotypes.

Gender and the level of drinking of the protagonist in a vignette were systematically varied to examine the effects of these variables on the inferences 400 undergraduates drew about the personal attributes and future of the character. Results showed that gender of the target did not significantly affect judgments about the protagonist, but perceptions of the character were strongly influenced by the alcohol-related behaviors attributed to him or her in the vignette. Evaluations of the protagonist generally became less favorable as drinking level increased. Abstainers were also viewed more positively than at least some comparison groups of drinkers on most measures. Although heavier drinkers were often stigmatized, they were also seen as having more fun. Subject gender, sex role attributes and attitudes toward women failed to influence judgments about the protagonists, but raters' own drinking habits did have an impact. Heavier drinkers showed a tendency to rate heavier drinking protagonists more favorably than did lighter drinkers. Implications of these results for prevailing theories about norms and evaluations affecting drinkers are discussed.

Beverage preference, beverage type and subject gender as determinants of alcohol consumption in the laboratory.

Effects of beverage preference, beverage type and subject gender on ad libitum consumption of alcoholic beverages in the laboratory were evaluated. Undergraduate social drinkers (18 male, 18 female), with equal numbers of each gender stating a preference for beer, wine or mixed drinks, were selected. Subjects participated in three separate 30-minute ad lib drinking sessions and were presented with one of the three types of alcoholic beverage at each session. Data on total volume of beverage and of absolute ethanol consumed as well as blood alcohol concentration (BAC) attained were collected in each session. Subjects preferring wine or mixed drinks drank more alcohol and reached higher BACs when imbibing their beverage of choice than when drinking non-preferred beverages. Subjects preferring beer, however, showed no differences on these drinking measures as a function of beverage type. Men's reports of routine alcohol use had a high positive correlation with actual alcohol consumption observed in the laboratory, whereas for female subjects the correlation was near zero. Implications for interpretation of past ad lib drinking studies and the planning of future ones are discussed.

Expectations of alcohol-induced positive affect: a cross-cultural comparison.

OBJECTIVE: Our aim was to investigate the extent to which positive affect is a cross-culturally expected result of drinking alcohol. This first required development of a quantitative estimate of positive affect on a common scale, an essential step neglected in previous comparative research on alcohol expectancies. METHOD: Approximately equal numbers of male and female respondents (N = 1,008; 521 women) from eight countries were asked to complete a survey inquiring about emotional and behavioral responses they expect people to experience after consuming alcoholic drinks, and about limited aspects of their own drinking habits. Multisample latent covariance structure analysis with means was applied to the data and a cross-culturally invariant model of positive affect was extracted. RESULTS: The latent construct for positive affect that emerged was defined by manifest "interpersonal warmth or closeness," "pleasure of social interactions" and "optimism." There were significant national differences in means for this factor, and self-reported drinking frequency was also marginally related to expected positive affect. CONCLUSIONS: Multisample latent covariance structure analysis with means proved a useful tool capable of addressing critical problems in comparative cross-cultural research. In addition, there were indications that the expectation of increased positive affect associated with drinking may be influenced by contextual factors and cultural traditions, making positive affect less easily attributable to the direct pharmacological action of alcohol consumption than has previously been believed.

Verbal and nonverbal fluency in children with heavy prenatal alcohol exposure.

OBJECTIVE: Executive function deficits, including verbal fluency, have been documented in children with histories of prenatal alcohol exposure. Whereas nonverbal fluency impairments have been reported in adults with such exposure, these abilities have not been tested in children. Deficits in both verbal and nonverbal fluency were predicted and assessed in children and adolescents with histories of heavy prenatal alcohol exposure. METHOD: There was a total of 28 (54% female) subjects; children with heavy prenatal alcohol exposure with (n = 10) and without (n = 8) fetal alcohol syndrome (FAS) were compared to nonexposed controls (n = 10) on the design and verbal fluency measures from the Delis-Kaplan Executive Function System. Both fluency measures consist of three conditions, including a new set-shifting task. All tests require the generation of multiple responses within both rule and time constraints. RESULTS: Data were analyzed using repeated measures analyses of variance and hierarchical regression analyses. Compared to controls, children with heavy prenatal alcohol exposure with and without FAS displayed deficits in both fluency domains, but did not differ from each other. In addition, prenatal alcohol exposure was a significant predictor of performance on the set-shifting design fluency task above and beyond performance on more traditional fluency tasks. IQ was not a significant predictor for the traditional or set-shifting fluency measures, whereas diagnostic group remained a significant predictor when IQ was included in the model. CONCLUSIONS: This study adds to the literature on the integrity of executive functions in children with heavy prenatal alcohol exposure, documenting fluency impairment in both verbal and nonverbal domains. It is important to note that these impairments were demonstrated in higher functioning alcohol-exposed children, both with and without FAS, and that diagnostic group explained such deficiencies above and beyond general intellectual ability.

Aggression in boys with attention deficit-hyperactivity disorder: methylphenidate effects on naturalistically observed aggression, response to provocation, and social information processing.

High and low-aggressive boys with attention deficit-hyperactivity disorder (ADHD) were compared and the effects of methylphenidate were examined on measures from three domains of aggression: (1) directly observed verbal and nonverbal aggressive behaviors exhibited in the context of a day treatment program, (2) aggressive responding when provoked during a laboratory task, and (3) social information processing patterns exhibited on tasks designed to tap the putative cognitive components of aggression. The high-aggressive (HA) and low-aggressive (LA) subgroups differed significantly on observational measures of aggression and on the laboratory provocation task, but the HA group showed more deviant cognitions on only one of the numerous measures of social information processing. Regarding medication effects on the direct observation measures, methylphenidate decreased aggression for both subgroups. On the laboratory provocation task, methylphenidate had only minimal effects. Significant drug effects were obtained on only two recall social information processing measures.

Effects of alcohol intoxication on parenting behavior in interactions with child confederates exhibiting normal or deviant behaviors.

Experimental analogue methods were used to study how acute alcohol intoxication in parents influences their perceptions of and reactions to child behaviors, as well as their strategies for management of those behaviors. All participating parents had a grade school-aged son, but in half the cases this target child had a diagnosed externalizing disorder, whereas for the remaining half neither the target son nor any other offspring of the parents evidenced any psychopathology. Equal numbers of married fathers, married mothers, and single mothers from each of these groups received either alcoholic or nonalcoholic beverages prior to videotaped interactions with male child confederates who, depending on condition, enacted behaviors characteristic of either normal boys or boys with attention deficit hyperactivity/conduct/oppositional defiant disorders (ADHD/CD/ODD). Results indicated that intoxicated parents rated their ADHD/CD/ODD child partners as less deviant than did sober parents. Alcohol intoxication caused all participant groups to exhibit less attention and productive work and more commands, indulgences, and off-task talk in the interactions. Implications for better understanding of the role of psychosocial factors in the correlation between adult drinking problems and childhood behavior disorders are discussed.

Effects of deviant child behavior on parental distress and alcohol consumption in laboratory interactions.

Levels of adult distress and ad lib alcohol consumption following interactions with child confederates were investigated in parents of children with no diagnosable psychiatric disorders. Sixty parents (20 married couples and 20 single mothers) interacted with boys trained to enact behaviors characteristic of either normal children or "deviant" children with externalizing behavior disorders--attention-deficit hyperactivity disorder (ADHD), conduct disorder (CD), and oppositional defiant disorder (ODD). Relative to the normal child role, interactions with deviant confederates were rated as significantly more unpleasant, resulted in feelings of role inadequacy, and produced significantly more anxiety, depression, and hostility. After the interactions, parents were given the opportunity to drink as much of their preferred alcoholic beverage as they desired while anticipating a second interaction with the same child. The participants consumed more alcohol following exposure to deviant as opposed to normal confederates.

Drinking and creativity: objective and subjective effects.

A literature characterized by considerable speculation but a paucity of empirical studies prompted this experiment on the relation between drinking and creativity. After being queried about how they believed alcohol would affect their creative performance, 40 male undergraduate social drinkers were assigned to one of four treatments in a balanced placebo design. Those actually receiving alcohol consumed a mixture containing .6 g of ethanol per kg of body weight. All subjects then completed the entire Figural portion and the Unusual Uses subtest of the Verbal portion of the Torrance Tests of Creative Thinking. Posttesting explored subjects' own evaluations of their creative products and the kinds of attributions they made about factors contributing to the outcomes. Results showed minimal effects of beverage manipulations on measured creativity even when a priori belief and concurrent mood scores were covaried. However, those individuals who thought they had received alcohol gave significantly more positive evaluations of their creative performances than did subjects who believed they were in the non-alcohol treatments. Subjects did not attribute changes in creativity to drinking. Theoretical and practical implications of these findings were discussed.

Image reduction to submicrometer dimensions by asymmetric crystal reflection of x rays.

An image-reduction method utilizing asymmetric Bragg reflection is demonstrated by 9.5-fold and 22.6-fold one-dimensional reductions of a 30 cell/mm gold mesh having a web width of 8mum. Applicability of the method to microphotolithography is suggested.

Children and alcohol.

The literature on what, when, and how young children learn about alcohol and drinking is critically reviewed and key issues are highlighted. Available evidence points to recognition of alcohol, identification of drinking norms and rules, formation of attitudes toward drinking and drinkers, and appreciation of some of the consequences of alcohol consumption as early as the preschool years. Understanding of drinking motives appears to require a level of cognitive development that is not present until about 10 to 12 years of age, although there is a dearth of research on this probably crucial determinant of later decisions to drink. Among the factors involved in the acquisition of alcohol cognitions and dispositions are observational learning via families, media, and peers as well as personal drinking experience. Salience of alcohol and its management in the child's immediate environment appears to be an important moderator/mediator of learning. Application of relevant theory to understanding the development of the meaning of alcohol and drinking in preadolescent children is seen as underdeveloped at this time. However, there are a number of potentially fruitful avenues to pursue which could have important implications for future education and prevention efforts.