Preparing clinicians for practice: effectiveness and design of on-call simulation.

BACKGROUND: Final year medical students and postgraduate doctors regularly contend with feelings of under-preparedness when transitioning into new areas of clinical practice. This lack of confidence is most evident in the context of on-call work which frequently requires sound clinical prioritisation, rigorous decision making and the management of acutely unwell patients, often with reduced senior support and staffing. This has prompted the emergence of on-call simulation which seeks to enhance participant confidence in performing on-call tasks and facilitate the development of key clinical and non-technical skills. This narrative review examined the use of on-call simulation in medical student and newly qualified doctor cohorts, its effectiveness in achieving its stated outcomes and to identify novel areas for the development of existing models. METHOD: A search strategy was developed in conjunction with a specialist medical librarian. OVID Medline and Embase searches identified articles related to the use and design of on-call simulation in medical education with no restrictions placed upon date or language of publication. Key findings from articles were summarised to develop comprehensive themes for discussion. RESULTS: Twenty Three unique publications were reviewed which unanimously reported that on-call simulation had a positive effect on self-reported participant confidence in performing on-call roles. Furthermore the value on-call simulation when used as an induction activity was also evident. However, there was limited evidence around improved patient and performance outcomes following simulation. It also remains resource intensive as an educational tool and there is a distinct absence of interprofessional education in current models. CONCLUSIONS: We concluded that on-call simulation must adopt an interprofessional educational approach, incorporating other clinical roles. Further studies are needed to characterise the impact on patient outcomes. It remains highly useful as a confidence-boosting induction activity, particularly in specialities where clinical exposure is limited. Virtual and tabletop simulation formats, could potentially address the resource burden of manikin-based models, particularly with ever growing demands on medical educators and the expansion of training posts.

Considerable variation in current coronoid height and fracture measurement techniques: a systematic review.

BACKGROUND: Coronoid fractures usually occur in the presence of a significant osseoligamentous injury to the elbow. Fracture size and location correlate with degree of instability and many authors have attempted to analyze the effect of fracture variation on decision making and outcome. There remains no standardized technique for measuring coronoid height or fracture size. The aim of this study was to appraise the literature regarding techniques for coronoid height measurement in order to understand variation. METHODS: Preferred Reporting Items of Systematic Reviews and Meta-Analyses guidelines were followed. A search was performed to identify studies with either a description of coronoid height, fracture size, or bone loss using the terms (Coronoid) AND (Measurement) OR (Size) OR (Height). Articles were shortlisted by screening for topic relevance based on title, abstract and, if required, full-text review. Exclusion criteria were non-English articles, those on nonhuman species or parts other than the ulna coronoid process, and studies that included patients with pre-existing elbow pathology. Shortlisted articles were grouped based on study type, imaging modality, measurement technique, and measurement parameter as well as its location along the coronoid. RESULTS: Thirty out of the initially identified 494 articles met the inclusion criteria. Twenty-one articles were clinical studies, 8 were cadaveric studies, and 1 combined patients as well as cadavers. A variety of imaging modalities (plain radiographs, 2-dimensional computed tomography [CT], 3-dimensional CT, magnetic resonance imaging or a combination of these) were used with CT scan (either 2-dimensional images or 3-dimensional reconstructions or both) being the most common modality used by 21 studies. Measurement technique also varied from uniplanar linear measurements in 15 studies to multiplanar area and volumetric measurements in 6 studies to techniques describing various angles and indices as an indirect measure of coronoid height in 8 studies. Across the 30 shortlisted studies, 19 different measurement techniques were identified. Fifteen studies measured normal coronoid height while the other 15 measured intact coronoid and/or fracture fragment height. The location of this measurement was also variable between studies with measurements at the apex of the coronoid in 24/30 (80%) of studies. Measurement accuracy was assessed by only 1 study. A total of 12/30 (40%) studies reported on the interobserver and intraobserver reliability of their measurement technique. CONCLUSION: The systemic review demonstrated considerable variability between studies that report coronoid height or fracture size measurements. This variability makes comparison of coronoid height or fracture measurements and recommendations based on these between studies unreliable. There is need for development of a consistent, easy to use, and reproducible technique for coronoid height and bone loss.

Copy number gain of 11q13.3 genes associates with pathological stage in hypopharyngeal squamous cell carcinoma.

Squamous cell carcinomas of the hypopharynx (HPSCC) and oropharynx (OPSCC) have markedly different patient outcomes. Differences in HPV prevalence between these two patient groups may account for some of this difference, but other molecular markers of prognosis or pathological phenotype have not been established. Copy number gain of oncogenes is a well-established molecular change contributing to HNSCC development. Quantitative PCR was used to explore copy number gains of specific genes (3q-PIK3CA, TP63; 11q13.3-CCND1, ANO1) in tumor DNA recovered from HPSCC (n = 48) and OPSCC (n = 52) patients. Associations between copy number gain, patient demographics, HPV/p16INK4a status and pathological stage were examined. HPV/p16 prevalence in HPSCC and OPSCC groups was 2.1% and 46.0%, respectively. HPSCCs had frequent gains of CCND1 (56.3%) and ANO1 (56.3%) but few gains of PIK3CA (6.3%). By contrast, OPSCCs had significantly fewer CCND1 (23.1%) and ANO1 (17.3%) gains, and significantly more PIK3CA (26.9%) gains. A mutually exclusive relationship between HPV/p16 and 11q13.3 gains was observed in OPSCCs, while PIK3CA and TP63 gains were similar across HPV-associated and smoking/alcohol-associated patients. ANO1 gain was significantly linked to tumor pathology in HPSCC, associating with nodal metastasis and smaller and less invasive tumors at presentation (P = 0.010). Our results provide a convincing link between a specific molecular change and disease phenotype that appears unique to our HPSCC population, supporting a model of 11q13.3 in promoting metastatic disease progression in HNSCC, and suggest a role for ANO1 as a molecular marker of metastatic disease. © 2016 Wiley Periodicals, Inc.

Return of large fin whale feeding aggregations to historical whaling grounds in the Southern Ocean.

Fin whales (Balaenoptera physalus quoyi) of the Southern Hemisphere were brought to near extinction by twentieth century industrial whaling. For decades, they had all but disappeared from previously highly frequented feeding grounds in Antarctic waters. Our dedicated surveys now confirm their return to ancestral feeding grounds, gathering at the Antarctic Peninsula in large aggregations to feed. We report on the results of an abundance survey and present the first scientific documentation of large fin whale feeding aggregations at Elephant Island, Antarctica, including the first ever video documentation. We interpret high densities, re-establishment of historical behaviours and the return to ancestral feeding grounds as signs for a recovering population. Recovery of a large whale population has the potential to augment primary productivity at their feeding grounds through the effects of nutrient recycling, known as 'the whale pump'. The recovery of fin whales in that area could thus restore ecosystem functions crucial for atmospheric carbon regulation in the world's most important ocean region for the uptake of anthropogenic CO2.

Effect of severe hurricanes on biorock coral reef restoration projects in Grand Turk, Turks and Caicos Islands.

Artificial reefs are often discouraged in shallow waters over concerns of storm damage to structures and surrounding habitat. Biorock coral reef restoration projects were initiated in waters around 5 m deep in Grand Turk, at Oasis (October 2006) and at Governor's Beach (November 2007). Hemi-cylindrical steel modules, 6m long were used, four modules at Oasis and six at Governor's Beach. Each project has over 1200 corals transplanted from sites with high sedimentation damage, and are regularly monitored for coral growth, mortality and fish populations. Corals show immediate growth over wires used to attach corals. Growth has been measured from photographs using a software program and is faster at Governor's Beach. After hurricanes Hanna and Ike (September 2008) the Governor's Beach structure was fully standing since the waves passed straight through with little damage, the Oasis structures which were tie-wired rather than welded had one module collapse (since been replaced with a new, welded structure). Hurricane Ike was the strongest hurricane on record to hit Grand Turk. Most cables were replaced following the hurricanes due to damage from debris and high wave action. The projects lost about a third of the corals due to hurricanes. Most of those lost had only been wired a few days before and had not yet attached themselves firmly. These projects have regenerated corals and fish populations in areas of barren sand or bedrock and are now attractive to snorkelers. High coral survival and low structural damage after hurricanes indicate that Biorock reef restoration can be effective in storm-impacted areas.

Formalin fixed paraffin embedded (FFPE) material is amenable to HPV detection by the Xpert(®) HPV assay.

BACKGROUND: The Xpert(®) HPV Assay (Cepheid(®), Sunnyvale, USA) is a rapid, cartridge-based HPV test validated for use on cervical cytology samples. However, there is an increasing demand for HPV annotation of formalin fixed paraffin embedded (FFPE) material. OBJECTIVES: The aim of this study was to determine the suitability of the Xpert HPV assay for the detection of nucleic acid (NA) derived from FFPE samples. STUDY DESIGN: A total of 88, 10 µm sections derived from FFPE tissue blocks were assessed, 74 originated from oropharyngeal squamous cell carcinomas (OPSCC) and 14 from a range of other sites. All had previously been tested with a sensitive Luminex(®) based assay with a component also tested with p16 immunohistochemistry (IHC). NA was extracted from samples using the easyMag(®) platform and after dilution was added directly to the Xpert cartridge. Agreement between assays was assessed. RESULTS: Overall agreement between the assays was 92%; with a Kappa for HR-HPV detection of 0.833 (95% CI 0.725-0.953). In the 50 samples that had been annotated for p16 status overall agreement between the Xpert assay and the p16 IHC was 90%. CONCLUSIONS: These data indicate that FFPE material is amenable to HPV detection by the Xpert assay. To our knowledge, this is the first study to interrogate the use of the Xpert(®) HPV assay for this application.

Public Health Amendment (Vaccination of Children Attending Child Care Facilities) Act 2013: its impact in the Northern Rivers, NSW.

OBJECTIVE: The objective of the study was to explore the impact of implementation of the Public Health Amendment (Vaccination of Children Attending Child Care Facilities) Act 2013 on child-care centres in the Northern Rivers region of New South Wales (NSW), from the perspective of child-care centre directors. Importance of study: Immunisation is an effective public health intervention, but more than 75 000 Australian children are not fully vaccinated. A recent amendment to the NSW Public Health Act 2010 asks child-care facilities to collect evidence of complete vaccination or approved exemption before allowing enrolment. METHODS: Ten child-care centre directors participated in a semiscripted interview. Interviews were recorded, transcribed and analysed. RESULTS: Common themes included misinterpretation of the amendment before implementation, the importance of adequate notice for implementation, lack of understanding of assessment of compliance, increased administrative requirements, the importance of other public health efforts, and limited change in vaccination rates. Child-care centres differed in their experience of the resources provided by the government, interactions with Medicare, and ease of integration with existing record-keeping methods. CONCLUSIONS: Participants felt that the amendment was successfully implemented. The amendment was felt to have fulfilled its aim of prompting parents who had forgotten to vaccinate, but failed to significantly affect conscientious objectors. Overall, the amendment was perceived to be a positive step in improving vaccination rates, but its impact was largely complementary to other components of the multifaceted vaccination policy.

A quality improvement evaluation case study: impact on public health outcomes and agency culture.

BACKGROUND: Quality improvement (QI) is increasingly recognized as an important strategy to improve healthcare services and health outcomes, including reducing health disparities. However, there is a paucity of evidence documenting the value of QI to public health agencies and services. PURPOSE: The purpose of this project was to support and assess the impact on the outcomes and organizational culture of a QI project to increase immunization rates among children aged 2 years (4:3:1:3:3:1 series) within a large public health agency with a major pediatric health mission. METHODS: The intervention consisted of the use of a model-for-improvement approach to QI for the delivery of immunization services in public health clinics, utilizing plan-do-study-act cycles and multiple QI techniques. A mixed-method (qualitative and quantitative) model of evaluation was used to collect and analyze data from June 2009 to July 2011 to support both summative and developmental evaluation. The Florida Immunization Registry (Florida SHOTS [State Health Online Tracking System]) was used to monitor and analyze changes in immunization rates from January 2009 to July 2012. An interrupted time-series application of covariance was used to assess significance of the change in immunization rates, and paired comparison using parametric and nonparametric statistics were used to assess significance of pre- and post-QI culture items. RESULTS: Up-to-date immunization rates increased from 75% to more than 90% for individual primary care clinics and the overall county health department. In addition, QI stakeholder scores on ten key items related to organizational culture increased from pre- to post-QI intervention. Statistical analysis confirmed significance of the changes. CONCLUSIONS: The application of QI combined with a summative and developmental evaluation supported refinement of the QI approach and documented the potential for QI to improve population health outcomes and improve public health agency culture.

Effect of severe hurricanes on Biorock Coral Reef Restoration Projects in Grand Turk, Turks and Caicos Islands

Artificial reefs are often discouraged in shallow waters over concerns of storm damage to structures and surrounding habitat. Biorock coral reef restoration projects were initiated in waters around 5m deep in Grand Turk, at Oasis (October 2006) and at Governor’s Beach (November 2007). Hemi-cylindrical steel modules, 6m long were used, four modules at Oasis and six at Governor’s Beach. Each project has over 1200 corals transplanted from sites with high sedimentation damage, and are regularly monitored for coral growth, mortality and fish populations. Corals show immediate growth over wires used to attach corals. Growth has been measured from photographs using a software program and is faster at Governor’s Beach. After hurricanes Hanna and Ike (September 2008) the Governor’s Beach structure was fully standing since the waves passed straight through with little damage, the Oasis structures which were tie-wired rather than welded had one module collapse (since been replaced with a new, welded structure). Hurricane Ike was the strongest hurricane on record to hit Grand Turk. Most cables were replaced following the hurricanes due to damage from debris and high wave action. The projects lost about a third of the corals due to hurricanes. Most of those lost had only been wired a few days before and had not yet attached themselves firmly. These projects have regenerated corals and fish populations in areas of barren sand or bedrock and are now attractive to snorkelers. High coral survival and low structural damage after hurricanes indicate that Biorock reef restoration can be effective in storm-impacted areas. Rev. Biol. Trop. 58 (Suppl. 3): 141-149. Epub 2010 October 01.

Con frecuencia no se favorece la creación de arrecifes artificiales en aguas someras debido a que se estima que las tormentas pueden producir daños en las estructuras y en el hábitat circundante. En las aguas de Grand Turk, a unos 5m de profundidad, se iniciaron proyectos de restauración de arrecifes coralinos en Oasis (octubre 2006) y en Governor’s Beach (noviembre 2007). Se utilizaron módulos de acero semicilíndricos, 4 en Oasis y 6 en Governor’s Beach. A cada proyecto se han trasplantado más de 1200 corales desde sitios con un elevado daño por sedimentación y se monitorean regularmente para evaluar crecimiento y mortalidad de los corales, así como la población de peces. Los corales muestran un crecimiento inmediato sobre los alambres utilizados para asegurar los corales. Este crecimiento se ha medido usando fotografías y un programa de computación y es más rápido en Governor’s Beach. Después de los huracanes Hanna e Ike (setiembre 2008), las estructuras en Governor’s Beach se mantuvieron erectas debido a que las olas pasaron a través de las mismas sin afectarlas, una de las estructuras en Oasis colapsó debido a que todas se amarraron con alambre en vez de soldarse (desde entonces se sustituyó con una nueva, soldada esta vez). El huracán Ike ha sido el más fuerte de los históricamente registrados que ha impactado Grand Turk. La mayor pare de los cables fueron reemplazados debido a daños causados por la acción de detritus y de las grandes olas. Los proyectos perdieron alrededor de un tercio de los corales debido a los huracanes. La mayoría de los corales perdidos habían sido amarrados a las estructuras unos días antes de los huracanes y consecuentemente no se habían adosado firmemente a las mismas. Estos proyectos han regenerado poblaciones de corales y peces en áreas inhóspitas de arena o roca y constituyen ahora una atracción para el buceo superficial. La alta tasa de supervivencia de corales y el bajo daño a las estructuras después de los huracanes indican que la tecnología Biorock para restauración de arrecifes coralinos es efectiva en áreas impactadas por tormentas.