A national qualitative investigation of the impact of service change on doctors' training during Covid-19.

BACKGROUND: The Covid-19 crisis sparked service reconfigurations in healthcare systems worldwide. With postgraduate medical education sitting within these systems, service reconfigurations substantially impact trainees and their training environment. This study aims to provide an in-depth qualitative understanding of the impact of service reconfiguration on doctors' training during the pandemic, identifying opportunities for the future as well as factors that pose risks to education and training and how these might be mitigated. METHODS: Qualitative parallel multi-centre case studies examined three Trusts/Health Boards in two countries in the United Kingdom. Data were collected from online focus groups and interviews with trainees and supervisors using semi-structured interview guides (September to December 2020). A socio-cultural model of workplace learning, the expansive-restrictive continuum, informed data gathering, analysis of focus groups and coding. RESULTS: Sixty-six doctors participated, representing 25 specialties/subspecialties. Thirty-four participants were male, 26 were supervisors, 17 were specialty trainees and 23 were foundation doctors. Four themes described the impact of pandemic-related service reconfigurations on training: (1) Development of skills and job design, (2) Supervision and assessments, (3) Teamwork and communication, and (4) Workload and wellbeing. Service changes were found to both facilitate and hinder education and training, varying across sites, specialties, and trainees' grades. Trainees' jobs were redesigned extensively, and many trainees were redeployed to specialties requiring extra workforce during the pandemic. CONCLUSIONS: The rapid and unplanned service reconfigurations during the pandemic caused unique challenges and opportunities to doctors' training. This impaired trainees' development in their specialty of interest, but also presented new opportunities such as cross-boundary working and networking.

Selectivity of upper limb posterior root muscle reflexes via cervicothoracic spinal cord stimulation.

Recent studies have reported that transcutaneous spinal stimulation (tSCS) may facilitate improved upper limb motor function in those with incomplete tetraplesia. However, little is known about how tSCS engages upper limb motor pools. This study aimed to explore the extent to which discrete upper limb motor pools can be selectively engaged via altering stimulus location and intensity. 14 participants with intact nervous systems completed two test visits, during which posterior root-muscle reflexes (PRMR) were evoked via a 3x3 cathode matrix applied over the cervicothoracic spine. An incremental recruitment curve at C7 vertebral level was initially performed to attain minimal threshold intensity (MTI) in each muscle. Paired pulses (1ms square monophasic with inter-pulse interval of 50ms) were subsequently delivered at a frequency of 0.25Hz at two intensities (MTI and [Formula: see text]) across all nine locations. in a random order. Evoked response to the 1st (PRMR1) and 2nd (PRMR2) stimuli were recorded from four upper limb muscles. A significant effect of spinal level was observed in all muscles for PRMR1 with greater responses recorded more caudally. Unexpectedly, contralateral cathode placement significantly increased PRMR1 in Biceps Brachii (P=0.012), Flexor Carpi Radialis (P=0.035) and Abductor Pollicis Brevis (P=0.001). Post-activation depression (PAD) was also significantly increased with contralateral cathode placement in Biceps Brachii (P=0.001), Triceps Brachii (P=0.012) and Flexor Carpi Radialis (P=0.001). These results suggest that some level of unilateral motor pool selectivity may be attained via altering stimulus intensity and location during cervicothoracic tSCS.

Effect of Initial Knee angle and Arm Facilitation on biomechanics of the Sit-to-Stand movement.

Spinal cord injuries cause loss of muscle function and subsequently reduce independence. Therapeutic interventions such as transcutaneous spinal cord stimulation are increasingly being used to help improve motor functioning however, a comprehensive understanding of the biomechanical elements of movement may help optimize stimulation protocols. Twenty healthy participants completed five sit-to-stand (STS) transitions while initial knee angle and arm facilitation were altered. Electromyography (EMG) activation of four lower limb muscles and centre of pressure dynamics were recorded. Acute initial knee angles resulted in a change in duration of phases within the STS, and restrictive arm positioning caused the time to completion to increase (p=0.04). Muscle activation patterns across phases were compared and showed significant differences between phases in both the Tibialis Anterior and Rectus Femoris (p<0.006). Acute initial knee angles were also found to significantly increase Biceps Femoris activation across multiple phases (p=0.034). Altering the starting position and limb movement result in vastly different temporal and muscular strategies to complete the STS. Thus, joint angle and upper limb facilitation should be considered when designing rehabilitative interventions for clinical cohorts.

Integrating melt electrowriting and inkjet bioprinting for engineering structurally organized articular cartilage.

Successful cartilage engineering requires the generation of biological grafts mimicking the structure, composition and mechanical behaviour of the native tissue. Here melt electrowriting (MEW) was used to produce arrays of polymeric structures whose function was to orient the growth of cellular aggregates spontaneously generated within these structures, and to provide tensile reinforcement to the resulting tissues. Inkjet printing was used to deposit defined numbers of cells into MEW structures, which self-assembled into an organized array of spheroids within hours, ultimately generating a hybrid tissue that was hyaline-like in composition. Structurally, the engineered cartilage mimicked the histotypical organization observed in skeletally immature synovial joints. This biofabrication framework was then used to generate scaled-up (50 mm × 50 mm) cartilage implants containing over 3,500 cellular aggregates in under 15 min. After 8 weeks in culture, a 50-fold increase in the compressive stiffness of these MEW reinforced tissues were observed, while the tensile properties were still dominated by the polymer network, resulting in a composite construct demonstrating tension-compression nonlinearity mimetic of the native tissue. Helium ion microscopy further demonstrated the development of an arcading collagen network within the engineered tissue. This hybrid bioprinting strategy provides a versatile and scalable approach to engineer cartilage biomimetic grafts for biological joint resurfacing.

New patient-reported experience measure for children with allergic disease: development, validation and results from integrated care.

OBJECTIVES: To develop and validate a new allergy-specific patient-reported experience measure (PREM) for children and their parents, and to collect feedback in an integrated care setting. DESIGN: Two allergy-specific PREMs were produced using focus groups, cognitive testing, two prospective validation studies (collaboration: Royal College of Paediatrics and Child Health, Picker Institute Europe, Imperial College/London): 'Your Allergy Care', for children aged 8-16 years; 'Your Child's Allergy Care', for parents of children aged 0-7 years. SETTING: Community event, primary/secondary/tertiary allergy care settings. MAIN OUTCOME MEASURES: Performance of PREMs in validation study; reported experience of allergy care. PARTICIPANTS: 687 children with allergic conditions and their parents/carers. RESULTS: In total, 687 questionnaires were completed; 503/687 (253 child; 250 parent) for the final survey. In both surveys, demographic variations were not associated with differences in results. Although 71% of patients reported one or more allergic conditions (food allergy/eczema/hay fever/asthma), 62% required multiple visits before receiving final diagnosis. Overall, patient experience was good for communication with patient/parent, competence and confidence in ability, and 73% felt looked after 'very well' and 23% 'quite well'. Areas for improvement included communication with nurseries/schools, more information on side effects, allergic conditions and allergen/irritant avoidance. Allergy care in primary/emergency care settings was associated with higher problem-scores (worse experience) than in specialist clinics. CONCLUSIONS: These new PREMs will allow allergy-specific patient experience reporting for children and parents and help identification of priority areas for improvement and commissioning of care. Efforts towards better allergy care provision must be targeted at primary and emergency care settings and underpinned by improving communication between healthcare providers and the community.

Is there a relationship between surgical case volume and mortality in congenital heart disease services? A rapid evidence review.

OBJECTIVE: To identify and synthesise the evidence on the relationship between surgical volume and patient outcomes for adults and children with congenital heart disease. DESIGN: Evidence synthesis of interventional and observational studies. DATA SOURCES: MEDLINE, EMBASE, CINAHL, Cochrane Library and Web of Science (2009-2014) and citation searching, reference lists and recommendations from stakeholders (2003-2014) were used to identify evidence. STUDY SELECTION: Quantitative observational and interventional studies with information on volume of surgical procedures and patient outcomes were included. RESULTS: 31 of the 34 papers identified (91.2%) included only paediatric patients. 25 (73.5%) investigated the relationship between volume and mortality, 7 (20.6%) mortality and other outcomes and 2 (5.9%) non-mortality outcomes only. 88.2% were from the US, 97% were multicentre studies and all were retrospective observational studies. 20 studies (58.8%) included all congenital heart disease conditions and 14 (41.2%) single conditions or procedures. No UK studies were identified. Most studies showed a relationship between volume and outcome but this relationship was not consistent. The relationship was stronger for single complex conditions or procedures. We found limited evidence about the impact of volume on non-mortality outcomes. A mixed picture emerged revealing a range of factors, in addition to volume, that influence outcome including condition severity, individual centre and surgeon effects and clinical advances over time. CONCLUSIONS: The heterogeneity of findings from observational studies suggests that, while a relationship between volume and outcome exists, this is unlikely to be a simple, independent and directly causal relationship. The effect of volume on outcome relative to the effect of other, as yet undetermined, health system factors remains a complex and unresolved research question.

Demonstrating the effect of forensic firearm countermeasures: Bullet characteristics generated due to barrel modifications.

Forensic awareness and the declining availability of firearms have resulted in an increase in the use of modified and re-activated firearms in crime. Although some modifications are undertaken to simply acquire a functioning firearm, others are perpetrated as a direct forensic countermeasure to prevent the association between a firearm and a crime. This article describes the effects of these modifications on bullet striation patterns imparted from the barrel to a fired bullet. The key results indicated that the investigated modifications display assessable characteristics. The use of an oversized barrel imparted striations consistent with firing with the absence of typical rifling. Subsequent or consecutively fired bullets possessed striation variations, with the first showing the least evidence of striations. The application of a choke resulted in more obvious bullet elongation compared to a smoothbore barrel. The restriction caused merging of lands and groves of the imparted rifling and obscured their usual definition. Effects of breech adaption were also characterised by observing the buckling and enlargement of the cartridge case. This deformity of the cartridge case was most evident when the barrel pressure increased due to the presence of the choke. From this study it was evident that unique characteristic impressions associated with different modifications most commonly found in criminal investigations can be utilised by a forensic expert and impart significant intelligence to an investigation.

Does dropping day 5 PEP follow-up affect outcomes? An audit of HIV post-exposure prophylaxis at a central London sexual health clinic.

UK post-exposure prophylaxis (PEP) guidelines were updated by the British Association for Sexual Health and HIV (BASHH) in 2011. In 2013, we changed policy to omit day 5 PEP follow-up at 56 Dean Street as it was felt clinically unnecessary. This audit compares our performance against BASHH standards for PEP attenders during June 2012 and June 2013. We identified 162 PEP prescriptions; PEP assessment and appropriate sexually transmitted infection testing was done well. PEP completion rates and post-PEP HIV testing were lower than BASHH standards. Following omission of day 5 review, documentation that results have been checked was poor; however, attendance at follow-up was not adversely affected.

Parallel canonical Monte Carlo simulations through sequential updating of particles.

In canonical Monte Carlo simulations, sequential updating of particles is equivalent to random updating due to particle indistinguishability. In contrast, in grand canonical Monte Carlo simulations, sequential implementation of the particle transfer steps in a dense grid of distinct points in space improves both the serial and the parallel efficiency of the simulation. The main advantage of sequential updating in parallel canonical Monte Carlo simulations is the reduction in interprocessor communication, which is usually a slow process. In this work, we propose a parallelization method for canonical Monte Carlo simulations via domain decomposition techniques and sequential updating of particles. Each domain is further divided into a middle and two outer sections. Information exchange is required after the completion of the updating of the outer regions. During the updating of the middle section, communication does not occur unless a particle moves out of this section. Results on two- and three-dimensional Lennard-Jones fluids indicate a nearly perfect improvement in parallel efficiency for large systems.

Spatial updating grand canonical Monte Carlo algorithms for fluid simulation: generalization to continuous potentials and parallel implementation.

Spatial updating grand canonical Monte Carlo algorithms are generalizations of random and sequential updating algorithms for lattice systems to continuum fluid models. The elementary steps, insertions or removals, are constructed by generating points in space either at random (random updating) or in a prescribed order (sequential updating). These algorithms have previously been developed only for systems of impenetrable spheres for which no particle overlap occurs. In this work, spatial updating grand canonical algorithms are generalized to continuous, soft-core potentials to account for overlapping configurations. Results on two- and three-dimensional Lennard-Jones fluids indicate that spatial updating grand canonical algorithms, both random and sequential, converge faster than standard grand canonical algorithms. Spatial algorithms based on sequential updating not only exhibit the fastest convergence but also are ideal for parallel implementation due to the absence of strict detailed balance and the nature of the updating that minimizes interprocessor communication. Parallel simulation results for three-dimensional Lennard-Jones fluids show a substantial reduction of simulation time for systems of moderate and large size. The efficiency improvement by parallel processing through domain decomposition is always in addition to the efficiency improvement by sequential updating.

Scaling fields and pressure mixing in the Widom-Rowlinson model.

We address the issues of scaling fields and of pressure mixing in the penetrable sphere model. This model has an exact symmetry locus from which analytical results may be derived. Based on exact results, we demonstrate that the scaling fields are analytic functions of temperature and chemical potential only. We conclude that there is no pressure mixing in this model. Our findings are in accord with numerical simulations for the same model.

Simulation of symmetric tricritical behavior in electrolytes.

Despite extensive experimental, theoretical, and simulation efforts, a unified description of ionic phase transitions and criticality has not yet emerged. In this work, we investigate the phase behavior of the restricted primitive model of electrolyte solutions on the simple cubic lattice using grand canonical Monte Carlo simulations and finite-size scaling techniques. The phase diagram of the system is distinctly different from its continuum-space analog. We find order-disorder transitions for reduced temperatures T* < or approximately 0.51, where the ordered structures resemble those of the NaCl crystal. The order-disorder transition is continuous for 0.15 < or approximately T* < or approximately 0.51 and becomes first order at lower temperatures. The line of first-order transitions is a line of three-phase coexistence between a disordered and two ordered phases. The line of continuous, second-order transitions meets this line of triple points at a tricritical point at T* approximately equal to 0.1475. We locate the line of continuous transitions, and the line of triple points using finite-size scaling techniques. The tricritical temperature is estimated by extrapolation of the size-dependent tricritical temperatures obtained from a sixth-order Landau expansion of the free energy. Our calculated phase diagram is in qualitative agreement with mean-field theories.

The evolution of the emergency care practitioner role in England: experiences and impact.

BACKGROUND: The emergency care practitioner (ECP) is a generic practitioner who combines extended nursing and paramedic skills. The "new" role emerged out of changing workforce initiatives intended to improve staff career opportunities in the National Health Service and ensure that patients' health needs are assessed appropriately. OBJECTIVE: To describe the development of ECP Schemes in 17 sites, identify criteria contributing to a successful operational framework, analyse routinely collected data and provide a preliminary estimate of costs. METHODS: There were three methods used: (a) a quantitative survey, comprising a questionnaire to project leaders in 17 sites, and analysis of data collected routinely; (b) qualitative interpretation based on telephone interviews in six sites; and (c) an economic costing study. RESULTS: Of 17 sites, 14 (82.5%) responded to the questionnaire. Most ECPs (77.4%) had trained as paramedics. Skills and competencies have been extended through educational programmes, training, and assessment. Routine data indicate that 54% of patient contacts with the ECP service did not require a referral to another health professional or use of emergency transport. In a subset of six sites, factors contributing to a successful operational framework were strategic visions crossing traditional organisational boundaries and appropriately skilled workforce integrating flexibly with existing services. Issues across all schemes were patient safety, appropriate clinical governance, and supervision and workforce issues. On the data available, the mean cost per ECP patient contact is 24.00 pounds sterling, which is less than an ED contact of 55.00 pounds sterling. CONCLUSION: Indications are that the ECP schemes are moving forward in line with original objectives and could be having a significant impact on the emergency services workload.

Cholestatic pruritus - the role of cutaneous mast cells and nerves.

BACKGROUND: The pathogenesis of pruritus in cholestatic liver disease is poorly understood. Cutaneous mast cells and nerves are thought to contribute to pruritus in several dermatological diseases. AIM: To determine if cutaneous mast cell density, neural density and mast cell-neural interaction are increased in patients with pruritus and cholestatic liver disease. METHODS: Skin biopsy specimens from (i). patients with pruritus due to cholestatic liver disease (CLDP+; n = 6), (ii). patients with chronic liver disease without pruritus (CLDP-; n = 5), and (iii). healthy controls (n = 6) were studied. Biopsies were dual stained immunohistochemically for mast cells and nerves. RESULTS: Mast cell density in the control group was not significantly different from that in CLDP+ group or from that in the CLDP- group. Similarly neural density was not significantly different between groups when assessed either in terms of total nerve area, or in terms of the number of neural elements seen. The frequency of mast cell-nerve contact was not significantly different between groups. CONCLUSIONS: These findings suggest that mast cells, nerves or interaction between the two may not contribute to cholestatic pruritus. Therefore, therapies targeted at cutaneous mast cells or nerves are unlikely to be of benefit.

Isolation and endocrine regulation of an HMG-CoA synthase cDNA from the male Jeffrey pine beetle, Dendroctonus jeffreyi (Coleoptera: Scolytidae).

We have isolated a full length 3-hydroxy-3-methylglutaryl coenzyme A synthase (HMG-S) cDNA from the male Jeffrey pine beetle, Dendroctonus jeffreyi Hopkins, and studied the effects of topical applications of juvenile hormone III (JH III) on its expression. The predicted translation product of this apparently single copy gene has 63% and 58% identity with HMG-S1 and HMG-S2 from Blattella germanica (L.), and 61% identity with Drosophila melanogaster Hmgs. HMG-S transcript levels remain uniformly low in JH III-treated and control D. jeffreyi females, but are induced approximately 2.5- to 5-fold in JH III-treated males. JH III causes a dose- and time-dependent increase in HMG-S transcripts in the male metathoracic-abdominal region. Since monoterpenoid pheromone precursor synthesis and HMG-CoA reductase expression are under the control of JH III in the metathorax of Ips bark beetles, the observed HMG-S expression pattern suggests that the isoprenoid pathway is similarly important for semiochemical production in D. jeffreyi.

Effectiveness of screening and monitoring tests for diabetic retinopathy--a systematic review.

AIMS: To determine which screening and monitoring tests for diabetic retinopathy are most effective and under what circumstances. METHODS: A systematic review of the English language literature, published from 1983 to April 1999. RESULTS: Available studies are generally limited in their ability to answer the important questions on the effectiveness of tests for early detection of diabetic retinopathy. No randomized controlled trials were identified although primary studies exist for two screening tests: ophthalmoscopy, either direct or indirect, and retinal photography, using either mydriasis or non-mydriasis. Retinal photography under mydriasis appears to be the most effective test, with the majority reporting levels of sensitivity in excess of 80%. However effectiveness is compromised when photographs are ungradable. Ophthalmoscopy can also reach acceptable standards of sensitivity and specificity. CONCLUSION: Based on an assessment of available cohort studies, the most effective strategy for testing is the use of mydriatic retinal photography with the additional use of ophthalmoscopy for cases where photographs are ungradable. This does not exclude the use of ophthalmoscopy alone for opportunistic case finding but there is evidence of considerable variation in effectiveness of this test.

A systematic review of foot ulcer in patients with Type 2 diabetes mellitus. II: treatment.

AIM: To assess the value of treatments for foot ulcers in patients with Type 2 diabetes mellitus. METHODS: A systematic review of interventions to treat diabetic foot ulcers. RESULTS: The evidence base for treating infections and dressing wounds is poor. A number of new and potentially promising treatments are being developed but currently available studies are often small, inadequately powered and use different methods and outcomes. CONCLUSIONS: Given the prevalence, morbidity and healthcare costs of diabetic foot disease, it is surprising that available trials provide inadequate evidence to improve upon current empirically based treatment approaches. Substantial effort and resources should be deployed in order to investigate both new and existing treatments in a co-ordinated, systematic and consistent manner, so that a proper evidence base can be established for this important disease area.