Implementing a cirrhosis order set in a tertiary healthcare system: a theory-informed formative evaluation.

BACKGROUND: Standardized order sets are a means of increasing adherence to clinical practice guidelines and improving the quality of patient care. Implementation of novel quality improvement initiatives like order sets can be challenging. Before the COVID-19 pandemic, we conducted a formative evaluation to understand healthcare providers' perspectives on implementing clinical changes and the individual, collective and organizational contextual factors that might impact implementation at eight hospital sites in Alberta, Canada. METHODS: We utilized concepts from the Consolidated Framework for Implementation Research (CFIR) and Normalisation Process Theory (NPT) to understand the context, past implementation experiences, and perceptions of the cirrhosis order set. Eight focus groups were held with healthcare professionals caring for patients with cirrhosis. Data were coded deductively using relevant constructs of NPT and CFIR. A total of 54 healthcare professionals, including physicians, nurses, nurse practitioners, social workers and pharmacists and a physiotherapist, participated in the focus groups. RESULTS: Key findings revealed that participants recognized the value of the cirrhosis order set and its potential to improve the quality of care. Participants highlighted potential implementation challenges, including multiple competing quality improvement initiatives, feelings of burnout, lack of communication between healthcare provider groups, and a lack of dedicated resources to support implementation. CONCLUSIONS: Implementing a complex improvement initiative across clinician groups and acute care sites presents challenges. This work yielded insights into the significant influence of past implementation of similar interventions and highlighted the importance of communication between clinician groups and resources to support implementation. However, by using multiple theoretical lenses to illuminate what and how contextual and social processes will influence uptake, we can better anticipate challenges during the implementation process.

A dust-obscured massive maximum-starburst galaxy at a redshift of 6.34.

Massive present-day early-type (elliptical and lenticular) galaxies probably gained the bulk of their stellar mass and heavy elements through intense, dust-enshrouded starbursts--that is, increased rates of star formation--in the most massive dark-matter haloes at early epochs. However, it remains unknown how soon after the Big Bang massive starburst progenitors exist. The measured redshift (z) distribution of dusty, massive starbursts has long been suspected to be biased low in z owing to selection effects, as confirmed by recent findings of systems with redshifts as high as ~5 (refs 2-4). Here we report the identification of a massive starburst galaxy at z = 6.34 through a submillimetre colour-selection technique. We unambiguously determined the redshift from a suite of molecular and atomic fine-structure cooling lines. These measurements reveal a hundred billion solar masses of highly excited, chemically evolved interstellar medium in this galaxy, which constitutes at least 40 per cent of the baryonic mass. A 'maximum starburst' converts the gas into stars at a rate more than 2,000 times that of the Milky Way, a rate among the highest observed at any epoch. Despite the overall downturn in cosmic star formation towards the highest redshifts, it seems that environments mature enough to form the most massive, intense starbursts existed at least as early as 880 million years after the Big Bang.

An immuno-epidemiological model for transient immune protection: A case study for viral respiratory infections.

The dynamics of infectious disease in a population critically involves both within-host pathogen replication and between host pathogen transmission. While modeling efforts have recently explored how within-host dynamics contribute to shaping population transmission, fewer have explored how ongoing circulation of an epidemic infectious disease can impact within-host immunological dynamics. We present a simple, influenza-inspired model that explores the potential for re-exposure during a single, ongoing outbreak to shape individual immune response and epidemiological potential in non-trivial ways. We show how even a simplified system can exhibit complex ongoing dynamics and sensitive thresholds in behavior. We also find epidemiological stochasticity likely plays a critical role in reinfection or in the maintenance of individual immunological protection over time.

A high-resolution spectroscopic system for remote measurement of plasma parameters.

Plasma diagnostics are usually performed with immersive probes that collect the cumulative electric currents created by charged particles. Idealized models are applied to the resulting I-V curves to extract plasma flow parameters. Our non-invasive technique, based on passive emission spectroscopy (PES), allows for the remote measurement of undisturbed plasma parameters via fine spectral effects. Importantly, it can be applied to each plasma species separately, including neutral components. However, extremely high spectral resolution is required to resolve shapes of the spectral lines. We describe a portable instrumentation system that delivers sub-pm resolution in visible and near-infrared regions of the spectrum. It can be used to measure various plasma parameters but most notably allows the drift velocities of ions and neutrals to be resolved with ∼100 m/s precision. We discuss details of our experimental apparatus, along with capabilities and limitations of the PES implementation.

Non-use of cancer information services among people experiencing cancer in Ireland.

PURPOSE: The purpose of this study was to explore the reasons for non-use of a national cancer society's cancer information services among people experiencing cancer. METHOD: This study used a qualitative design. Semi-structured interviews were conducted with a total of 17 participants who had not previously utilised the Cancer Society's information services. Data were analysed using Thematic Analysis. RESULTS: The key themes to emerge from the date were 'living in the here and now' and 'awareness of the Cancer Society'. For most participants, not utilising cancer information services was a means of coping with the initial diagnosis and the impact of treatment. Those who progressed to being ready to seek information identified the multi-disciplinary team as the primary source of trusted information, with particular mention of cancer nurse specialists. For participants with children, their role as a parent was central in how they managed their diagnosis. The majority of participants lacked awareness of the range of services provided by the Cancer Society. CONCLUSIONS: Reasons for non-use of cancer information services were identified as: readiness to seek information and a lack of knowledge of the Cancer Societies' services. Cancer information services need to continue make a concerted effort to enhance visibility and awareness of its services to optimise patient engagement.

Recent Canadian efforts to develop population-level pregnancy intervention studies to mitigate effects of natural disasters and other tragedies.

The preconception, pregnancy and immediate postpartum and newborn periods are times for mothers and their offspring when they are especially vulnerable to major stressors - those that are sudden and unexpected and those that are chronic. Their adverse effects can transcend generations. Stressors can include natural disasters or political stressors such as conflict and/or migration. Considerable evidence has accumulated demonstrating the adverse effects of natural disasters on pregnancy outcomes and developmental trajectories. However, beyond tracking outcomes, the time has arrived for gathering more information related to identifying mechanisms, predicting risk and developing stress-reducing and resilience-building interventions to improve outcomes. Further, we need to learn how to encapsulate both the quantitative and qualitative information available and share it with communities and authorities to mitigate the adverse developmental effects of future disasters, conflicts and migrations. This article briefly reviews prenatal maternal stress and identifies three contemporary situations (wildfire in Fort McMurray, Alberta, Canada; hurricane Harvey in Houston, USA and transgenerational and migrant stress in Pforzheim, Germany) where current studies are being established by Canadian investigators to test an intervention. The experiences from these efforts are related along with attempts to involve communities in the studies and share the new knowledge to plan for future disasters or tragedies.

Eastern Canadian Gastrointestinal Cancer Consensus Conference 2018.

The annual Eastern Canadian Gastrointestinal Cancer Consensus Conference was held in Halifax, Nova Scotia, 20-22 September 2018. Experts in radiation oncology, medical oncology, surgical oncology, and pathology who are involved in the management of patients with gastrointestinal malignancies participated in presentations and discussion sessions for the purpose of developing the recommendations presented here. This consensus statement addresses multiple topics in the management of pancreatic cancer, pancreatic neuroendocrine tumours, hepatocellular cancer, and rectal and colon cancer, including ■ surgical management of pancreatic adenocarcinoma,■ adjuvant and metastatic systemic therapy options in pancreatic adenocarcinoma,■ the role of radiotherapy in the management of pancreatic adenocarcinoma,■ systemic therapy in pancreatic neuroendocrine tumours,■ updates in systemic therapy for patients with advanced hepatocellular carcinoma,■ optimum duration of adjuvant systemic therapy for colorectal cancer, and■ sequence of therapy in oligometastatic colorectal cancer.

Eastern Canadian Colorectal Cancer Consensus Conference 2017.

The annual Eastern Canadian Gastrointestinal Cancer Consensus Conference 2017 was held in St. John's, Newfoundland and Labrador, 28-30 September. Experts in radiation oncology, medical oncology, surgical oncology, and cancer genetics who are involved in the management of patients with gastrointestinal malignancies participated in presentations and discussion sessions for the purpose of developing the recommendations presented here. This consensus statement addresses multiple topics in the management of gastric, rectal, and colon cancer, including ■ identification and management of hereditary gastric and colorectal cancer (crc);■ palliative systemic therapy for metastatic gastric cancer;■ optimum duration of preoperative radiation in rectal cancer-that is, short- compared with long-course radiation;■ management options for peritoneal carcinomatosis in crc;■ implications of tumour location for treatment and prognosis in crc; and■ new molecular markers in crc.

Primary health care: perspective of the faculty of a department of medicine.

A full-time faculty in one dependent of medicine, 66 (85%) of whom are subspecialists, were surveyed to determine standards for provision and attitudes toward the teaching and practice of primary health care (PHC). A 40-item questionnaire on specific attributes of PHC provision was given to 70 eligible faculty members; 66 (94%) responded. Of 17 standards, nine were supported by 50 (75%) or more of the faculty and eight by from 24 (44%) to 48 (73%) faculty members. However, 51 faculty members (77%) indicated some discomfort with primary responsibility for the complete, ongoing care of their patients. Most frequent reasons for this discomfort were clinic inefficiency (31 votes [47%]) and competing commitments (29 votes [44%]). Few faculty indicated they did not enjoy PHC (eight [12%] of the faculty) or considered PHC inappropriate for academic physicians (ten [15%] of the faculty). These results indicate the complexity of faculty attitudes toward PHC and point to a need for departments of medicine to examine thier teaching and practice of PHC.

Response to "Effects of caffeine on behavior of schizophrenic inpatients".

This article addresses itself to the apparent conflict between those reports indicating that caffeine affects schizophrenic behavior and the present study which failed to show substantial behavior or medication changes with caffeine. It is suggested that there are important subgroups of schizophrenic patients who are unusually sensitive to caffeine's apparent psychotogenic actions as reported in case reports and data on violence and destruction. It is also suggested that there are subgroups of schizophrenia which seem to require increased medication doses to "cover" caffeine effects.

Accountability in public short-term adult AOD residential treatment. Fontainebleau Treatment Center.

Fontainebleau Treatment Center provides short-term public residential AOD treatment and primary health care to a lower-socioeconomic adult population. The multimodal focus of treatment includes interactive group therapy, behavioral contracting, relapse prevention, and 12-step involvement. Research funded by the National Institute on Drug Abuse indicated both positive treatment outcome and significant cost efficacy. These results may be in some contrast to prevailing assumptions about public sector, government-operated behavioral health-care delivery to high-risk populations. Multiple variables for consideration in future outcome research are discussed, with potential for database inclusion toward standardization of treatment and cost protocols.

HIV-positive patients' experiences of stigma during hospitalization.

The aim of this research study was to explore, within an Irish context, HIV-positive patients' experiences of hospitalization and particularly their experiences of nursing care. This article reports on one of the dominant themes to emerge in the study--the experience of stigma during hospitalization among persons with HIV. A volunteer sample of 10 former inpatients of hospitals in the Republic of Ireland's capital, Dublin, were interviewed in depth, and the resulting data were analyzed using a qualitative content analysis. Findings indicate that while some participants experienced stigma from nurses, such stigma was stratified according to the means by which the disease had been contracted, with drug users expressing the greatest feelings of stigma from nurses. Data also suggest that the type of nursing care favored by many participants was that of segregated care within specialized units. This type of care was preferred because it enabled the patient to avoid being discredited by other patients who did not have the virus. This environment also offered the potential of social support from other patients with similar diagnoses. Finally, patients experienced breaches in confidentiality because of institutional policies that made their disease conspicuous and from some nurses' nonchalance in handling information about their disease. The analysis used in this study draws on Goffman's conceptualizations of stigma to explain the social process underlying the accounts given by study participants.

Developing competency in the neonatal intensive care unit: a hospital training program.

There are few specialized programs available to train occupational therapists and physical therapists to treat competently in a neonatal intensive care unit (NICU), yet hospitals are trying to fill such positions, and the need for advanced training is essential. A hospital-based program that provides clinical NICU training to therapists from other hospitals is presented. The program is short-term and highly individualized and emphasizes learning pertinent medical information, nonintrusive evaluation skills, and therapeutic intervention with advanced clinical judgment.

The effects of word length, articulation, oral-motor movement, and lexicality on gait: a pilot study.

Previous research has suggested that articulatory demands are important predictors of the impact of dual-task interference on spatial-temporal parameters of gait. In this study, we evaluated the effects of word length, oral-motor movement, articulation, and lexicality, within a verbal task, on a continuous gait task. Fifteen healthy young women participated in a study in which two word lengths (monosyllabic and bisyllabic) were crossed with four levels of secondary task complexity (no dual-task, non-speech movement, spoken non-word, and spoken word). Spatial and temporal parameters of gait were measured using a 23' instrumented carpet. Results indicated a significant multivariate main effect for task type, F(15, 120)=3.07, that explained 71.1% of the demonstrated variability in gait. Univariate analyses of this main effect revealed statistically significant effects for velocity, step time, swing time, and stance time, but no statistically significant effect for step length. Post hoc analyses suggested that dual-task interference produced significant changes in the parameters of gait, but that this interference was not significantly greater with non-words as compared to the non-speech movement condition, nor was it significantly greater with words as compared to non-words. The results of this systematic deconstruction of a simple verbal task suggest that the motor component of a secondary speech task may produce the largest amount of interference within a dual-task interference paradigm.