Complex conversations in a healthcare setting: experiences from an interprofessional workshop on clinician-patient communication skills.

BACKGROUND: Communication is pivotal to the effective care and treatment of patients in our health care systems. Despite this understanding, clinicians are not sufficiently educated to confidently conduct complex discussions with patients. Communication skills workshops have been shown to be an effective educational format to improve clinician skills. However, despite the increasing interprofessional focus within modern medicine, there have been few studies looking at interprofessional communication workshops. METHODS: A qualitative study was conducted to assess how an interprofessional communication skills workshop affected the communication skills of clinicians at a tertiary health service. Pre- and post-workshop surveys were undertaken by participants, followed by focus group interviews eight-weeks post workshop. RESULTS: Clinicians were able to incorporate learnt communication skills into their daily practice. This was associated with an improvement in confidence of clinicians in having complex discussions, in addition to a reduction in the burden of having complex discussions. Participants responded positively to the interdisciplinary format, reporting benefits from the learning experience that translated into daily practice. CONCLUSION: Clinicians' communication skills in conducting complex clinician-patient conversations can be improved by participation in interprofessional communication skills workshops. We identified that the interprofessional aspect of the workshops not only improved interprofessional understanding and relationships, but also developed increased self-awareness during complex discussions, and reduced the sense of burden felt by clinicians.

The role of data custodians in establishing and maintaining social licence for health research.

In this article we explore the role of data custodians in establishing and maintaining social licence for the use of personal information in health research. Personal information from population-level data collections can be used to make significant contributions to health and medical research, but this use is dependent on community acceptance or a social licence. We conducted semi-structured interviews with data custodians across Australia to better understand data custodians' views on their roles and responsibilities. This inductive, thematic analysis of the interview data focuses on three factors that contribute to social licence - reciprocity, non-exploitation and the public good. While the data custodians interviewed did not explicitly frame their role in the context of social licence, their descriptions of their roles and responsibilities clearly indicated that they did have some role to play in building and maintaining social licence.

Authorising the Release of Data without Consent for Health Research: The Role of Data Custodians and HRECs in Australia.

In Australia, access to administrative data for research without consent invokes a plethora of governance requirements. Whether these requirements are met is assessed by at least one human research ethics committee (HREC) and each of the custodians of the relevant data collections. In this article, we examined and compared the decision-making processes of data custodians and HRECs. These processes were investigated using three case studies and qualitative interviews with data custodians around Australia. The investigation demonstrated that there was significant overlap and duplication in the review of applications for access to data without consent between HRECs and data custodians. This was the result of overlapping requirements in the relevant legislation and policies with those in the National Statement for Ethical Conduct in Human Research 2007 (updated 2018) as well as confusion about the distinct roles of HRECs and data custodians.

Data Custodians and the Decision-making Process: Releasing Data for Research.

The empirical research presented in this article was prompted by concerns expressed by researchers about the decision-making processes of government data custodians. Data custodians are responsible for the collection, use and disclosure of vast collections of personal information, including the release of data from these collections for research. Researchers were concerned that the decision-making processes were time-consuming, complex and not transparent. The authors sought the views of data custodians in response, exploring the issues from the other side of the data divide. The majority of the 13 data custodians interviewed for this project were located in government sector agencies and their decision-making process was thus highly regulated and constrained by principles of administrative law. They did, however, have many thoughtful suggestions for change to improve the experience for all the stakeholders involved in the process of seeking and granting access to government-held data collections for research.

An evaluation of a data linkage training workshop for research ethics committees.

BACKGROUND: In Australia research projects proposing the use of linked data require approval by a Human Research Ethics Committee (HREC). A sound evaluation of the ethical issues involved requires understanding of the basic mechanics of data linkage, the associated benefits and risks, and the legal context in which it occurs. The rapidly increasing number of research projects utilising linked data in Australia has led to an urgent need for enhanced capacity of HRECs to review research applications involving this emerging research methodology. The training described in this article was designed to respond to an identified need among the data linkage units in the Australian Population Health Research Network (PHRN) and HREC members in Australia. METHODS: Five one-day face to face workshops were delivered in the study period to a total of 98 participants. Participants in the workshops represented all six categories of HREC membership composition listed in the National Health and Medical Research Centres' (NHMRC) National Statement on Ethical Conduct in Human Research. Participants were assessed at three time points, prior to the training (T1), immediately after the training (T2) and 8 to 17 months after the training (T3). RESULTS: Ninety participants completed the pre and post questionnaires; 58 of them completed the deferred questionnaire. Participants reported significant improvements in levels of knowledge, understanding and skills in each of the eight areas evaluated. The training was beneficial for those with prior experience in the area of ethics and data linkage as well as those with no prior exposure. CONCLUSIONS: Our preliminary work in this area demonstrates that the provision of intensive face to face ethics training in data linkage is feasible and has a significant impact on participant's confidence in reviewing HREC applications.

Evaluation in health promotion: thoughts from inside a human research ethics committee.

Health promotion research, quality improvement and evaluation are all activities that raise ethical issues. In this paper, the Chair and a member of human resear ch ethics committees provide an insiders' point of view on how to demonstrate ethical conduct in health promotion research and quality improvement. Several common issues raised by health promotion research and evaluation are discussed including researcher integrity, conflicts of interest, use of information, consent and privacy.

Government databases and public health research: facilitating access in the public interest.

Access to datasets of personal health information held by government agencies is essential to support public health research and to promote evidence-based public health policy development. Privacy legislation in Australia allows the use and disclosure of such information for public health research. However, access is not always forthcoming in a timely manner and the decision-making process undertaken by government data custodians is not always transparent. Given the public benefit in research using these health information datasets, this article suggests that it is time to recognise a right of access for approved research and that the decisions, and decision-making processes, of government data custodians should be subject to increased scrutiny. The article concludes that researchers should have an avenue of external review where access to information has been denied or unduly delayed.

Privacy protectionism and health information: is there any redress for harms to health?

Health information collected by governments can be a valuable resource for researchers seeking to improve diagnostics, treatments and public health outcomes. Responsible use requires close attention to privacy concerns and to the ethical acceptability of using personal health information without explicit consent. Less well appreciated are the legal and ethical issues that are implicated when privacy protection is extended to the point where the potential benefits to the public from research are lost. Balancing these issues is a delicate matter for data custodians. This article examines the legal, ethical and structural context in which data custodians make decisions about the release of data for research. It considers the impact of those decisions on individuals. While there is strong protection against risks to privacy and multiple avenues of redress, there is no redress where harms result from a failure to release data for research.

Bilateral anterior capsulotomy for intractable depression.

A group of eight patients with severe depression lasting 6 years or longer were treated with anterior capsulotomy and followed prospectively. Stereotactic surgery was used to produce radiofrequency lesions in the anterior limbs of both internal capsules. For all patients, there are follow-up data for at least 24 months. At 24-to-36 months postoperatively, four patients were either not-depressed or mildly depressed; one was mildly-to-moderately depressed; one was moderately-to-severely depressed; and only one remained severely depressed. One patient developed a progressive vascular dementia with parkinsonism caused by autopsy-proven arteriolosclerosis.

Reconsidering the value of consent in biobank research.

Biobanks for long-term research pose challenges to the legal and ethical validity of consent to participate. Different models of consent have been proposed to answer some of these challenges. This paper contributes to this discussion by considering the meaning and value of consent to participants in biobanks. Empirical data from a qualitative study is used to provide a participant view of the consent process and to demonstrate that, despite limited understanding of the research, consent provides the research participants with some level of control and a form of self determination that they value. Participation is framed as a moral act of a responsible citizen providing reinforcement of self identity. Consent symbolizes the trust invested in researchers and research institutions to use the biobank for the public good. The paper argues that consent continues to play an important role in biobank participation and that a participant view should inform proposals to modify consent processes.

Cord blood maternal microchimerism following unrelated cord blood transplantation.

Cord blood transplantation (CBT) is associated with low risk of leukemia relapse. Mechanisms underlying antileukemia benefit of CBT are not well understood, however a previous study strongly but indirectly implicated cells from the mother of the cord blood (CB) donor. A fetus acquires a small number of maternal cells referred to as maternal microchimerism (MMc) and MMc is sometimes detectable in CB. From a series of 95 patients who underwent double or single CBT at our center, we obtained or generated HLA-genotyping of CB mothers in 68. We employed a technique of highly sensitive HLA-specific quantitative-PCR assays targeting polymorphisms unique to the CB mother to assay CB-MMc in patients post-CBT. After additional exclusion criteria, CB-MMc was evaluated at multiple timepoints in 36 patients (529 specimens). CB-MMc was present in seven (19.4%) patients in bone marrow, peripheral blood, innate and adaptive immune cell subsets, and was detected up to 1-year post-CBT. Statistical trends to lower relapse, mortality, and treatment failure were observed for patients with vs. without CB-MMc post-CBT. Our study provides proof-of-concept that maternal cells of the CB graft can be tracked in recipients post-CBT, and underscore the importance of further investigating CB-MMc in sustained remission from leukemia following CBT.

Implementing Pharmacogenomics Testing: Single Center Experience at Arkansas Children's Hospital.

Pharmacogenomics (PGx) is a growing field within precision medicine. Testing can help predict adverse events and sub-therapeutic response risks of certain medications. To date, the US FDA lists over 280 drugs which provide biomarker-based dosing guidance for adults and children. At Arkansas Children's Hospital (ACH), a clinical PGx laboratory-based test was developed and implemented to provide guidance on 66 pediatric medications for genotype-guided dosing. This PGx test consists of 174 single nucleotide polymorphisms (SNPs) targeting 23 clinically actionable PGx genes or gene variants. Individual genotypes are processed to provide per-gene discrete results in star-allele and phenotype format. These results are then integrated into EPIC- EHR. Genomic indicators built into EPIC-EHR provide the source for clinical decision support (CDS) for clinicians, providing genotype-guided dosing.

Past and future global transformation of terrestrial ecosystems under climate change.

Impacts of global climate change on terrestrial ecosystems are imperfectly constrained by ecosystem models and direct observations. Pervasive ecosystem transformations occurred in response to warming and associated climatic changes during the last glacial-to-interglacial transition, which was comparable in magnitude to warming projected for the next century under high-emission scenarios. We reviewed 594 published paleoecological records to examine compositional and structural changes in terrestrial vegetation since the last glacial period and to project the magnitudes of ecosystem transformations under alternative future emission scenarios. Our results indicate that terrestrial ecosystems are highly sensitive to temperature change and suggest that, without major reductions in greenhouse gas emissions to the atmosphere, terrestrial ecosystems worldwide are at risk of major transformation, with accompanying disruption of ecosystem services and impacts on biodiversity.

Maternal microchimerism is prevalent in cord blood in memory T cells and other cell subsets, and persists post-transplant.

Among reported advantages of umbilical cord blood (CB) in transplantation is lower leukemia relapse probability. Underlying cellular mechanisms of graft-vs.-leukemia (GVL) are thought to include a prominent role for T cells. Cells of the CB's mother, maternal microchimerism (MMc), were recently strongly, but indirectly, implicated in this GVL benefit. We assayed MMc directly and hypothesized benefit accrues from CB maternal T cells. MMc was quantified in 51 CBs and, within memory T, naïve T, B, NK cells, and monocytes in 27 CBs. Polymorphism-specific quantitative-PCR assays targeted maternal genotypes non-shared with CBs. Overall MMc was common and often at substantial levels. It was present in 52.9% of CB and in 33.3-55.6% of tested subsets. Remarkably, MMc quantities were greater in memory T cells than other subsets (p < 0.001). Expressed as genome equivalents (gEq) per 105 total gEq tested (gEq/105), memory T cell MMc averaged 850.2 gEq/105, while other subset mean quantities were 13.8-30.1 gEq/105. After adjustment for proportionality in CB, MMc remained 6-17 times greater in memory T, and 3-9 times greater in naïve T, vs. non-T-cell subsets. Further, CB-origin MMc was detected in vivo in a patient up to 6 mo post-transplantation, including among T cells. Overall, results revealed levels and phenotypes of CB MMc with potential relevance to CB transplantation and, more broadly, to offspring health.

The effects of silver coated external fixation pins.

We performed a randomized controlled trial in order to assess the effect silver coating of an external fixator pin has on pin infection. The experimental silver coated pins (SC) were compared to control stainless steel (SS) pins. A clamp design monolateral fixator was used, and pins were randomized to clamp position to allow side-by-side comparisons of pins in a similar environment. Nineteen patients and 33 clamps were entered and completed the study. There were no significant differences between the two types of pins in the rate of pin tract infection, clinical appearances of the pin sites, bacteriology of the pin tracts, torque to remove the pins, or radiographic lucency around the pin. We concluded that with the numbers available in this study, there were no detectable differences between the performance of SC and SS pins.

Consent to Donate Surgical Biospecimens for Research: Perceptions of People With Colorectal Cancer.

BACKGROUND: Biospecimens for cancer research are commonly sought from people who undergo surgery for a new diagnosis of cancer, and the demand for these biospecimens is increasing. OBJECTIVE: The objective of this study was to explore the perceptions of people with colorectal cancer regarding the impact of an opt-in model of consent for biospecimen donation. METHODS: The qualitative method of Grounded Theory was used, and data were gathered through digitally recorded semistructured interviews with 18 participants. Data were analyzed using the constant comparative method to the descriptive level. RESULTS: Four major categories were identified describing the response to the consent process used for donating tissue for research purposes. These were as follows: consent is "no big deal" compared with the diagnosis of cancer; helping others; trusting the surgeon; and information related to donation of biospecimens. CONCLUSIONS: Results from this study indicate that the achievement of ideal informed and voluntary consent is difficult when patients are confronted with the trauma of newly diagnosed illness. Innovative approaches are implicated to obtain consent while protecting the autonomy and dignity of patients. IMPLICATIONS FOR PRACTICE: The results from this study can contribute to further development of processes for the donation of biospecimens for research purposes that respect the needs and views of patients.

The mood disorders association of british columbia psychiatric urgent care program: a preliminary evaluation of a suggested alternative model of outpatient psychiatric care.

OBJECTIVE: To describe an alternative model of psychiatric outpatient care for patients with mood and anxiety disorders (the Mood Disorders Association of British Columbia Psychiatric Urgent Care Program or the MDA Program) using group medical visits (GMV) and (or) email communications in lieu of individual follow-up appointments. METHOD: Annual costs of the MDA Program were compared with average costs of private psychiatrists offering outpatient care and patients being treated in a mental health centre. In addition, questionnaires as to patient satisfaction with the MDA Program intake, GMV experience, and family physician satisfaction with the MDA Program were administered. RESULTS: The MDA Program model of care is significantly more cost effective than individual psychiatric outpatient care or health authority mental health centre care for patients with moderate or severe illness. Patients and family physicians were very satisfied with the model of care and GMVs offered. CONCLUSIONS: The MDA Program model of care appears to be efficient and cost-effective, and patients and referring physicians appear satisfied with the care offered in this program.

Millennial climatic fluctuations are key to the structure of last glacial ecosystems.

Whereas fossil evidence indicates extensive treeless vegetation and diverse grazing megafauna in Europe and northern Asia during the last glacial, experiments combining vegetation models and climate models have to-date simulated widespread persistence of trees. Resolving this conflict is key to understanding both last glacial ecosystems and extinction of most of the mega-herbivores. Using a dynamic vegetation model (DVM) we explored the implications of the differing climatic conditions generated by a general circulation model (GCM) in "normal" and "hosing" experiments. Whilst the former approximate interstadial conditions, the latter, designed to mimic Heinrich Events, approximate stadial conditions. The "hosing" experiments gave simulated European vegetation much closer in composition to that inferred from fossil evidence than did the "normal" experiments. Given the short duration of interstadials, and the rate at which forest cover expanded during the late-glacial and early Holocene, our results demonstrate the importance of millennial variability in determining the character of last glacial ecosystems.

Recurrent preeclampsia: the effect of weight change between pregnancies.

OBJECTIVE: To estimate whether the risk of recurrent preeclampsia is affected by interpregnancy change in body mass index (BMI). METHODS: We conducted a population-based cohort study using Missouri maternally linked birth certificates for 17,773 women whose first pregnancies were complicated by preeclampsia. The women were placed into three groups: those who decreased their BMIs, those who maintained their BMIs, and those who increased their BMIs between their first two pregnancies. The primary outcome was recurrent preeclampsia in the second pregnancy. Adjusted risk ratios and 95% confidence intervals were calculated using Poisson regression analysis. RESULTS: The overall rate of recurrent preeclampsia in women who decreased their BMIs between pregnancies was 12.8% (risk ratio 0.70, confidence interval 0.60-0.81) compared with 14.8% if BMI was maintained and 18.5% in those who increased their BMIs (risk ratio 1.29, confidence interval 1.20-1.38). Within the normal weight, overweight, and obese weight categories, women who decreased BMI between pregnancies were less likely to experience recurrent preeclampsia. Women in all weight categories who increased their BMIs between pregnancies were more likely to experience recurrent preeclampsia. CONCLUSION: Interpregnancy weight reduction decreases the risk of recurrent preeclampsia and should be encouraged in women who experience preeclampsia. LEVEL OF EVIDENCE: II.

Evidence for last interglacial chronology and environmental change from Southern Europe.

Establishing phase relationships between earth-system components during periods of rapid global change is vital to understanding the underlying processes. It requires records of each component with independent and accurate chronologies. Until now, no continental record extending from the present to the penultimate glacial had such a chronology to our knowledge. Here, we present such a record from the annually laminated sediments of Lago Grande di Monticchio, southern Italy. Using this record we determine the duration (17.70 +/- 0.20 ka) and age of onset (127.20 +/- 1.60 ka B.P.) of the last interglacial, as reflected by terrestrial ecosystems. This record also reveals that the transitions at the beginning and end of the interglacial spanned only approximately 100 and 150 years, respectively. Comparison with records of other earth-system components reveals complex leads and lags. During the penultimate deglaciation phase relationships are similar to those during the most recent deglaciation, peaks in Antarctic warming and atmospheric methane both leading Northern Hemisphere terrestrial warming. It is notable, however, that there is no evidence at Monticchio of a Younger Dryas-like oscillation during the penultimate deglaciation. Warming into the first major interstadial event after the last interglacial is characterized by markedly different phase relationships to those of the deglaciations, warming at Monticchio coinciding with Antarctic warming and leading the atmospheric methane increase. Diachroneity is seen at the end of the interglacial; several global proxies indicate progressive cooling after approximately 115 ka B.P., whereas the main terrestrial response in the Mediterranean region is abrupt and occurs at 109.50 +/- 1.40 ka B.P.