Mortality and readmission differences associated with after-hours hospital admission: A population-based cohort study in Queensland Australia.

Background and Aims: Policy makers and health system managers are seeking evidence on the risks involved for patients associated with after-hours care. This study of approximately 1 million patients who were admitted to the 25 largest public hospitals in Queensland Australia sought to quantify mortality and readmission differences associated with after-hours hospital admission. Methods: Logistic regression was used to assess whether there were any differences in mortality and readmissions based on the time inpatients were admitted to hospital (after-hours versus within hours). Patient and staffing data, including the variation in physician and nursing staff numbers and seniority were included as explicit predictors within patient outcome models. Results: After adjusting for case-mix confounding, statistically significant higher mortality was observed for patients admitted on weekends via the hospital's emergency department compared to within hours. This finding of elevated mortality risk after-hours held true in sensitivity analyses which explored broader definitions of after-hours care: an "Extended" definition comprising a weekend extending into Friday night and early Monday morning; and a "Twilight" definition comprising weekends and weeknights.There were no significant differences in 30-day readmissions for emergency or elective patients admitted after-hours. Increased mortality risks for elective patients was found to be an evening/weekend effect rather than a day-of-week effect. Workforce metrics that played a role in observed outcome differences within hours/after-hours were more a time of day rather than day of week effect, i.e. staffing impacts differ more between day and night than the weekday versus weekend. Conclusion: Patients admitted after-hours have significantly higher mortality than patients admitted within hours. This study confirms an association between mortality differences and the time patients were admitted to hospital, and identifies characteristics of patients and staffing that affect those outcomes.

Fostering resilience in young people with intellectual disabilities using a 'settings' approach.

The need to foster resilience amongst young people with intellectual disabilities is increasingly recognised within policy. Critically, understanding of the actual means by which this aspiration might be most sensitively and effectively met is considered weak. This paper reports on an exploratory case-study of a social enterprise community café - The Usual Place - that through the promotion of employability, seeks to promote resilience amongst its young 'trainees' with intellectual disabilities. Two research questions were set: "how is 'resilience' conceptualized within the organisation" and "what features within the organisation are significant in fostering resilience"? We identify a range of significant features associated with being able to successfully foster resilience - the need for a foundational 'whole organisation'(settings) approach based on high levels of participation and choice; the negotiation of a constructive dynamic tension between 'support' and 'exposure'; and the embedding of these actions in embodied actions and day-to-day organisational activities.

The use of kiosks to improve triage efficiency in the emergency department.

Triage is a system used to prioritise patients as they enter the emergency department (ED) based on their need for urgent care. In recent decades, EDs have becoming increasingly overcrowded, leading to longer pre-triage waiting times for patients. E-triage interventions like kiosks have been proposed as a solution to overcrowding. We conducted a literature review into the effectiveness of kiosks in improving triage efficiency. After rigorously searching five biomedical databases and screening candidate articles in Endnote, we identified nine papers pertaining to the introduction of kiosks in emergency departments. Six articles had positive findings-with E-triage interventions improving some aspect of the triage process-such as reducing pre-triage times. Conversely, only three articles reported negative findings, such as low uptake. Consequently, EDs should consider introducing kiosks to complement the current nurse-led triage process and thereby promote better patient outcomes.

Nuclease resistance and protein recognition properties of DNA and hybrid PNA-DNA four-way junctions.

Nucleic acids possess unique biochemical features that make them ideal candidates to inhibit "difficult to target" proteins. The limited stability of nucleic acids in vivo presents a major obstacle to their development as drugs. Here, immobile four-way junctions (4WJs) are used to target the DNA-binding cytokine, High Mobility Group B1. Hybrid 4WJs composed of DNA and peptide nucleic acids (PNA) are investigated. PNA possess enhanced nuclease stability vs. DNA. 4WJs are incubated with Exonuclease III and DNase I. The nuclease assays show that 4WJs containing multiple PNAs possess significantly higher stability. Circular dichroism assays are used to probe the groove topology of 4WJs with the minor groove binder, DAPI. The CD data indicates that multi-PNA 4WJs possess altered minor groove dimensions that reduces DAPI binding affinity. Logic suggests that the minor groove of multi-PNA hybrids possess significant perturbations to the topology and local electrostatic environment that prevents proper binding/recognition by nucleases and thus enhances stability.

The expression of 'policy' in palliative care: A critical review.

The importance of 'policy' within palliative care has steadily increased over the past 25 years. Whilst this has been welcomed within the palliative care field and seen as a route to greater recognition, we focus here on a more critical perspective that challenge the effectiveness of a 'policy turn' in palliative care. Applying Bacchi's "What's the Problem Represented to Be?" (WPR) framework to data from a systematic search, we address the research question, "in what ways has 'policy' been articulated in palliative care literature?". The paper describes the construction of 'the problem' context and reflects critically on the robustness and pragmatic utility of such representations. In particular, we identify five elements as prominent and problematic: (1) a lack of empirical evidence that connects policy to practice; (2) the dominance of 'Global North' approaches; (3) the use of a policy narrative based on 'catastrophe' in justifying the need for palliative care; (4) the use of idealistic and aspirational 'calls to action'; and (5) a disengaged and antagonistic orientation to existing health systems. We conclude by suggesting that the efficacy of palliative care policy could be enhanced via greater emphases on 'Global South' perspectives, 'assets-based' approaches and attention to pragmatic implementation.

Clinical validation and implementation of droplet digital PCR for the detection of BRAF mutations from cell-free DNA.

Droplet digital PCR (ddPCR) has been demonstrated in many research studies to be a sensitive method in the analysis of circulating tumour DNA (ctDNA) for identifying mutations and tracking disease. The transition of ddPCR into the diagnostic setting requires a number of critical steps including the assessment of accuracy and precision and ultimately implementation into clinical use. Here we present the clinical validation of ddPCR for the detection of BRAF mutations (V600E and V600K) from plasma. We describe the performance characteristics assessed including the limit of blank, limit of detection, ruggedness, accuracy, precision and the effect of the matrix. Overall, each assay could achieve a limit of detection of 0.5% variant allele fraction and was highly accurate, with 100% concordance of results obtained from routine diagnostic testing of formalin fixed tumour samples or reference controls (n=36 for BRAF V600E and n=30 for BRAF V600K). Inter-laboratory reproducibility across 12 plasma samples for each assay was also assessed and results were 100% concordant. Overall, we report the successful validation and translation of a ddPCR assay into clinical routine practice.

Strong suppression of heat conduction in a laboratory replica of galaxy-cluster turbulent plasmas.

In conventional gases and plasmas, it is known that heat fluxes are proportional to temperature gradients, with collisions between particles mediating energy flow from hotter to colder regions and the coefficient of thermal conduction given by Spitzer's theory. However, this theory breaks down in magnetized, turbulent, weakly collisional plasmas, although modifications are difficult to predict from first principles due to the complex, multiscale nature of the problem. Understanding heat transport is important in astrophysical plasmas such as those in galaxy clusters, where observed temperature profiles are explicable only in the presence of a strong suppression of heat conduction compared to Spitzer's theory. To address this problem, we have created a replica of such a system in a laser laboratory experiment. Our data show a reduction of heat transport by two orders of magnitude or more, leading to large temperature variations on small spatial scales (as is seen in cluster plasmas).

Influence of opioid limiting legislation on patient narcotic usage and provider burden in orthopedic trauma.

OBJECTIVE: Opiate consumption in the United States has reached alarming levels. As a result, the state of Florida enacted House Bill 21 (HB21) in July 2018. Following HB21, we hypothesized total opioids prescribed would decrease, with a resulting increase in phone calls, unscheduled visits for pain control, and refills dispensed. DESIGN: Retrospective cohort study comparing opiate usage 6 months before and after HB21 enactment. SETTING: Single Level I academic trauma center. PARTICIPANTS: Patients with isolated lower extremity fractures who were treated with a single surgery. INTERVENTION: Opioid prescription limitations according to Florida's HB21. MAIN OUTCOME MEASURES: We compared morphine milligram equivalents (MMEs) dispensed at discharge, length of stay (LOS), readmissions, emergency room (ER) visits, calls for pain control, refills, and total MMEs dispensed for 3 months postoperatively. RESULTS: A total of 116 patients met inclusion criteria. Our results demonstrated a decrease in the median MMEs provided at discharge (288 vs. 184, p 0.005) and total MMEs dispensed (375 vs. 225, p 0.0003). There was no significant difference in LOS (2 vs. 2.5 days, p 0.979), unscheduled clinic visits for pain (two per group), ER visits for pain (eight per group), or phone calls for pain (13 vs. 9, p 0.344). There were no readmissions for pain control pre-HB21 and one post-HB21. The percentage of patients obtaining >1 refill decreased from 22.4 to 1.7 percent (p 0.002). CONCLUSIONS: Legislation restricting opioid pain medications may be effective in decreasing opiate use in orthopedic trauma patients while decreasing provider burden.

Higher quality of care in emergency departments with physiotherapy service models.

OBJECTIVE: To investigate the quality of care provided by EDs with physiotherapy services compared to those without, using established musculoskeletal process and outcome quality indicators (QIs). METHODS: An analysis was undertaken of prospective observational and chart audit data collected from 628 patients who presented with a musculoskeletal injury in any of the eight participating EDs in Queensland in 2016-2017. The care provided was scored against 46 musculoskeletal QIs. Quality of care was first compared between EDs with physiotherapists to EDs with a limited physiotherapy service, and second between EDs with primary contact physiotherapists to EDs without. χ2 and Fisher's exact tests were used to identify significant results. RESULTS: In the first comparison, EDs with physiotherapists performed significantly higher on 15 QIs and EDs with only limited physiotherapy performed higher on two QIs. In the second comparison, EDs with primary contact physiotherapists performed significantly higher on 17 QIs when compared to EDs without and three QIs demonstrated significance in favour of EDs without primary contact physiotherapists. Performance differences occurred across both process and outcome QIs, including musculoskeletal assessment, diagnostics, pain assessment and management, fracture management, medication safety, mobility, patient information, referrals and follow-up, re-presentations and patient experience. CONCLUSIONS: EDs with physiotherapists provide at least equivalent or higher quality of care for patients with musculoskeletal injuries than those EDs with limited access to physiotherapists. This may be because of their specialised training in musculoskeletal diagnosis and treatment, as well as the impact of teaching and mentoring for other ED clinicians.

An Applicant's Residency Program Region May Influence Where They Complete Fellowship.

The primary goal of this study was to determine if an applicant's geographic region of residency was associated with where they matched for fellowship. San Francisco Match (SF Match) provided results regarding applicant data and match results from 2014-2018 for orthopaedic subspecialties except hand and shoulder and elbow. Residency programs were divided into five regions: (Northeast [NE], Southeast [SE], Midwest [MW], Southwest [SW] and West [W]). The MW region had the fewest number of fellowship positions per applicant (0.62), the W region had the most (1.7). Applicants from each region were significantly (p < 0.0001) more likely to complete fellowship in the same region where they completed residency, and there were significant (p < 0.05) differences between regions for specific subspecialties. There are imbalances in terms of the number of applicants and specific fellowship spots available in each region. This imbalance seems important considering the strong associations found between the region in which an applicant completes residency and fellowship. Level of Evidence: Level 3. (Journal of Surgical Orthopaedic Advances 30(1):030-035, 2021).

Time-resolved turbulent dynamo in a laser plasma.

Understanding magnetic-field generation and amplification in turbulent plasma is essential to account for observations of magnetic fields in the universe. A theoretical framework attributing the origin and sustainment of these fields to the so-called fluctuation dynamo was recently validated by experiments on laser facilities in low-magnetic-Prandtl-number plasmas ([Formula: see text]). However, the same framework proposes that the fluctuation dynamo should operate differently when [Formula: see text], the regime relevant to many astrophysical environments such as the intracluster medium of galaxy clusters. This paper reports an experiment that creates a laboratory [Formula: see text] plasma dynamo. We provide a time-resolved characterization of the plasma's evolution, measuring temperatures, densities, flow velocities, and magnetic fields, which allows us to explore various stages of the fluctuation dynamo's operation on seed magnetic fields generated by the action of the Biermann-battery mechanism during the initial drive-laser target interaction. The magnetic energy in structures with characteristic scales close to the driving scale of the stochastic motions is found to increase by almost three orders of magnitude and saturate dynamically. It is shown that the initial growth of these fields occurs at a much greater rate than the turnover rate of the driving-scale stochastic motions. Our results point to the possibility that plasma turbulence produced by strong shear can generate fields more efficiently at the driving scale than anticipated by idealized magnetohydrodynamics (MHD) simulations of the nonhelical fluctuation dynamo; this finding could help explain the large-scale fields inferred from observations of astrophysical systems.

Surgical Management of a Displaced Posterior Column Pelvic Fracture Involving the Triradiate Cartilage in a 15-Year-Old Adolescent Boy: A Case Report.

CASE: A 15-year-old adolescent boy sustained a displaced acetabular fracture involving the ilioischial physis of the triradiate cartilage after a ground-level fall. The patient was managed operatively with open reduction and internal fixation and was followed for 9 months postoperatively. At 4 months postoperatively, the patient had resumed full weight bearing on the injured extremity and was participating in sports with no difficulties. CONCLUSION: Pediatric pelvic fractures through the triradiate cartilage are rare, and no consensus exists on the treatment of these injuries. Previous authors largely described nonoperative management with suboptimal outcomes. We present the case of a patient treated with initial operative fixation who successfully returned to full activities.

After-hours emergency department care: Does time or day of arrival affect survival?

OBJECTIVE: To determine whether after-hours presentation to EDs is associated with differences in 7-day and 30-day mortality. The influence of patient case-mix and workforce staffing differences are also explored. METHODS: We conducted a retrospective observational study of 3.7 million ED episodes across 30 public hospitals in Queensland, Australia during May 2013-September 2015 using routinely collected hospital data linked to hospital staffing data and the death registry. Episodes were categorised as within/after-hours using time of presentation. Staffing was derived from payroll records and explored by defining 11 staffing ratios. RESULTS: Weekend presentation was slightly more associated (7-day mortality odds ratio 1.05, 95% confidence interval [CI] 1.01-1.10) or no more associated (30-day mortality odds ratio 1.01, 95% CI 0.98-1.03) with death than weekday presentation. When weeknights are included in the 'after-hours' period, odds ratios are smaller, so that after-hours presentation is no more associated (7-day mortality odds ratio 1.03, 95% CI 0.99-1.08) or less associated (30-day mortality odds ratio 0.95, 95% CI 0.93-0.97) with death. No significant after-hours patient case-mix differences were observed between weekday and weekend presentations for 7-day mortality. In other combinations of outcome and after-hours definition, some differences (especially measures relating to severity of presenting condition) were found. Staffing ratios were not strongly associated with any within/after-hours differences in ED mortality. CONCLUSIONS: After-hours presentation on the weekend to an ED is associated with higher 7-day mortality even after controlling for case-mix.

Conformation and protein interactions of intramolecular DNA and phosphorothioate four-way junctions.

The objectives of this study are to evaluate the structure and protein recognition features of branched DNA four-way junctions in an effort to explore the therapeutic potential of these molecules. The classic immobile DNA 4WJ, J1, is used as a matrix to design novel intramolecular junctions including natural and phosphorothioate bonds. Here we have inserted H2-type mini-hairpins into the helical termini of the arms of J1 to generate four novel intramolecular four-way junctions. Hairpins are inserted to reduce end fraying and effectively eliminate potential nuclease binding sites. We compare the structure and protein recognition features of J1 with four intramolecular four-way junctions: i-J1, i-J1(PS1), i-J1(PS2) and i-J1(PS3). Circular dichroism studies suggest that the secondary structure of each intramolecular 4WJ is composed predominantly of B-form helices. Thermal unfolding studies indicate that intramolecular four-way junctions are significantly more stable than J1. The Tm values of the hairpin four-way junctions are 25.2° to 32.2°C higher than the control, J1. With respect to protein recognition, gel shift assays reveal that the DNA-binding proteins HMGBb1 and HMGB1 bind the hairpin four-way junctions with affinity levels similar to control, J1. To evaluate nuclease resistance, four-way junctions are incubated with DNase I, exonuclease III (Exo III) and T5 exonuclease (T5 Exo). The enzymes probe nucleic acid cleavage that occurs non-specifically (DNase I) and in a 5'→3' (T5 Exo) and 3'→5' direction (Exo III). The nuclease digestion assays clearly show that the intramolecular four-way junctions possess significantly higher nuclease resistance than the control, J1.

Teaching virtual protein-centric CUREs and UREs using computational tools.

Readily available, free, computational approaches, adaptable for topics accessible for first to senior year classes and individual research projects, emphasizing contributions of noncovalent interactions to structure, binding and catalysis were used to teach Course-based Undergraduate Research Experiences that fulfil generally accepted main CURE components: Scientific Background, Hypothesis Development, Proposal, Experiments, Teamwork, Data Analysis of quantitative data, Conclusions, and Presentation.

Trends in opioid prescribing in Australia: a systematic review.

Objective This review systematically identified studies that estimated the prevalence of prescription opioid use in Australia, assessed the prevalence estimates for bias and identified areas for future research. Methods Literature published after 2000 containing a potentially representative estimate of prescription opioid use in adults, in the community setting, in Australia was included in this review. Studies that solely assessed opioid replacement, illicit opioid usage or acute hospital in-patient use were excluded. Databases searched included PubMed, EMBASE, Web of Science and the grey literature. Results The search identified 2253 peer-reviewed publications, with 34 requiring full-text review. Of these, 20 were included in the final qualitative analysis, in addition to four publications from the grey literature. Most studies included analysed prescription claims data for medicines dispensed via Australia's national medicines subsidy scheme (the Pharmaceutical Benefits Scheme). Although data sources were good quality, all prevalence estimates were at least at moderate risk of bias, predominantly due to incompleteness of data or potential confounding. Included publications demonstrated a significant rise in opioid use up to 2017 (including a 15-fold increase in prescriptions dispensed over the 20 years to 2015), predominantly driven by a sharp rise in oxycodone use. Although opioid prescription numbers continue to escalate, usage, as measured by oral morphine equivalent per capita, may have plateaued since 2014. Codeine remains the most prevalently obtained opioid, followed by oxycodone and tramadol. There was a substantial delay (median 30 months; interquartile range 20-37 months) to publication of opioid usage data from time of availability. Conclusions Australia has experienced a marked increase in opioid prescribing since the 1990s. Current published literature is restricted to incomplete, delayed and historical data, limiting the ability of clinicians and policy makers to intervene appropriately. What is known about the topic? Opioid prescriptions in Australia have continued to increase since the 1990s and may be mirroring the epidemic being seen in the US. What does this paper add? This paper systematically identifies all publications that have examined the prevalence of prescription opioid use in Australia since 2000, and only identified prevalence estimates that were at moderate or high risk of bias, and found significant delays to publication of these estimates. What are the implications for practitioners? Because published literature on the prevalence of prescription opioid consumption is restricted to incomplete, delayed and historical data, the ability of clinicians and policy makers to appropriately intervene to curb prescription opioid use is limited. A national policy of real-time monitoring and reporting of opioid prescribing may support improvements in practice.

How the Reputation of Orthopaedic Residency Programs Is Associated with Orthopaedic Fellowship Match Results.

BACKGROUND: The primary goal of the present study was to determine if applicants from higher-ranking U.S. orthopaedic surgery residency programs match at a more desired position on their fellowship match-rank list compared with those applicants from lower-ranked residency programs. METHODS: San Francisco Match provided results regarding applicant data and match results from 2014 to 2018 for all orthopaedic subspecialties except the hand and the shoulder and elbow. Unmatched applicants and international medical graduates were excluded. Residency programs were divided into 5 tiers (with tier 1 being the highest-ranked residency programs and tier 5 being the lowest-ranked programs) on the basis of 2018 Doximity rankings of orthopaedic residency programs. Statistical analysis consisted of descriptive statistics, chi-square tests, and analysis of variance. RESULTS: Two thousand eight hundred and eleven applicants met inclusion criteria. Applicants from residency programs in tiers 1 and 2 applied to significantly fewer programs than those from tiers 3, 4, or 5 (p < 0.0001). Applicants from each tier were significantly more likely to attain interviews than applicants from all tiers below them (p < 0.01). Applicants from tier-1 residency programs matched at a significantly higher position on their rank list (p < 0.001) and were more desirably ranked by fellowship programs (p = 0.003) compared with all other tiers. CONCLUSIONS: Applicants from the highest-ranking residency programs apply to fewer programs, interview at a greater percentage of these programs, and are more likely to match to 1 of their top-ranking programs than applicants from lower-ranking programs. However, the association of the applicant match position with the program ranking appears to be most pronounced when it comes to fellowships selecting which applicants to interview. These findings may help future applicants when determining which programs to apply to during the match.

Controlled substance prescribing and education in orthopedic residencies: A program director survey.

BACKGROUND: Opioid misuse is currently plaguing the US. Efforts to reduce this include opioid prescribing education (OPE). Orthopaedic residents often prescribe opioids but, their education is unknown. METHODS: A survey was sent to orthoapedic residency program directors (PDs) regarding their program's controlled substance (CS) policies and knowledge of local CS regulations. RESULTS: There were 60 (36.8%) completed surveys. 54 (90.0%) programs allow resident outpatient opioid prescribing. Nine (16.7%) programs require individual DEA registration and 7 (13.0%) were unsure about DEA registrations. State laws regarding PDMP utilization and OPE for fully licensed physicians were correctly answered by 52 (86.7%) and 43 (71.6%), respectively. 27 (45.0%) programs had a mandatory OPE. Six (10.0%) PDs were unsure about a mandatory OPE. 16 (48.5%) programs that did not confirm an OPE were considering adding one. CONCLUSIONS: The majority of programs permit residents outpatient opioid prescribing; less than half provide mandatory OPE. Several PDs were unaware local CS prescribing regulations and education. This study demonstrates opportunities to improve OPE among orthopaedic residencies and PDs' knowledge regarding CS regulations.

Musculoskeletal injury quality outcome indicators for the emergency department.

High standards of care for musculoskeletal injuries presenting to emergency departments (ED) must be maintained despite financial constraints, the model of care in place, or the pressure to reach time-based performance measures. Outcome quality indicators (QIs) provide a tangible way of assessing and improving the outcomes of health-care delivery. This study aimed to develop a set of outcome QIs for musculoskeletal injuries in the ED that are meaningful, valid, feasible to collect, simple to use for clinical quality improvement and chosen by experts in the field. The study used a multi-phase mixed methods design, commencing with a systematic review of available outcome QIs. An expert panel then developed a set of preliminary QIs based on the available scientific evidence. Prospective observational data collection was undertaken across eight EDs with subsequent retrospective chart audits, follow-up phone calls and audit of administrative databases. After statistical analysis, validated results were presented to the expert panel who discussed, refined and formally voted on a final outcome QI set. A total of 41 preliminary outcome QIs were field tested in EDs, with data collected on 633 patients. Using the field study results, the expert panel voted 11 outcome QIs into the final set. These covered effectiveness of pain management, timeliness to discharge, re-presentations to the ED and unplanned visits to health professionals in the community, missed injuries, opioids side effects and the patient experience. An evidence-based set of outcome quality indicators is now available to support clinical quality improvement of musculoskeletal injury care in the ED setting.

Process quality indicators for musculoskeletal injuries in the emergency department.

OBJECTIVES: Measuring quality of care for musculoskeletal injuries presenting to the ED is important given their prevalence, variations in care, the associated morbidity and financial impacts and pressure to achieve time-based performance measures. Process quality indicators (QIs) provide a quantitative method to measure the actions taken during healthcare delivery. This study aimed to develop a set of process QIs to measure the quality of care for musculoskeletal injuries in the ED. METHODS: A multiphase mixed-methods study was undertaken from 2015 to 2018, commencing with a systematic review to identify existing musculoskeletal QIs. This review, along with current evidence regarding musculoskeletal injury management in the ED, informed an expert panel who developed a preliminary set of process QIs. The preliminary set was field tested at eight EDs in Queensland, Australia, to determine the validity, reliability, feasibility and usefulness of each QI. Prospective observational data collection and retrospective chart audits were used to score the process QIs. These results were presented to the expert panel who determined a final QI set. RESULTS: A total of 633 patients were recruited and 36 process QIs included in the final set. The QIs covered important domains of pain assessment and management, history taking and physical examination, appropriateness and timeliness of imaging, fracture management, mobility, patient information and discharge considerations including safety and referrals. The best performing QIs included the use of opioid sparing analgesics and avoiding prescription of 'just in case' opioids at discharge. The poorest performing QIs included the completion of spinal red flag questioning and referrals for fragility fractures. CONCLUSION: An evidence and best practice-based set of QIs has been developed to allow EDs to assess and quantify the quality of care for musculoskeletal presentations. This will allow EDs to compare and benchmark, leading to the optimisation of care for patients.