Globalization of the Cruise Industry: A Tale of Ships Part II - Asia Post 1994

Cruising has grown over 7% a year since 1980. Sustained rapid expansion in North America, followed by local expansion in Europe and Asia, has made cruising a global industry, with 365 ships and estimated sales of $37.8 US billion (CIN, 2017). This global development has been fueled by innovation and introduction of market changing resident ships appealing to the mass traveler which were quickly matched by competitors, establishment of industry and port marketing organizations, awareness of cruising as a vacation option, and availability of suitable port and berthing facilities. When these four conditions coexisted the industry experienced rapid growth. Since 1966, the cruise industry has developed from a Miami-centered industry to a global industry centered in North America, Europe, Asia, and Australia/New Zealand. Given the high cost of state-of-the-art ships, their deployment is a good indication of industry’s confidence in market growth. This chapter chronicles the development of the Asian cruise industry from 1994 through 2017. Data from Cruise Industry News Annual Reports (CIN) and Berlitz Complete Guide to Cruising and Cruise Ships (Ward) are examined and conclusions are drawn

The Australasian Resuscitation In Sepsis Evaluation: FLUid or vasopressors In Emergency Department Sepsis, a multicentre observational study (ARISE FLUIDS observational study): Rationale, methods and analysis plan

There is uncertainty about the optimal i.v. fluid volume and timing of vasopressor commencement in the resuscitation of patients with sepsis and hypotension. We aim to study current resuscitation practices in EDs in Australia and New Zealand (the Australasian Resuscitation In Sepsis Evaluation: FLUid or vasopressors In Emergency Department Sepsis [ARISE FLUIDS] observational study).ARISE FLUIDS is a prospective, multicentre observational study in 71 hospitals in Australia and New Zealand. It will include adult patients presenting to the ED during a 30 day period with suspected sepsis and hypotension (systolic blood pressur

Behavioural ‘nudging’ interventions to reduce low-value care for low back pain in the emergency department (NUDGED): protocol for a 2×2 factorial, before-after, cluster randomised trial

Introduction:Opioids and imaging are considered low-value care for most people with low back pain. Yet around one in three people presenting to the emergency department (ED) will receive imaging, and two in three will receive an opioid. NUDG-ED aims to determine the effectiveness of two different behavioural ‘nudge’ interventions on low-value care for ED patients with low back pain. Methods and analysis:NUDG-ED is a 2×2 factorial, open-label, before-after, cluster randomised controlled trial. The trial includes 8 ED sites in Sydney, Australia. Participants will be ED clinicians who manage back pain, and patients who are 18 years or over presenting to ED with musculoskeletal back pain. EDs will be randomly assigned to receive (i) patient nudges, (ii) clinician nudges, (iii) both interventions or (iv) no nudge control. The primary outcome will be the proportion of encounters in ED for musculoskeletal back pain where a person received a non-indicated lumbar imaging test, an opioid at discharge or both. We will require 2416 encounters over a 9-month study period (3-month before period and 6-month after period) to detect an absolute difference of 10% in use of low-value care due to either nudge, with 80% power, alpha set at 0.05 and assuming an intra-class correlation coefficient of 0.10, and an intraperiod correlation of 0.09. Patient-reported outcome measures will be collected in a subsample of patients (n≥456) 1 week after their initial ED visit. To estimate effects, we will use a multilevel regression model, with a random effect for cluster and patient, a fixed effect indicating the group assignment of each cluster and a fixed effect of time. Ethics and dissemination:This study has ethical approval from Southwestern Sydney Local Health District Human Research Ethics Committee (2023/ETH00472). We will disseminate the results of this trial via media, presenting at conferences and scientific publications.</p

The Australasian Resuscitation In Sepsis Evaluation : fluids or vasopressors in emergency department sepsis (ARISE FLUIDS), a multi-centre observational study describing current practice in Australia and New Zealand

Objectives: To describe haemodynamic resuscitation practices in ED patients with suspected sepsis and hypotension. Methods: This was a prospective, multicentre, observational study conducted in 70 hospitals in Australia and New Zealand between September 2018 and January 2019. Consecutive adults presenting to the ED during a 30-day period at each site, with suspected sepsis and hypotension (systolic blood pressure <100 mmHg) despite at least 1000 mL fluid resuscitation, were eligible. Data included baseline demographics, clinical and laboratory variables and intravenous fluid volume administered, vasopressor administration at baseline and 6- and 24-h post-enrolment, time to antimicrobial administration, intensive care admission, organ support and in-hospital mortality. Results: A total of 4477 patients were screened and 591 were included with a mean (standard deviation) age of 62 (19) years, Acute Physiology and Chronic Health Evaluation II score 15.2 (6.6) and a median (interquartile range) systolic blood pressure of 94 mmHg (87–100). Median time to first intravenous antimicrobials was 77 min (42–148). A vasopressor infusion was commenced within 24 h in 177 (30.2%) patients, with noradrenaline the most frequently used (n = 138, 78%). A median of 2000 mL (1500–3000) of intravenous fluids was administered prior to commencing vasopressors. The total volume of fluid administered from pre-enrolment to 24 h was 4200 mL (3000–5661), with a range from 1000 to 12 200 mL. Two hundred and eighteen patients (37.1%) were admitted to an intensive care unit. Overall in-hospital mortality was 6.2% (95% confidence interval 4.4–8.5%). Conclusion: Current resuscitation practice in patients with sepsis and hypotension varies widely and occupies the spectrum between a restricted volume/earlier vasopressor and liberal fluid/later vasopressor strategy

Increasing the Effectiveness of Vaginal Microbicides: A Biophysical Framework to Rethink Behavioral Acceptability

Microbicide candidates delivered via gel vehicles are intended to coat the vaginal epithelium after application. The coating process depends on intrinsic biophysical properties of the gel texture, which restricts the potential choices for an effective product: the gel first must be physically synthesizable, then acceptable to the user, and finally applied in a manner promoting timely adequate coating, so that the user adherence is optimized. We present a conceptual framework anchoring microbicide behavioral acceptability within the fulfillment of the product biophysical requirements.We conducted a semi-qualitative/quantitative study targeting women aged 18-55 in Northern California to assess user preferences for microbicide gel attributes. Attributes included: (i) the wait time between application and intercourse, (ii) the gel texture and (iii) the trade-off between wait time and gel texture. Wait times were assessed using a mathematical model determining coating rates depending upon the gel's physical attributes.71 women participated. Results suggest that women would independently prefer a gel spreading rapidly, in 2 to 15 minutes (P<0.0001), as well as one that is thick or slippery (P<0.02). Clearly, thick gels do not spread rapidly; hence the motivation to study the trade-off. When asked the same question 'constrained' by the biophysical reality, women indicated no significant preference for a particular gel thickness (and therefore waiting time) (P>0.10) for use with a steady partner, a preference for a watery gel spreading rapidly rather than one having intermediate properties for use with a casual partner (P = 0.024).Biophysical constraints alter women's preferences regarding acceptable microbicide attributes. Product developers should offer a range of formulations in order to address all preferences. We designed a conceptual framework to rethink behavioral acceptability in terms of biophysical requirements that can help improve adherence in microbicide use ultimately enhancing microbicide effectiveness

Hospital mortality of adults admitted to Intensive Care Units in hospitals with and without Intermediate Care Units: a multicentre European cohort study.

INTRODUCTION: The aim of the study was to assess whether adults admitted to hospitals with both Intensive Care Units (ICU) and Intermediate Care Units (IMCU) have lower in-hospital mortality than those admitted to ICUs without an IMCU. METHODS: An observational multinational cohort study performed on patients admitted to participating ICUs during a four-week period. IMCU was defined as any physically and administratively independent unit open 24 hours a day, seven days a week providing a level of care lower than an ICU but higher than a ward. Characteristics of hospitals, ICUs and patients admitted to study ICUs were recorded. The main outcome was all-cause in-hospital mortality until hospital discharge (censored at 90 days). RESULTS: One hundred and sixty-seven ICUs from 17 European countries enrolled 5,834 patients. Overall, 1,113 (19.1%) patients died in the ICU and 1,397 died in hospital, with a total of 1,397 (23.9%) deaths. The illness severity was higher for patients in ICUs with an IMCU (median Simplified Acute Physiology Score (SAPS) II: 37) than for patients in ICUs without an IMCU (median SAPS II: 29, P <0.001). After adjustment for patient characteristics at admission such as illness severity, and ICU and hospital characteristics, the odds ratio of mortality was 0.63 (95% CI 0.45 to 0.88, P = 0.007) in favour of the presence of IMCU. The protective effect of the IMCU was absent in patients who were admitted for basic observation, for example, after surgery (odds ratio 1.15, 95% CI 0.65 to 2.03, P = 0.630) but was strong in patients admitted to an ICU for other reasons (odds ratio 0.54, 95% CI 0.37 to 0.80, P = 0.002). CONCLUSIONS: The presence of an IMCU in the hospital is associated with significantly reduced adjusted hospital mortality for adults admitted to the ICU. This effect is relevant for the patients requiring full intensive treatment. TRIAL REGISTRATION: Clinicaltrials.gov NCT01422070. Registered 19 August 2011

The air pollution tradeoff in India: saving more lives versus reducing the inequality of exposure

Chronic exposure to ambient fine particulate matter (PM _2.5 ) represents one of the largest global public health risks, leading to millions of premature deaths annually. For a country facing high and spatially variable exposures, prioritizing where to reduce PM _2.5 concentrations leads to an inherent tradeoff between saving the most lives and reducing inequality of exposure. This tradeoff results from the shape of the concentration–response (C-R) function between exposure to PM _2.5 and mortality, which indicates that the additional lives saved per unit reduction in PM _2.5 declines as concentrations increase, suggesting that more lives can be saved by reducing exposures in clean locations than in dirty locations. We estimated this C-R function for urban areas of India, finding that a 10 µ gm ^−3 reduction in PM _2.5 in already-clean locations will reduce the mortality rate substantially (4.2% for a reduction from 30 to 20 µ gm ^−3 ), while a 10 µ gm ^−3 reduction in the dirtiest locations will reduce mortality only modestly (1.2% for a reduction from 90 to 80 µ gm ^−3 ). Policymakers face a troubling tradeoff between maximizing lives saved and reducing the inequality of exposure. Many air pollution policies impose an upper limit on exposure, thereby cleaning the dirtiest locations and reducing exposure inequality. We explore the implications of this PM _2.5 /mortality relationship by considering a thought experiment. If India had a fixed amount of resources to devote to PM _2.5 concentration reductions across urban areas, what is the lives saved/inequality of exposure tradeoff from three different methods of deploying those resources? Across our three scenarios: (1) which reduces exposures for the dirtiest districts, (2) which reduces exposures everywhere equally, and (3) which reduces exposures to save the most lives—scenario 1 saves 18 000 lives per year while reducing the inequality of exposure by 65%, while scenario 3 saves 126 000 lives per year, but increases inequality by 19%

Early acquisition of non-technical skills using a blended approach to simulation-based medical education

Abstract Background Non-technical skills are emerging as an important component of postgraduate medical education. Between 2013 and 2016, a new blended training program incorporating non-technical skills was introduced at an Australian university affiliated hospital. Program participants were medical officers in years 1 and 2 of postgraduate training. Methods An interdisciplinary faculty trained in simulation-based education led the program. The blended approach combined open access online resources with multiple opportunities to participate in simulation-based learning. The aim of the study was to examine the value of the program to the participants and the effects on the wider hospital system. The mixed methods evaluation included data from simulation centre records, hospital quality improvement data, and a post-hoc reflective survey of the enrolled participants (n = 68). Results Over 30 months, 283 junior doctors were invited to participate in the program. Enrolment in a designated simulation-based course was completed by 169 doctors (59.7%). Supplementary revision sessions were made available to the cohort with a median weekly attendance of five participants. 56/68 (82.4%) of survey respondents reported increased confidence in managing deteriorating patients. During the period of implementation, the overall rate of hospital cardiac arrests declined by 42.3%. Future objectives requested by participants included training in graded assertiveness and neurological emergencies. Conclusions Implementation of a non-technical skills program was achieved with limited simulation resources and was associated with observable improvements in clinical performance. The participants surveyed reported increased confidence in managing deteriorating patients, and the program introduction coincided with a significant reduction in the rate of in-hospital cardiac arrests

Exploring the use of Virtual Reality to manage distress in adolescent patients in the Emergency Departments

Background: Adolescents are more likely than others to use emergency departments and find them distressing due to long waits, loud sounds, bright lights, privacy intrusions, and exposure to the distress of others. VR could be effective in not only dealing with pain while in emergency, but also blocking out distressing stimuli for a calming experience that could assist them in regulating their emotions.Aims: To explore the potential benefits of deploying VR for adolescents in the emergency department.Methods: Twenty-six participants who had voluntarily attended the ED in two university teaching hospitals received the VR intervention. Pre and post measures assessing changes in state anxiety, stress and affect, and physical bio-markers, were obtained.Results: The use of VR intervention was associated with significant reductions in distress (SSSQ-D; p&lt;0.001) and negative affect (I-PANAS-SF; p&lt;0.001). Most participants chose ‘Netflix’ as their content of choice. The technology was well received by the participants of the study with subjective reports indicating that receiving VR intervention was “insanely cool”, “takes you away from what’s actually happening”, and some participants felt “privileged to get this experience in a hospital.”Conclusions: VR technology can effectively be used in emergency departments to assist adolescents and young adults better manage their distress and take steps toward activating more self-control mechanisms that will in turn allow for more meaningful engagements to be established with health clinicians. This technology has broad implications for reducing distress in adolescents in a variety of clinical contexts