NaHCO3 loading causes increased arterial pressure and kidney damage in rats with chronic kidney disease.

Sodium bicarbonate (NaHCO3) is commonly utilized as a therapeutic to treat metabolic acidosis in people with chronic kidney disease (CKD). While increased dietary sodium chloride (NaCl) is known to promote volume retention and increase blood pressure, the effects of NaHCO3 loading on blood pressure and volume retention in CKD remain unclear. In the present study, we compared the effects of NaCl and NaHCO3 loading on volume retention, blood pressure, and kidney injury in both 2/3 and 5/6 nephrectomy remnant kidney rats, a well-established rodent model of CKD. We tested the hypothesis that NaCl loading promotes greater volume retention and increases in blood pressure than equimolar NaHCO3. Blood pressure was measured 24 h daily using radio telemetry. NaCl and NaHCO3 were administered in drinking water ad libitum or infused via indwelling catheters. Rats were housed in metabolic cages to determine volume retention. Our data indicate that both NaHCO3 and NaCl promote hypertension and volume retention in remnant kidney rats, with salt-sensitivity increasing with greater renal mass reduction. Importantly, while NaHCO3 intake was less pro-hypertensive than equimolar NaCl intake, NaHCO3 was not benign. NaHCO3 loading significantly elevated blood pressure and promoted volume retention in rats with CKD when compared with control rats receiving tap water. Our findings provide important insight into the effects of sodium loading with NaHCO3 in CKD and indicate that NaHCO3 loading in patients with CKD is unlikely to be benign.

Integration of Th17- and Lymphotoxin-Derived Signals Initiates Meningeal-Resident Stromal Cell Remodeling to Propagate Neuroinflammation.

Tertiary lymphoid tissues (TLTs) have been observed in the meninges of multiple sclerosis (MS) patients, but the stromal cells and molecular signals that support TLTs remain unclear. Here, we show that T helper 17 (Th17) cells induced robust TLTs within the brain meninges that were associated with local demyelination during experimental autoimmune encephalitis (EAE). Th17-cell-induced TLTs were underpinned by a network of stromal cells producing extracellular matrix proteins and chemokines, enabling leukocytes to reside within, rather than simply transit through, the meninges. Within the CNS, interactions between lymphotoxin αß (LTαß) on Th17 cells and LTßR on meningeal radio-resistant cells were necessary for the propagation of de novo interleukin-17 responses, and activated T cells from MS patients expressed elevated levels of LTßR ligands. Therefore, input from both Th17 cells and the lymphotoxin pathway induce the formation of an immune-competent stromal cell niche in the meninges.

Brown-Norway chromosome 1 mitigates the upregulation of proinflammatory pathways in mTAL cells and subsequent age-related CKD in Dahl SS/JrHsdMcwi rats.

Chronic kidney disease (CKD) has a strong genetic component; however, the underlying pathways are not well understood. Dahl salt-sensitive (SS)/Jr rats spontaneously develop CKD with age and are used to investigate the genetic determinants of CKD. However, there are currently several genetically diverse Dahl SS rats maintained at various institutions and the extent to which some exhibit age-related CKD is unclear. We assessed glomerulosclerosis (GS) and tubulointerstitial fibrosis (TIF) in 3- and 6-mo-old male and female SS/JrHsdMcwi, BN/NHsd/Mcwi [Brown-Norway (BN)], and consomic SS-Chr 1BN/Mcwi (SS.BN1) rats, in which chromosome 1 from the BN rat was introgressed into the genome of the SS/JrHsdMcwi rat. Rats were fed a 0.4% NaCl diet. GS (31 ± 3% vs. 7 ± 1%) and TIF (2.3 ± 0.2 vs. 0.5 ± 0.1) were significantly greater in 6-mo-old compared with 3-mo-old SS/JrHsdMcwi rats, and CKD was exacerbated in males. GS was minimal in 6- and 3-mo-old BN (3.9 ± 0.6% vs. 1.2 ± 0.4%) and SS.BN1 (2.4 ± 0.5% vs. 1.0 ± 0.3%) rats, and neither exhibited TIF. In SS/JrHsdMcwi and SS.BN1 rats, mean arterial blood pressure was significantly greater in 6-mo-old compared with 3-mo-old SS/JrHsdMcwi (162 ± 4 vs. 131 ± 2 mmHg) but not SS.BN1 (115 ± 2 vs. 116 ± 1 mmHg) rats. In 6-mo-old SS/JrHsdMcwi rats, blood pressure was significantly greater in females. RNA-sequencing analysis revealed that inflammatory pathways were upregulated in isolated medullary thick ascending tubules in 7-wk-old SS/JrHsdMcwi rats, before the development of tubule pathology, compared with SS.BN1 rats. In summary, SS/JrHsdMcwi rats exhibit robust age-related progression of medullary thick ascending limb abnormalities, CKD, and hypertension, and gene(s) on chromosome 1 have a major pathogenic role in such changes.NEW & NOTEWORTHY This study shows that the robust age-related progression of kidney disease in Dahl SS/JrHsdMcw rats maintained on a normal-salt diet is abolished in consomic SS.BN1 rats. Evidence that medullary thick ascending limb segments of SS/JrHsdMcw rats are structurally abnormal and enriched in proinflammatory pathways before the development of protein casts provides new insights into the pathogenesis of kidney disease in this model.

Lipopolysaccharide Pretreatment Prevents Medullary Vascular Congestion following Renal Ischemia by Limiting Early Reperfusion of the Medullary Circulation.

BACKGROUND: Vascular congestion of the renal medulla-trapped red blood cells in the medullary microvasculature-is a hallmark finding at autopsy in patients with ischemic acute tubular necrosis. Despite this, the pathogenesis of vascular congestion is not well defined. METHODS: In this study, to investigate the pathogenesis of vascular congestion and its role in promoting renal injury, we assessed renal vascular congestion and tubular injury after ischemia reperfusion in rats pretreated with low-dose LPS or saline (control). We used laser Doppler flowmetry to determine whether pretreatment with low-dose LPS prevented vascular congestion by altering renal hemodynamics during reperfusion. RESULTS: We found that vascular congestion originated during the ischemic period in the renal venous circulation. In control animals, the return of blood flow was followed by the development of congestion in the capillary plexus of the outer medulla and severe tubular injury early in reperfusion. Laser Doppler flowmetry indicated that blood flow returned rapidly to the medulla, several minutes before recovery of full cortical perfusion. In contrast, LPS pretreatment prevented both the formation of medullary congestion and its associated tubular injury. Laser Doppler flowmetry in LPS-pretreated rats suggested that limiting early reperfusion of the medulla facilitated this protective effect, because it allowed cortical perfusion to recover and clear congestion from the large cortical veins, which also drain the medulla. CONCLUSIONS: Blockage of the renal venous vessels and a mismatch in the timing of cortical and medullary reperfusion results in congestion of the outer medulla's capillary plexus and promotes early tubular injury after renal ischemia. These findings indicate that hemodynamics during reperfusion contribute to the renal medulla's susceptibility to ischemic injury.

An assessment of the simulated performance of basic clinical procedures by junior doctors during the first year of clinical practice.

BACKGROUND: Upon entering the healthcare system, junior doctors may lack the skills required to care for patients, and feel unprepared for their role, with considerable variation in the level of proficiency in the performance of particular clinical procedures. OBJECTIVE: To compare the performance and proficiency (self-report and observed) of the performance of nine basic clinical procedures. METHODS: Seventeen interns were observed performing nine clinical procedures in a simulated setting in June 2021 (Assessment 1) and January 2022 (Assessment 2). The observers identified whether each step in the procedure was performed correctly, and provided an overall assessment of proficiency. The participants also rated their own level proficiency. RESULTS: At Assessment 1 the number of steps performed correctly ranged from a mean of 41.9-83.5%. At Assessment 2 the number of steps performed correctly ranged from a mean of 41.9-97.8%. The most common median proficiency rating for Assessment 1 was 'close supervision', and was 'indirect supervision' at Assessment 2. There was a significant and large effect size in the improvement in performance from Assessment 1 to Assessment 2. Low correlations were found between observer and self-reported proficiency in performance of the procedures. CONCLUSIONS: The large improvement in performance across the two assessments is encouraging. However, there is a need to address the variability in performance on graduation from medical school, and to ensure that any assessment of proficiency is not only reliant on self-report.

Identifying Factors that Support the Delivery of Exceptional Care in General Practice and Development of the IDEAL Framework: A Qualitative Study.

The positive deviance approach seeks to identify and learn from those that perform exceptionally well. Positive deviance as an approach to quality improvement is gaining traction in general practice. This study aimed to explore and compare stakeholders' perceptions of the factors that support the delivery of exceptional care in general practice and to refine a previously developed theoretical framework of factors associated with positively deviant care in general practice: the Identifying and Disseminating the Exceptional to Achieve Learning (IDEAL) framework. Semi-structured interviews were conducted with 33 purposively sampled patients, general practitioners, practice nurses, and practice managers in Irish general practice. Subsequently, a directed content analysis approach was employed to deductively analyse interview data using the IDEAL framework, and newly emerging factors were inductively analysed and abstracted into the framework. Several distinct strategies (e.g. patient activation and team collaboration), structures (e.g. facilities and staffing), and contextual factors (e.g. communication and rapport, and culture) were found to support the delivery of exceptional care, and differences in perceptions, values, and expectations emerged between patients and practice staff. Interview data largely supported the pre-determined factors posited by the IDEAL framework, and new factors were abstracted into the framework (e.g. facilities and infrastructure). Stakeholder engagement regarding the factors supporting exceptional care in general practice supported and extended the IDEAL framework, contributing to a more comprehensive understanding of how exceptional care is delivered in general practice. The refined framework will support researchers, policymakers, and teams looking to support, measure, and achieve exceptionally good patient care in general practice.

New mechanisms for the kidney-protective effect of alkali in chronic kidney disease.

Worldwide, more than one in ten adults are estimated to have chronic kidney disease (CKD). As CKD progresses, both the cost of treatment and associated risk of morbidity and mortality increase exponentially. As such, there is a great need for therapies that effectively slow CKD progression. Evidence from several small clinical trials indicates that alkali therapy may slow the rate of CKD progression. The biological mechanisms underlying this protective effect, however, remain unknown. In their recently published manuscript, Pastor Arroyo et al. (Clin Sci (Lond) (2022) 136(8): https://doi.org/10.1042/CS20220095) demonstrate that the alkali sodium bicarbonate protects against loss of renal function in a crystal nephropathy model in mice. Using unbiased approaches in both mice and human tissue, the authors go on to identify two novel mechanisms that may underly this protection. The first pathway is through promoting pathways of cell metabolism, which they speculate helps the remaining functional nephrons adapt to the greater metabolic needs required to maintain kidney filtration. The second pathway is by restoration of α-Klotho levels, which may limit the expression of adhesion molecules in the injured kidney. This, the authors speculate, may prevent inflammation from driving the functional decline of the kidney. Identifying these novel pathways represents an important step forward harnessing the potential benefits of alkali therapy in CKD.

Persistent vascular congestion in male spontaneously hypertensive rats contributes to delayed recovery of renal function following renal ischemia perfusion compared with females.

Acute kidney injury (AKI) due to ischemia is a serious and frequent clinical complication with mortality rates as high as 80%. Vascular congestion in the renal outer medulla occurs early after ischemia reperfusion (IR) injury, and congestion has been linked to worsened outcomes following IR. There is evidence implicating both male sex and preexisting hypertension as risk factors for poor outcomes following IR. The present study tested the hypothesis that male spontaneously hypertensive rats (SHR) have greater vascular congestion and impaired renal recovery following renal IR vs. female SHR and normotensive male Sprague-Dawley rats (SD). Thirteen-week-old male and female SHR and SD were subjected to sham surgery or 30 min of warm bilateral ischemia followed by reperfusion. Rats were euthanized 24 h or 7 days post-IR. IR increased renal injury in all groups vs. sham controls at 24 h. At 7 days post-IR, injury remained elevated only in male SHR. Histological examination of SD and SHR kidneys 24 h post-IR showed vascular congestion in males and females. Vascular congestion was sustained only in male SHR 7 days post-IR. To assess the role of vascular congestion on impaired recovery following IR, additional male and female SHR were pretreated with heparin (200 U/kg) prior to IR. Heparin pretreatment reduced IR-induced vascular congestion and improved renal function in male SHR 7 days post-IR. Interestingly, preventing increases in blood pressure (BP) in male SHR did not alter sustained vascular congestion. Our data demonstrate that IR-induced vascular congestion is a major driving factor for impaired renal recovery in male SHR.

The patient's "story": an examination of patient-reported safety incidents in general practice.

BACKGROUND: Patient safety incidents (PSIs) are typically studied through engagement with healthcare providers, without input from patients despite their privileged viewpoint of care experiences. OBJECTIVES: To examine the potential of the patient viewpoint as a lens for future safety improvement initiatives, by: (i) collecting and analysing patients' accounts of PSIs; and (ii) comparing patient and clinician perceptions of PSIs. METHODS: Firstly, Critical Incident Technique (CIT) interviews were used to obtain rich descriptions of PSIs, which were then condensed into patient stories. Deductive content analysis was used to code the safety deficiencies described in patient stories using patient-derived safety categories. Secondly, General Practitioners (GPs) and patients individually rated the perceived severity and likelihood of each story. RESULTS: A total of 32 eligible patient stories were obtained from 25 interviews. Stories commonly described deficiencies related to communication, staff performance, and compassion/dignity/respect. There were significant differences in GP (n = 14) and patient (n = 11) severity and likelihood ratings. GPs were significantly more likely to consider stories to be a lower severity, and occurring with a lower frequency than patients. CONCLUSION: Elicitation of the patient perspective using the CIT allowed for the rich description of safety deficiencies that occur in general practice. Given that patients bring a unique and important viewpoint on safety, there is a need to make greater efforts to include the patient perspective of safety in healthcare.

A systematic review of the use of positive deviance approaches in primary care.

BACKGROUND: The Positive Deviance (PD) approach focuses on identifying and learning from those who demonstrate exceptional performance despite facing similar resource constraints to others. Recently, it has been embraced to improve the quality of patient care in a variety of healthcare domains. PD may offer one means of enacting effective quality improvement in primary care. OBJECTIVE(S): This review aimed to synthesize the extant research on applications of the PD approach in primary care. METHODS: Seven electronic databases were searched; MEDLINE, CINAHL, Embase, PsycINFO, Academic Search Complete, Psychology and Behavioral Sciences Collection, and Web of Science. Studies reporting original data on applications of the PD approach, as described by the PD framework, in primary care were included, and data extracted. Thematic analysis was used to classify positively deviant factors and to develop a conceptual framework. Methodological quality was appraised using the Quality Assessment with Diverse Studies (QuADS). RESULTS: In total, 27 studies were included in the review. Studies most frequently addressed Stages 1 and 2 of the PD framework, and targeted 5 core features of primary care; effectiveness, chronic disease management, preventative care, prescribing behaviour, and health promotion. In total, 268 factors characteristic of exceptional care were identified and synthesized into a framework of 37 themes across 7 system levels. CONCLUSION: Several useful factors associated with exceptional care were described in the literature. The proposed framework has implications for understanding and disseminating best care practice in primary care. Further refinement of the framework is required before its widespread recommendation.

The positive deviance approach is focused on identifying people/organizations performing particularly well, in spite of having similar challenges and resources to others, and learning about how they work so well. Recently, this approach has been used in healthcare to learn about how to improve the quality and safety of care for patients. This review aims to explore how the positive deviance approach has been used in primary care settings and to summarize the findings from this research. Overall, 27 studies were included in the review. We found that studies typically focused on identifying positive deviants (i.e. those performing particularly well) and finding out what helps them do that, without looking to see if these same practices work elsewhere or teaching others about them. The positive deviance approach was used to improve several different parts of primary care including; care effectiveness, management of chronic diseases, preventative care, prescribing, and health promotion. Several success strategies were identified from the studies' findings and were organized into a framework describing what practices contribute to particularly good performance in primary care. This framework will be useful for those looking to improve quality of care in primary care.

Identifying hot spots for harm and blind spots across the care pathway from patient complaints about general practice.

INTRODUCTION: Healthcare complaints are underutilized for quality improvement in general practice. Systematic analysis of complaints has identified hot spots (areas across the care pathway where issues occur frequently) and blind spots (areas across the care pathway that cannot be observed by staff) in secondary care. The Healthcare Complaints Analysis Tool (HCAT) has been adapted to the HCAT(GP). AIMS: This study aimed to: (i) assess whether the HCAT(GP) can systematically analyze complaints about general practice; and (ii) identify hot spots and blind spots in general practice. METHODS: GP complaints were sampled. Complaints were coded with the HCAT(GP), classified by HCAT(GP) category (e.g. Safety, Environment, Listening), stage of care (e.g. accessing care, referral/follow-up), severity (e.g. low, medium, high), and harm (e.g. none, major). Descriptive statistics were run to identify discrete issues. A chi-square test of independence identified hot spots, and logistic regression was used for blind spots. RESULTS: A total of 230 complaints, encompassing 432 issues (i.e. unique problems within complaints), were categorized. Relationship issues (e.g. problems with listening, communication, and patient rights) emerged most frequently (n = 174, 40%). Hot spots were identified in the consultation and the referral/follow-up stages (χ 2(5, n = 432) = 17.931, P < 0.05). A blind spot for multiple issues was identified, with the likelihood of harm increasing with number of issues (odds ratio = 2.02, confidence interval = 1.27-3.23, P < 0.05). CONCLUSIONS: Complaints are valuable data for improving general practice. This study demonstrated that the HCAT(GP) can support the systematic analysis of general practice complaints, and identify hot spots and blind spots in care.

Systematic review of interventions to improve gender equity in graduate medicine.

Women are substantially underrepresented in senior and leadership positions in medicine and experience gendered challenges in their work settings. This systematic review aimed to synthesise research that has evaluated interventions for improving gender equity in medicine. English language electronic searches were conducted across MEDLINE, CINAHL, Academic Search Complete, PsycINFO and Web of Science. Reference list screening was also undertaken. Peer-reviewed studies published between 2000 and March 2020 that evaluated interventions to improve gender equity, or the experiences of women, in academic or clinical medicine were reviewed. Dual reviewer data extraction on setting, participants, type of intervention, measurement and outcomes was completed. Methodological rigour and strength of findings were evaluated. In total, 34 studies were included. Interventions were typically focused on equipping the woman (82.4%), that is, delivering professional development activities for women. Fewer focused on changing cultures (20.6%), ensuring equal opportunities (23.5%) or increasing the visibility or valuing of women (23.5%). Outcomes were largely positive (87.3%) but measurement typically relied on subjective, self-report data (69.1%). Few interventions were implemented in clinical settings (17.6%). Weak methodological rigour and a low strength of findings was observed. There has been a focus to-date on interventions which Equip the Woman Interventions addressing systems and culture change require further research consideration. However, institutions cannot wait on high quality research evidence to emerge to take action on gender equity. Data collated suggest a number of recommendations pertaining to research on, and the implementation of, interventions to improve gender equity in academic and clinical settings.

An analysis of complaints about hospital care in the Republic of Ireland.

BACKGROUND: Patients and family members make complaints about their hospital care in order to express their dissatisfaction with the care received and prompt quality improvement. Increasingly, it is being understood that these complaints could serve as important data on how to improve care if analysed using a standardized tool. The use of the Healthcare Complaints Analysis Tool (HCAT) for this purpose has emerged internationally for quality and safety improvement. Previous work has identified hot spots (areas in care where harm occurs frequently) and blind spots (areas in care that are difficult for staff members to observe) from complaints analysis. This study aimed to (i) apply the HCAT to a sample of complaints about hospital care in the Republic of Ireland (RoI) to identify hot spots and blind spots in care and (ii) compare the findings of this analysis to a previously published study on hospital complaints in the UK. METHODS: A sample of complaints was taken from 16 hospitals in the RoI in Quarter 4 of 2019 (n = 641). These complaints were coded using the HCAT to classify complaints by domain, category, severity, stage of care and harm. Chi-squared tests were used to identify hot spots, and logistic regression was used to identify blind spots. The findings of this study were compared to a previously published UK study that used HCAT to identify hot spots and blind spots. RESULTS: Hot spots were identified in Irish hospital complaints while patients were receiving care on the ward, during initial examination and diagnosis, and while they were undergoing operations or procedures. This aligned with hot spots identified in the UK study. Blind spots were found for systemic problems, where patients experience multiple issues across their care. CONCLUSIONS: Hot spots and blind spots for patient harm can be identified in hospital care using the HCAT analysis. These in turn could be used to inform improvement interventions, and direct stakeholders to areas that require urgent attention. This study also highlights the promise of the HCAT for use across different healthcare systems, with similar results emerging from the RoI and the UK.

Sweat Characteristics in Individuals With Varying Susceptibilities of Exercise-Associated Muscle Cramps.

ABSTRACT: Szymanski, M, Miller, KC, O'Connor, P, Hildebrandt, L, and Umberger, L. Sweat characteristics in individuals with varying susceptibilities of exercise-associated muscle cramps. J Strength Cond Res 36(5): 1171-1176, 2022-Many medical professionals believe dehydration and electrolyte losses cause exercise-associated muscle cramping (EAMC). Unlike prior field studies, we compared sweat characteristics in crampers and noncrampers but accounted for numerous factors that affect sweat characteristics including initial hydration status, diet and fluid intake, exercise conditions, and environmental conditions. Sixteen women and 14 men (mean ± SD; age = 21 ± 2 year, body mass = 69.1 ± 11.6 kg, height = 171.4 ± 9.9 cm) self-reported either no EAMC history (n = 8), low EAMC history (n = 10), or high EAMC history (n = 12). We measured V̇o2max, and subjects recorded their diet. At least 3 days later, subjects ran at 70% of their V̇o2max for 30 minutes in the heat (39.9 ± 0.6° C, 36 ± 2% relative humidity). Dorsal forearm sweat was collected and analyzed for sweat sodium concentration ([Na+]sw), sweat potassium concentration ([K+]sw), and sweat chloride concentration ([Cl-]sw). Sweat rate (SWR) was estimated from body mass and normalized using body surface area (BSA). Dietary fluid, Na+, and K+ ingestion was estimated from a 3-day diet log. We observed no differences for any variable among the original 3 groups (p = 0.05-p = 0.73). Thus, we combined the high and low cramp groups and reanalyzed the data against the noncramping group. Again, there were no differences for [Na+]sw (p = 0.68), [K+]sw (p = 0.86), [Cl-]sw, (p = 0.69), SWR/BSA (p = 0.11), dietary Na+ (p = 0.14), dietary K+ (p = 0.66), and fluid intake (p = 0.28). Fluid and electrolyte losses may play a more minor role in EAMC genesis than previously thought.

Renal mass reduction increases the response to exogenous insulin independent of acid-base status or plasma insulin levels in rats.

Impairments in insulin sensitivity can occur in patients with chronic kidney disease (CKD). Correction of metabolic acidosis has been associated with improved insulin sensitivity in CKD, suggesting that metabolic acidosis may directly promote insulin resistance. Despite this, the effect of acid or alkali loading on insulin sensitivity in a rodent model of CKD (remnant kidney) has not been directly investigated. Such studies could better define the relationship between blood pH and insulin sensitivity. We hypothesized that in remnant kidney rats, acid or alkali loading would promote loss of pH homeostasis and consequently decrease insulin sensitivity. To test this hypothesis, we determined the impact of alkali (2 wk) or acid (5-7 days) loading on plasma electrolytes, acid-base balance, and insulin sensitivity in either sham control rats, 2/3 nephrectomized rats, or 5/6 nephrectomized rats. Rats with 5/6 nephrectomy had the greatest response to insulin followed by rats with 2/3 nephrectomy and sham control rats. We found that treatment with 0.1 M sodium bicarbonate solution in drinking water had no effect on insulin sensitivity. Acid loading with 0.1 M ammonium chloride resulted in significant reductions in pH and plasma bicarbonate. However, acidosis did not significantly impair insulin sensitivity. Similar effects were observed in Zucker obese rats with 5/6 nephrectomy. The effect of renal mass reduction on insulin sensitivity could not be explained by reduced insulin clearance or increased plasma insulin levels. We found that renal mass reduction alone increases sensitivity to exogenous insulin in rats and that this is not acutely reversed by the development of acidosis.NEW & NOTEWORTHY Impairments in insulin sensitivity can occur in patients with chronic kidney disease, and previous work has suggested that metabolic acidosis may be the underlying cause. Our study investigated the effect of acid or alkali loading on insulin sensitivity in a rodent model of chronic kidney disease. We found that renal mass reduction increases the blood glucose response to insulin and that this is not acutely reversed by the development of acidosis.

The adaptation of the 'Healthcare Complaints Analysis Tool' for general practice.

BACKGROUND: Patient complaints about care in general practice are underutilized as a source of safety improvement data. OBJECTIVE: This study aimed to adapt a secondary care complaints analysis tool for use in general practice contexts and assess the validity, reliability and usability of the adapted tool. METHODS: The study was conducted in two phases. Phase A: The Healthcare Complaints Analysis Tool (HCAT) designed for use in secondary care was adapted for use in general practice using an iterative six-stage process. Phase B: Participants from key stakeholder groups [General practitioners (n = 5), complaints managers (n = 9), health service researchers (n = 4)]. Participants completed an online survey and analysed 20 fictionalized patient complaints using the adapted tool. Inter-rater reliability and agreement with a referent standard were analysed using Gwet's AC1 statistic. RESULTS: Phase A: The HCAT was adapted to the Healthcare Complaints Analysis Tool (General Practice) [HCAT(GP)]. The HCAT(GP) tool consists of three domains (clinical, management and relationship problems), and seven categories. The HCAT(GP) had both content and face validity. Phase B: Inter-rater reliability was substantial for the HCAT(GP) categories (Gwet's AC1 = 0.65). Within-group agreement on the seven HCAT(GP) categories was substantial to perfect (AC1 0.61-0.85). Participants had substantial to perfect agreement with the referent standard across the survey with a mean AC1 of 0.899 (Range 0.76-0.97). CONCLUSIONS: This study reports the adaptation of the HCAT(GP) and has established that the tool has sufficient validity, reliability and usability. This adapted tool can be applied to general practice complaints to identify areas for improvement.

Development and validation of a patient-report measure of safety climate for general practice.

BACKGROUND: Patients remain an under-utilized source of information on patient safety, as reflected by the dearth of patient-report measures of safety climate, particularly for use in general practice settings. Extant measures are marked by poor coverage of safety climate domains, inadequate psychometric properties and/or lack of consideration of usability. OBJECTIVE: To develop a novel patient-report measure of safety climate specifically for completion by general practice patients, and to establish the validity, reliability and usability of this measure. METHODS: An iterative process was used to develop the safety climate measure, with patient and general practitioner input. A cross-sectional design was employed to examine the validity (content, construct and convergent), reliability (internal consistency), and usability (readability and burden) of the measure. RESULTS: A total of 584 general practice patients completed the measure. The exploratory factor analysis identified five factors pertaining to safety climate in general practice: Feeling of Safety with GP; Practice Staff Efficiency and Teamwork; Staff Stress and Workload; Patient Knowledge and Accountability, and; Safety Systems and Behaviours. These factors strongly correlated with two global safety measures, demonstrating convergent validity. The measure showed strong internal consistency, and was considered usable for patients as indicated by readability and duration of completion. CONCLUSION: Our novel measure of safety climate for use in general practice demonstrates favourable markers of validity, reliability and usability. This measure will provide a mechanism for the patient voice to be heard in patient safety measurement, and to be used to improve patient safety in general practice.

Gender in authorship and editorship in medical education journals: A bibliometric review.

CONTEXT: Gender bias has been observed in the authorship and editorship of academic literature in varied medical specialties. This is important as peer-reviewed publications, and participation on editorial boards, are closely related to academic productivity and advancement. The aim of this paper was to examine whether gender-based disparities in authorship and editorship exist in leading medical education journals. METHODS: A retrospective bibliometric review was conducted of articles published at eight different time-points across a 49-year time period (specifically: 1970, 1980, 1990, 2000, 2005, 2010, 2015 and 2019) in four leading medical education journals (Academic Medicine, BMC Medical Education, Medical Education and Medical Teacher). First and last (as a proxy for senior) author gender was determined for each article, along with the gender of the 2019 editorial board members of each journal. Chi-square tests for trend were conducted to examine variations in author gender distributions over time, and binomial tests of proportions were conducted to examine gender distributions in authorship and editorship in 2019. Logistic regression analyses were carried out to determine factors that predicted the odds of authorship by women. RESULTS: A total of 5749 articles were included. A significant trend of increased women as first and last authors was observed across all journals. The percentage of women first authors increased from 6.6% in 1970 to 53.7% in 2019 (P < .001), and women last authors increased from 9.5% in 1970 to 46% in 2019 (P < .001). Overall, the distributions of women first authors, last authors and editorial board members in 2019 indicated greater gender parity than many other fields of medicine. CONCLUSIONS: Positive progress towards gender parity has been made in medical education scholarship. However, future research and efforts are needed to ensure the continued participation, and highlighting, of women in medical education scholarship and to address other factors which may hinder academic advancement for women in this field.

Physiological and performance responses of sprint interval training and endurance training in Gaelic football players.

PURPOSE: While ideal for developing aerobic capacity, traditional endurance training (ET) is extremely time-consuming and may lack the specificity to maintain indices of speed and power in team sport athletes. In contrast, low-volume short-duration sprint interval training (SIT) has been shown to improve [Formula: see text]O2max to a similar extent as ET. However, to date, few studies have compared the effects of running-based SIT and ET, on aerobic capacity and indices of speed and power of trained team sport athletes. METHODS: Club level male Gaelic football players were randomly assigned to SIT (n = 13; 26.5 ± 4.87 years) or ET (n = 12; 25.4 ± 2.58 years) groups. Participants trained 3 days week-1 for 6 weeks. [Formula: see text]O2max, RE, v[Formula: see text]O2max, blood lactate concentrations, Wingate test performance, running speed, jump performance and intermittent endurance performance (IEP) were measured at baseline and after 6 weeks. RESULTS: An increase in [Formula: see text]O2max (p < 0.05), v[Formula: see text]O2max (p < 0.001) and IEP (p < 0.001) following 6 weeks of both SIT and ET was observed. Wingate mean power (p < 0.001), peak power (p < 0.001) and fatigue index (p < 0.005) were all significantly improved following training in both groups. Velocity at LT was significantly higher and performance in the 20-m running speed and VJ tests were significantly reduced post training in the ET group (all p < 0.005). CONCLUSION: Despite the large difference in total training time, a running-based protocol of SIT is a time efficient training method for improving aerobic capacity and IEP while maintaining indices of lower body power and running speed in team-sport players.

Measuring and monitoring patient safety in hospitals in Saudi Arabia.

BACKGROUND: There is much variability in the measurement and monitoring of patient safety across healthcare organizations. With no recognized standardized approach, this study examines how the key components outlined in Vincent et al's Measuring and Monitoring Safety (MMS) framework can be utilized to critically appraise a healthcare safety surveillance system. The aim of this study is to use the MMS framework to evaluate the Saudi Arabian healthcare safety surveillance system for hospital care. METHODS: This qualitative study consisted of two distinct phases. The first phase used document analysis to review national-level guidance relevant to measuring and monitoring safety in Saudi Arabia. The second phase consisted of semi-structured interviews with key stakeholders between May and August 2020 via a video conference call and focused on exploring their knowledge of how patient safety is measured and monitored in hospitals. The MMS framework was used to support data analysis. RESULTS: Three documents were included for analysis and 21 semi-structured interviews were conducted with key stakeholders working in the Saudi Arabian healthcare system. A total of 39 unique methods of MMS were identified, with one method of MMS addressing two dimensions. Of these MMS methods: 10 (25 %) were concerned with past harm; 14 (35 %) were concerned with the reliability of safety critical processes, 3 (7.5 %) were concerned with sensitivity to operations, 2 (5 %) were concerned with anticipation and preparedness, and 11 (27.5 %) were concerned with integration and learning. CONCLUSIONS: The document analysis and interviews show an extensive system of MMS is in place in Saudi Arabian hospitals. The assessment of MMS offers a useful framework to help healthcare organizations and researchers to think critically about MMS, and how the data from different methods of MMS can be integrated in individual countries or health systems.