Contribution of a bonded scholarship scheme to staffing rural health facilities.

BACKGROUND: Local and international research has identified rural origin as an important reason why healthcare professionals (HCPs) work in rural areas, and in South Africa (SA) considerable effort has gone into recruiting and training rural-origin students. However, there is little information in the SA literature on where graduates supported by these initiatives work, and whether they contribute to the rural workforce long term. OBJECTIVE: To determine the number of years that rural-origin Umthombo Youth Development Foundation (UYDF)-supported graduates of different disciplines worked at rural public healthcare facilities (PHCFs). METHODS: A retrospective descriptive study reviewed work record data of 405 UYDF graduates, to calculate the number of years they worked at a rural PHCF. Data were analysed descriptively and presented in tables with totals and percentages. RESULTS: Ninety percent (363/405) of UYDF-supported graduates returned to work at a rural PHCF. High percentages of social workers (85%), optometrists (80%), speech therapists, nurses (72%) and dental therapists (70%) worked for ≥5 years at a rural PHCF, while only 13% of audiologists, 14% of doctors, 29% of pharmacists, and 28% of dentists and occupational therapists worked at a rural PHCF for ≥5 years. Ten percent (42/405) of graduates did not work at a rural PHCF at all. A total of 110/124 (89%) of doctors supported by UYDF had worked at a rural PHCF, with 32% (40/124) working at a rural PHCF for ≥3 years. Overall, 54% of UYDF-supported graduates (219/405) worked for ≥3 years at a rural PHCF, and 38.5% (157/405) worked for ≥5 years at rural PHCFs. The majority of UYDF graduates had contributed towards long-term staffing of rural PHCFs. Lack of professional development opportunities at rural PHCFs as well as the reduced number of funded posts at rural PHCFs reduced the effectiveness of the UYDF initiative. CONCLUSION: The UYDF Scholarship Scheme has shown that investment in rural students through a bonded scholarship can contribute to staffing rural PHCFs, as >90% of graduates worked at rural PHCFs, and for some disciplines >70% of graduates worked for ≥5 years at a rural PHCF. Allied HCPs worked on average for longer periods at rural PHCFs than doctors.

Measurement of the decay of laser-driven linear plasma wakefields.

We present measurements of the temporal decay rate of one-dimensional (1D), linear Langmuir waves excited by an ultrashort laser pulse. Langmuir waves with relative amplitudes of approximately 6% were driven by 1.7J, 50fs laser pulses in hydrogen and deuterium plasmas of density n_{e0}=8.4×10^{17}cm^{-3}. The wakefield lifetimes were measured to be τ_{wf}^{H_{2}}=(9±2) ps and τ_{wf}^{D_{2}}=(16±8) ps, respectively, for hydrogen and deuterium. The experimental results were found to be in good agreement with 2D particle-in-cell simulations. In addition to being of fundamental interest, these results are particularly relevant to the development of laser wakefield accelerators and wakefield acceleration schemes using multiple pulses, such as multipulse laser wakefield accelerators.

NTRK expression is common in xanthogranuloma and is associated with the solitary variant.

BACKGROUND: Previously identified mutually-exclusive driver genes in juvenile xanthogranuloma (JXG) and adult xanthogranuloma (AXG) include mutations in MAP kinase pathway genes such as MAP2K1, BRAF, ARAF, KRAS, NRAS, PIK3CD as well as fusions in BRAF and ALK, with a subset of cases with no identified driver yet. NTRK fusion has been identified in rare cases. METHODS: We identified two consecutive index cases of localized JXG or AXG with NTRK1 fusion by next-generation sequencing (NGS) and confirmed by pan-NTRK immunostain. We expanded the study to a total of 50 cases of JXG and AXG using screening by pan-NTRK immunostain. We confirmed the specificity of our approach with negative results in 5 cases of histiocytic neoplasia lacking an NTRK fusion by NGS and 14 cases of non-neoplastic histiocytic disease. RESULTS: We found 23 cases of JXG or AXG with overexpression of NTRK by immunostain, and these cases were restricted to localized disease (23 of 43 cases, 53.5%) rather than disseminated disease (zero of seven cases). CONCLUSIONS: NTRK expression is common in JXG or AXG and associated with localized rather than disseminated disease. We speculate that the potential importance of this in JXG and AXG has not been previously appreciated due to the tendency to focus sequencing studies on disseminated disease. We confirm the presence of an NTRK1 fusion in two positive cases by NGS, however, additional genetic studies are necessary to further explore this.

All-Optical GeV Electron Bunch Generation in a Laser-Plasma Accelerator via Truncated-Channel Injection.

We describe a simple scheme, truncated-channel injection, to inject electrons directly into the wakefield driven by a high-intensity laser pulse guided in an all-optical plasma channel. We use this approach to generate dark-current-free 1.2 GeV, 4.5% relative energy spread electron bunches with 120 TW laser pulses guided in a 110 mm-long hydrodynamic optical-field-ionized plasma channel. Our experiments and particle-in-cell simulations show that high-quality electron bunches were only obtained when the drive pulse was closely aligned with the channel axis, and was focused close to the density down ramp formed at the channel entrance. Start-to-end simulations of the channel formation, and electron injection and acceleration show that increasing the channel length to 410 mm would yield 3.65 GeV bunches, with a slice energy spread ∼5×10^{-4}.

Dark Energy Survey Year 1 Results: Cosmological Constraints from Cluster Abundances, Weak Lensing, and Galaxy Correlations.

We present the first joint analysis of cluster abundances and auto or cross-correlations of three cosmic tracer fields: galaxy density, weak gravitational lensing shear, and cluster density split by optical richness. From a joint analysis (4×2pt+N) of cluster abundances, three cluster cross-correlations, and the auto correlations of the galaxy density measured from the first year data of the Dark Energy Survey, we obtain Ω_{m}=0.305_{-0.038}^{+0.055} and σ_{8}=0.783_{-0.054}^{+0.064}. This result is consistent with constraints from the DES-Y1 galaxy clustering and weak lensing two-point correlation functions for the flat νΛCDM model. Consequently, we combine cluster abundances and all two-point correlations from across all three cosmic tracer fields (6×2pt+N) and find improved constraints on cosmological parameters as well as on the cluster observable-mass scaling relation. This analysis is an important advance in both optical cluster cosmology and multiprobe analyses of upcoming wide imaging surveys.

The training of healthcare professionals: An expense or an investment?

BACKGROUND: There is little information on the financial return of investment when funding the tertiary education of healthcare professionals (HCPs) in South Africa (SA). OBJECTIVES: To assess the cost-benefit of the Umthombo Youth Development Foundation (UYDF) scholarship scheme, which has supported the training of HCPs from rural areas in KwaZulu-Natal Province, SA, for the past 19 years, and to establish whether it is a worthwhile investment. METHODS: This was an economic analysis to estimate the costs and economic value of UYDF's investment in the training of HCPs, using a deterministic model developed in Excel 2010 (Microsoft, USA) to analyse the UYDF's historical, numerical and economic data. Costs were measured in monetary terms, and a rate of return on investment was calculated over the working life of HCPs who had been supported by the UYDF. RESULTS: With a >90% pass rate, the total cost of training the 254 graduates supported by the UYDF from 2009 to 2015 was estimated to be ZAR186 million. Graduates are expected to generate an estimated ZAR15 billion in lifetime earnings, which is equal to ZAR4 billion at 2015 prices, and represents an internal rate of return of 63%. Income tax paid on future earnings will be ~ZAR4 billion, assuming a 20 - 30% tax rate. CONCLUSIONS: The analysis has shown that the cost of HCPs' education, where the annual pass rate is >90%, and >98% of graduates are employed, is an excellent investment. Consideration should be given to finding ways of improving the pass rate at institutions of higher learning and ensuring that graduates obtain meaningful employment if such returns on investment are to be seen on a national level.

Defining adaptive capacity in healthcare: A new framework for researching resilient performance.

Resilience principles show promise for improving the quality of healthcare, but there is a need for further theoretical development to include all levels and scales of activity across the whole healthcare system. Many existing models based on engineering concepts do not adequately address the prominence of social, cultural and organisational factors in healthcare work. Promising theoretical developments include the four resilience potentials, the CARE model and the Moments of Resilience Model, but they are all under specified and in need of further elaboration. This paper presents the Integrated Resilience Attributes Framework in which these three theoretical perspectives are integrated to provide examples of anticipating, responding, monitoring and learning at different scales of time and space. The framework is intended to guide researchers in researching resilience, especially the linkages between resilience at different scales of time and space across the whole healthcare system.

Beyond 'find and fix': improving quality and safety through resilient healthcare systems.

OBJECTIVE: The aim was to develop a method based on resilient healthcare principles to proactively identify system vulnerabilities and quality improvement interventions. DESIGN: Ethnographic methods to understand work as it is done in practice using concepts from resilient healthcare, the Concepts for Applying Resilience Engineering model and the four key activities that are proposed to underpin resilient performance-anticipating, monitoring, responding and learning. SETTING: Accident and Emergency Department (ED) and the Older People's Unit (OPU) of a large teaching hospital in central London. PARTICIPANTS: ED-observations 104 h, and 14 staff interviews. OPU-observations 60 h, and 15 staff interviews. RESULTS: Data were analysed to identify targets for quality improvement. In the OPU, discharge was a complex and variable process that was difficult to monitor. A system to integrate information and clearly show progress towards discharge was needed. In the ED, patient flow was identified as a complex high-intensity activity that was not supported by the existing data systems. The need for a system to integrate and display information about both patient and organizational factors was identified. In both settings, adaptive capacity was limited by the absence of systems to monitor the work environment. CONCLUSIONS: The study showed that using resilient healthcare principles to inform quality improvement was feasible and focused attention on challenges that had not been addressed by traditional quality improvement practices. Monitoring patient and workflow in both the ED and the OPU was identified as a priority for supporting staff to manage the complexity of the work.

Nursing teamwork in the care of older people: A mixed methods study.

Healthcare is increasingly complex and requires the ability to adapt to changing demands. Teamwork is essential to delivering high quality care and is central to nursing. The aims of this study were to identify the processes that underpin nursing teamwork and how these affect the care of older people, identify the relationship between perceived teamwork and perceived quality of care, and explore in depth the experience of working in nursing teams. The study was carried out in three older people's wards in a London teaching hospital. Nurses and healthcare assistants completed questionnaires (n = 65) on known dynamics of teamwork (using the Nursing Teamwork Survey) together with ratings of organisational quality (using an adapted AHRQ HSPS scale). A sample (n = 22; 34%) was then interviewed about their perceptions of care, teamwork and how good outcomes are delivered in everyday work. Results showed that many care difficulties were routinely encountered, and confirmed the importance of teamwork (e.g. shared mental models of tasks and team roles and responsibilities, supported by leadership) in adapting to challenges. Perceived quality of teamwork was positively related to perceived quality of care. Work system variability and the external environment influenced teamwork, and confirmed the importance of team adaptive capacity. The CARE model shows the centrality of teamwork in adapting to variable demand and capacity to deliver care processes, and the influence of broader system factors on teamworking.

Knowledge of final-year medical students at the University of KwaZulu-Natal about family medicine, and long-term career choices

Background: While international experience suggests that well-trained primary care physicians improve the quality and cost effectiveness of health care, family medicine (FM) as the discipline of the specialist primary care physician appears to not be an attractive career for medical graduates in South Africa (SA). The aim of this study was to establish final-year medical students' knowledge about FM and its relevance to the healthcare system, explore their perceptions of the discipline's relevance, and identify their specialty preference.Methods: This was a descriptive study conducted amongst final-year medical students at the University of KwaZulu-Natal (UKZN) in 2017 attheconclusion of their seven-week FM module. Data were collected using a self-administered questionnaire and results were analysed descriptively.Results: The response rate of completed questionnaires was 80.2% (157/196). Students reported limited exposure to FM in their early undergraduate years and low levels of awareness about essential public health programmes. Students showed good awareness of the six roles of family physicians (FPs), but FM was only the sixth most popular choice for specialisation. Conclusions: In general, students had favourable views concerning FM and its role in the future of healthcare delivery in SA,although their knowledge of essential health programmes was poor. The majority of students had limited interest in pursuing a career in FM. A key recommendation to address these issues is to introduce FM into the curriculum earlier, to cover the key roles of the FP, and provide teaching that highlights the relevance of FM to health system programmes

A review of the management and outcome of patients admitted with cryptococcal meningitis at a regional hospital in KwaZulu-Natal province

Background: South Africa has 7.06 million people who are HIV-positive, with those having a low CD4 count being susceptible to cryptococcal meningitis (CCM), which has an estimated mortality of 30­50%. This study aimed to establish the outcome of patients admitted with CCM to a regional hospital in Durban between June 2015 and May 2016, and the extent to which the National Department of Health (NDoH) protocol was adhered to in managing their condition. Method: This retrospective observational descriptive study reviewed the records of patients ≥ 12 years old admitted with CCM between June 2015 and May 2016, from which their demographic and medical data were extracted.Results: Seventy-six complete records were found of which 49 were men and 27 were women. The average CD4 count was 55.9 cells/mm3, 85.5% were treated with intravenous amphotericin B and high-dose oral fluconazole, 6.7% received only amphotericin B and 5.2% received only fluconazole. There was an in-hospital mortality of 31.6%, and the NDoH protocol was adhered to in 72.4% (55/76) of patients. There was, however, no significant difference in outcome between those who were and were not managed as per the protocol (p = 0.177).Discussion and conclusion: In-hospital mortality for CCM continues to be significant despite high rates of adherence to the NDoH protocol in the majority of patients. For this to be addressed, early diagnosis of HIV and initiation of ART to prevent the profound immunosuppression is essential

Projected speciality career choices among undergraduate dental students in Scotland.

Background Despite increased numbers of dental specialists, around 90% of dentists in the UK continue to work in general practice. Previous research shows that undergraduate students indicate interest in speciality careers, however few studies have explored which specialties are of interest, when and why. The aim of this study was to explore whether Bachelor of Dental Surgery (BDS) undergraduates attending Glasgow Dental School (GDS) indicate a desire to pursue a speciality career, why, and the extent to which they feel prepared in this regard.Method We conducted an internet-based survey (response rate 81%; n = 331) of all GDS students between October and November 2016.Results One hundred and eighty-six students (56%) had decided to specialise. Seventy-eight percent of these students cited enjoyment of that service, or types of patient seen, as the single most influencing factor on their choice. Oral surgery was the most popular choice where one was indicated (35%), followed by orthodontics (26%). Just 14% of BDS4-5 students felt sufficiently exposed to cases in their chosen speciality. A large majority (88%) said they would like information regarding speciality pathways at BDS3 or before.Conclusions Educators should provide undergraduate students with information about specialties in a structured way, so that they can consider available options.

Rotationally inelastic collisions of excited NaK and NaCs molecules with noble gas and alkali atom perturbers.

We report measurements of rate coefficients at T ≈ 600 K for rotationally inelastic collisions of NaK molecules in the 2(A)1Σ+ electronic state with helium, argon, and potassium atom perturbers. Several initial rotational levels J between 14 and 44 were investigated. Collisions involving molecules in low-lying vibrational levels (v = 0, 1, and 2) of the 2(A)1Σ+ state were studied using Fourier-transform spectroscopy. Collisions involving molecules in a higher vibrational level, v = 16, were studied using pump/probe, optical-optical double resonance spectroscopy. In addition, polarization spectroscopy measurements were carried out to study the transfer of orientation in these collisions. Many, but not all, of the measurements were carried out in the "single-collision regime" where more than one collision is unlikely to occur within the lifetime of the excited molecule. The analysis of the experimental data, which is described in detail, includes an estimate of effects of multiple collisions on the reported rate coefficients. The most significant result of these experiments is the observation of a strong propensity for ΔJ = even transitions in collisions involving either helium or argon atoms; the propensity is much stronger for helium than for argon. For the initial rotational levels studied experimentally, almost all initial orientation is preserved in collisions of NaK 2(A)1Σ+ molecules with helium. Roughly between 1/3 and 2/3 of the orientation is preserved in collisions with argon, and almost all orientation is destroyed in collisions with potassium atoms. Complementary measurements on rotationally inelastic collisions of NaCs 2(A)1Σ+ with argon do not show a ΔJ = even propensity. The experimental results are compared with new theoretical calculations of collisions of NaK 2(A)1Σ+ with helium and argon. The calculations are in good agreement with the absolute magnitudes of the experimentally determined rate coefficients and accurately reproduce the very strong propensity for ΔJ = even transitions in helium collisions and the less strong propensity for ΔJ = even transitions in argon collisions. The calculations also show that collisions with helium are less likely to destroy orientation than collisions with argon, in agreement with the experimental results.

Implementing resilience engineering for healthcare quality improvement using the CARE model: a feasibility study protocol.

BACKGROUND: Resilience engineering (RE) is an emerging perspective on safety in complex adaptive systems that emphasises how outcomes emerge from the complexity of the clinical environment. Complexity creates the need for flexible adaptation to achieve outcomes. RE focuses on understanding the nature of adaptations, learning from success and increasing adaptive capacity. Although the philosophy is clear, progress in applying the ideas to quality improvement has been slow. The aim of this study is to test the feasibility of translating RE concepts into practical methods to improve quality by designing, implementing and evaluating interventions based on RE theory. The CARE model operationalises the key concepts and their relationships to guide the empirical investigation. METHODS: The settings are the Emergency Department and the Older Person's Unit in a large London teaching hospital. Phases 1 and 2 of our work, leading to the development of interventions to improve the quality of care, are described in this paper. Ethical approval has been granted for these phases. Phase 1 will use ethnographic methods, including observation of work practices and interviews with staff, to understand adaptations and outcomes. The findings will be used to collaboratively design, with clinical staff in interactive design workshops, interventions to improve the quality of care. The evaluation phase will be designed and submitted for ethical approval when the outcomes of phases 1 and 2 are known. DISCUSSION: Study outcomes will be knowledge about the feasibility of applying RE to improve quality, the development of RE theory and a validated model of resilience in clinical work which can be used to guide other applications. Tools, methods and practical guidance for practitioners will also be produced, as well as specific knowledge of the potential effectiveness of the implemented interventions in emergency and older people's care. Further studies to test the application of RE at a larger scale will be required, including studies of other healthcare settings, organisational contexts and different interventions.

Large-Scale Distribution of Total Mass versus Luminous Matter from Baryon Acoustic Oscillations: First Search in the Sloan Digital Sky Survey III Baryon Oscillation Spectroscopic Survey Data Release 10.

Baryon acoustic oscillations in the early Universe are predicted to leave an as yet undetected signature on the relative clustering of total mass versus luminous matter. A detection of this effect would provide an important confirmation of the standard cosmological paradigm and constrain alternatives to dark matter as well as nonstandard fluctuations such as compensated isocurvature perturbations (CIPs). We conduct the first observational search for this effect, by comparing the number-weighted and luminosity-weighted correlation functions, using the SDSS-III BOSS Data Release 10 CMASS sample. When including CIPs in our model, we formally obtain evidence at 3.2σ of the relative clustering signature and a limit that matches the existing upper limits on the amplitude of CIPs. However, various tests suggest that these results are not yet robust, perhaps due to systematic biases in the data. The method developed in this Letter used with more accurate future data such as that from DESI, is likely to confirm or disprove our preliminary evidence.

Evaluating multisite multiprofessional simulation training for a hyperacute stroke service using the Behaviour Change Wheel.

BACKGROUND: Stroke is a clinical priority requiring early specialist assessment and treatment. A London (UK) stroke strategy was introduced in 2010, with Hyper Acute Stroke Units (HASUs) providing specialist and high dependency care. To support increased numbers of specialist staff, innovative multisite multiprofessional simulation training under a standard protocol-based curriculum took place across London. This paper reports on an independent evaluation of the HASU training programme. The main aim was to evaluate mechanisms for behaviour change within the training design and delivery, and impact upon learners including potential transferability to the clinical environment. METHODS: The evaluation utilised the Behaviour Change Wheel framework. Procedures included: mapping training via the framework; examination of course material; direct and video-recorded observations of courses; pre-post course survey sheet; and follow up in-depth interviews with candidates and faculty. RESULTS: Patient management skills and trainee confidence were reportedly increased post-course (post-course median 6 [IQ range 5-6.33]; pre-course median 5 [IQ range 4.67-5.83]; z = 6.42, P < .001). Thematic analysis showed that facilitated 'debrief' was the key agent in supporting both clinical and non-clinical skills. Follow up interviews in practice showed some sustained effects such as enthusiasm for role, and a focus on situational awareness, prioritization and verbalising thoughts. Challenges in standardising a multi-centre course included provision for local context/identity. CONCLUSIONS: Pan-London simulation training under the London Stroke Model had positive outcomes in terms of self-reported skills and motivation. These effects persisted to an extent in practice, where staff could recount applications of learning. The evaluation demonstrated that a multiple centre simulation programme congruent with clinical practice can provide valuable standard training opportunities that support patient care.

Review of simulation studies in anaesthesia journals, 2001-2010: mapping and content analysis.

Despite widespread adoption of simulation-based training in medical education, there remains scepticism about its cost-effectiveness and long-term impact on patient outcomes. Medical simulation is well established in anaesthesia where it is considered an important educational tool. This review of key clinical anaesthesia literature is used as a case study of clinician uptake within a specialty and to investigate evidence for translational impact using both qualitative and quantitative data. We examined high-impact journal publications from 2001 to 2010 and extracted data covering authors, institutions, simulation modality, purposes of simulation, and various aspects of study design/methodology used. A total of 320 papers containing primary data were included. We found broad acceptance and uptake in anaesthesia with an increase in publications over the time period, mainly attributable to a steady increase in manikin studies. Studies using manikin technology (130/320; 41%) are distinguished as skills/performance studies (76; 58%) and studies focused on the use, testing, and validation of equipment (52; 40%). A total of 110 papers (34%) assessed the performance of technical and non-technical skills (68% and 32%, respectively). Growth in the use of structured checklists/validated tools to assess performance is mainly observed in the non-technical domain. Only 10% of these papers include follow-up data from the clinical environment. There is a lack of research examining performance transfer, sustainability, and direct patient outcomes and experiences. These publication patterns are instructive for those involved in medical educational and for other clinical specialties developing simulation.

The EEL-1 ubiquitin ligase promotes DNA damage-induced germ cell apoptosis in C. elegans.

E3 ubiquitin ligases target a growing number of pro- and anti-apoptotic proteins, including tumour suppressor p53, caspases, and the Bcl-2 family. The core apoptosis pathway is well conserved between mammals and Caenorhabditis elegans, but the extent to which ubiquitin ligases regulate apoptotic cell death is not known. To investigate the role of E3 ligases in apoptosis, we inhibited 108 of the 165 predicted E3 ubiquitin ligase genes by RNA interference and quantified apoptosis in the C. elegans germline after genotoxic stress. From this screen, we identified the homologous to E6-associated protein C terminus-domain E3 ligase EEL-1 as a positive regulator of apoptosis. Intriguingly, the human homologue of EEL-1, Huwe1/ARF-BP1/Mule/HectH9, has been reported to possess both pro- and anti-apoptotic functions through its ability to stimulate Mcl-1 and p53 degradation, respectively. Here, we demonstrate that eel-1 is required to promote DNA damage-induced germ cell apoptosis, but does not have a role in physiological germ cell apoptosis or developmental apoptosis in somatic tissue. Furthermore, eel-1 acts in parallel to the p53-like gene cep-1 and intersects the core apoptosis pathway upstream of the Bcl-2/Mcl-1 orthologue ced-9. Although ee1-1 mutants exhibit hypersensitivity to genotoxic stress they do not appear to be defective in DNA repair, suggesting a distinct role for EEL-1 in promoting damage-induced apoptosis in the germline.