Investigating medical handover practice: a process evaluation of a new initiative from an acute setting

Aims: To independently evaluate and assess the potential benefits and drawbacks of an innovative approach to the delivery of morning medical handover, in an acute medical emergency assessment unit (EAU). Methods: A survey was conducted with junior and middle-grade doctors attending the handover (N = 14). Three focus groups, with middle-grade doctors (n = 5), junior doctors (n = 11) and senior nurses (n = 3), were conducted to gain further insights into the views and experiences of attendees. Interviews with two medical consultants and two directors of postgraduate medical education were conducted to gain insight into the strategic training and management perspective. Focus groups and interviews were recorded, transcribed, and analysed using thematic analysis. The timeframe was May–August 2014. Results: Quantitative survey data were analysed using SPSS, generating descriptive frequencies. 79% of respondents preferred to discuss safety incidents verbally, 79% found it helpful to learn about clinical guidelines and 50% regarded the process as too long on most days. Qualitative findings revealed that the handover was regarded as a crucial process for prioritising and managing patients and communicating critical information across a multidisciplinary team. Including a nursing perspective was consistently viewed as particularly beneficial, owing to nurses’ detailed overview of patients within the unit. Discussing audit results, care bundles and clinical reminders was viewed as well placed, owing to their concise nature. However, the danger of detracting from the clinical handover by incorporating education and a lack of a consistent clear focus was highlighted. Detailed patient presentations and theoretical discussions were considered to be more suitable in an alternative setting, potentially during rounds and bedside teaching. Suggestions of utilising an electronic system, separating the night team handover from an EAU morning meeting, and changing shift times were also discussed. Conclusions: The foremost principle of a handover is to ensure that there is a robust clinical handover of continuous patient care from the outgoing to the incoming team. While there is the potential to augment this process with unique educational elements, it is essential that the delivery and content are carefully managed and structured in a manner that does not detract from the primary focus of a clinical handover and compromise clinical decision making. The handover model may benefit from having a more consistent time-bound structure, allowing the team to have a clear focus on managing and directing optimal patient care, whilst providing relevant educational aspects that improve patient safety and quality of care

Phosphorus Transport in Intensively Managed Watersheds

An edited version of this paper was published by AGU. Copyright 2019 American Geophysical Union.Understanding controls of P movement through watersheds are essential for improved landscape management in intensively managed regions. Here, we analyze observational data from 104 gaged river sites and 176 nongaged river sites within agriculturally dominated watersheds of Minnesota, USA, to understand the role of landscape features, land use practices, climate variability, and biogeochemical processes in total, dissolved and particulate P dynamics at daily to annual scales. Our analyses demonstrate that factors mediating P concentration‐discharge relationships varied greatly across watersheds and included near‐channel sediment sources, lake and wetland interception, assimilation by algal P, and artificial land drainage. The majority of gaged sites exhibited mobilizing behavior for all forms of P at event (i.e., daily) timescales and chemostatic behavior at annual timescales. The large majority of watershed P export (>70%, on average) occurred during high flow conditions, suggesting that more frequent large storm events arising from climate change will drive increased P losses from agricultural watersheds without substantial management changes. We found that P export could be dominated by dissolved P, particulate P, or an even mix of the two forms, depending on watershed attributes. Implementation of management practices to control P losses must be guided by understanding of how local landscapes interact with current and future climate conditions. Managing for both dissolved and particulate P is required to reduce overall P load in many agricultural watersheds

A culture-independent and culture-dependent study of the bacteria community from the bedrock soil interface

In nutrient limited soils, minerals constitute a major reservoir of bio-essential elements. Consequently, the release of nutritive elements during weathering is crucial. Bacteria have been shown to enhance weathering rates; however, there has been limited work that has focused on the bacterial weathering of bedrock or parent rock, which are the major sources of minerals, in nutrient limiting soils. In this study, both a culture-independent and culture-dependent approach was used to study the bacterial community at the interface between basaltic bedrock and nutrient limiting soil in Cadiar Idris region of Snowdonia National Park, United Kingdom. High throughput sequencing method, Ion Torrent, was used to characterise the bacterial community, which generated over 250,000 sequences. Taxonomical assignment demonstrated that approximately 50% (125,000 sequences) of the community consisted of the orders Actinomycetales, Burkholderiales, Clostridales, Bacillales, Rhizobiales and Acidobacterium, with unclassified sequences representing 44% ± 1.46% (110,000 ± 3650). Bacteria belonging to the genera Serratia, Pseudomonas, Bacillus, Paenibacillus, Chromobacterium, Janthinobacterium, Burkholderia and Arthrobacter, were isolated from the sample site. All of the isolates were able to grow in a minimal growth medium, which contained glucose, ammonium chloride with basalt as the sole source of bio-essential elements. Seventy percent of the isolates significantly enhanced basalt dissolution (p < 0.05). The rate of dissolution correlated to the production of oxalic acid and acidification of the growth medium. The findings of this work suggest that at the interface between bedrock and soil heterotrophic members of the bacterial community can enhance weathering, an essential part of biogeochemical cycling in nutrient limiting soil

Investigating optimal handover practice: an evaluation of a new initiative from an acute medical setting

Aims To independently evaluate and assess the potential benefits and drawbacks of an innovative approach to the delivery of morning medical handover, in an acute medical emergency assessment unit (EAU). Methods A survey was conducted with junior and middle-grade doctors attending the handover (N=14). Three focus groups, with middle-grade doctors (n=5), junior doctors (n=11) and senior nurses (n=3), were conducted to gain further insights into the views and experiences of attendees. Interviews with two medical consultants and two directors of postgraduate medical education were conducted to gain insight into the strategic training and management perspective. Focus groups and interviews were recorded, transcribed, and analysed using thematic analysis. The timeframe was May– August 2014. Results Quantitative survey data were analysed using SPSS, generating descriptive frequencies. 79% of respondents preferred to discuss safety incidents verbally, 79% found it helpful to learn about clinical guidelines and 50% regarded the process as too long on most days. Qualitative findings revealed that the handover was regarded as a crucial process for prioritising and managing patients and communicating critical information across a multidisciplinary team. Including a nursing perspective was consistently viewed as particularly beneficial, owing to nurses’ detailed overview of patients within the unit. Discussing audit results, care bundles and clinical reminders was viewed as well placed, owing to their concise nature. However, the danger of detracting from the clinical handover by incorporating education and a lack of a consistent clear focus was highlighted. Detailed patient presentations and theoretical discussions were considered to be more suitable in an alternative setting, potentially during rounds and bedside teaching. Suggestions of utilising an electronic system, separating the night team handover from an EAU morning meeting, and changing shift times were also discussed. Conclusions The foremost principle of a handover is to ensure that there is a robust clinical handover of continuous patient care from the outgoing to the incoming team. While there is the potential to augment this process with unique educational elements, it is essential that the delivery and content are carefully managed and structured in a manner that does not detract from the primary focus of a clinical handover and compromise clinical decision making. The handover model may benefit from having a more consistent time-bound structure, allowing the team to have a clear focus on managing and directing optimal patient care, whilst providing relevant educational aspects that improve patient safety and quality of care

Localized microglia dysregulation impairs central nervous system myelination in development

Myelination of neuronal axons is a critical aspect of central nervous system development and function. However, the fundamental cellular and molecular mechanisms influencing human developmental myelination and its failure are not fully understood. Here, we used digital spatial transcriptomics of a rare bank of human developing white matter to uncover that a localized dysregulated innate immune response is associated with impeded myelination. We identified that poorly myelinating areas have a distinct signature of Type II interferon signalling in microglia/macrophages, relative to adjacent myelinating areas. This is associated with a surprising increase in mature oligodendrocytes, which fail to form myelin processes appropriately. We functionally link these findings by showing that conditioned media from interferon-stimulated microglia is sufficient to dysregulate myelin process formation by oligodendrocytes in culture. We identify the Type II interferon inducer, Osteopontin (SPP1), as being upregulated in poorly myelinating brains, indicating a potential biomarker. Our results reveal the importance of microglia-mature oligodendrocyte interaction and interferon signaling in regulating myelination of the developing human brain.</p

Enabling women to access preferred methods of contraception : a rapid review and behavioural analysis

Background: Many pregnancies in the UK are either unplanned or ambivalent. This review aimed to (i) explore barriers and facilitators to women choosing and accessing a preferred method of contraception in the United Kingdom, and (ii) identify opportunities for behavioural interventions based on examination of interventions that are currently available nationally. Methods: Three databases were searched, and experts contacted to identify grey literature for studies presenting barriers and facilitators to women choosing and accessing a preferred method of contraception, conducted in the UK and published between 2009 and October 2019. Information on barriers and facilitators were coded into overarching themes, which were then coded into Mechanisms of Actions (MoAs) as listed in the Theory and Techniques Tool. National interventions were identified by consulting stakeholders and coded into the Behaviour Change Wheel. The match between barriers/facilitators and intervention content was assessed using the Behaviour Change Wheel. Results: We included 32 studies and identified 46 barrier and facilitator themes. The most cited MoA was Environmental Context and Resources, which primarily related to the services women had access to and care they received. Social Influences, Beliefs about Consequences (e.g., side effects) and Knowledge were also key. The behavioural analysis highlighted four priority intervention functions (Modelling, Enablement, Education and Environmental Restructuring) that can be targeted to support women to choose and access their preferred method of contraception. Relevant policy categories and behaviour change techniques are also highlighted. Conclusions: This review highlights factors that influence women’s choices and access to contraception and recommends opportunities that may be targeted for future interventions in order to support women to access preferred contraception. Registration Protocol was registered with PROSPERO (an international database of prospectively registered systematic reviews in health and social care) in December 2019, CRD42019161156

Association studies of up to 1.2 million individuals yield new insights into the genetic etiology of tobacco and alcohol use.

Tobacco and alcohol use are leading causes of mortality that influence risk for many complex diseases and disorders1. They are heritable2,3 and etiologically related4,5 behaviors that have been resistant to gene discovery efforts6-11. In sample sizes up to 1.2 million individuals, we discovered 566 genetic variants in 406 loci associated with multiple stages of tobacco use (initiation, cessation, and heaviness) as well as alcohol use, with 150 loci evidencing pleiotropic association. Smoking phenotypes were positively genetically correlated with many health conditions, whereas alcohol use was negatively correlated with these conditions, such that increased genetic risk for alcohol use is associated with lower disease risk. We report evidence for the involvement of many systems in tobacco and alcohol use, including genes involved in nicotinic, dopaminergic, and glutamatergic neurotransmission. The results provide a solid starting point to evaluate the effects of these loci in model organisms and more precise substance use measures

The role of ixazomib as an augmented conditioning therapy in salvage autologous stem cell transplant (ASCT) and as a post-ASCT consolidation and maintenance strategy in patients with relapsed multiple myeloma (ACCoRd [UK-MRA Myeloma XII] trial): study protocol for a Phase III randomised controlled trial

Background: Multiple myeloma (MM) is a plasma cell tumour with an approximate annual incidence of 4500 in the UK. Therapeutic options for patients with MM have changed in the last decade with the arrival of proteasome inhibitors and immunomodulatory drugs. Despite these options, almost all patients will relapse post first-line autologous stem cell transplantation (ASCT). First relapse management (second-line treatment) has evolved in recent years with an expanding portfolio of novel agents, driving response rates influencing the durability of response. A second ASCT, as part of relapsed disease management (salvage ASCT), has been shown to prolong the progression-free survival and overall survival following a proteasome inhibitor-containing re-induction regimen, in the Cancer Research UK-funded National Cancer Research Institute Myeloma X (Intensive) study. It is now recommended that salvage ASCT be considered for suitable patients by the International Myeloma Working Group and the National Institute for Health and Care Excellence NG35 guidance. Methods/design: ACCoRd (Myeloma XII) is a UK-nationwide, individually randomised, multi-centre, multiple randomisation, open-label phase III trial with an initial single intervention registration phase aimed at relapsing MM patients who have received ASCT in first-line treatment. We will register 406 participants into the trial to allow 284 and 248 participants to be randomised at the first and second randomisations, respectively. All participants will receive re-induction therapy until maximal response (four to six cycles of ixazomib, thalidomide and dexamethasone). Participants who achieve at least stable disease will be randomised (1:1) to receive either ASCTCon, using high-dose melphalan, or ASCTAug, using high-dose melphalan with ixazomib. All participants achieving or maintaining a minimal response or better, following salvage ASCT, will undergo a second randomisation (1:1) to consolidation and maintenance or observation. Participants randomised to consolidation and maintenance will receive consolidation with two cycles of ixazomib, thalidomide and dexamethasone, and maintenance with ixazomib until disease progression. Discussion: The question of how best to maximise the durability of response to salvage ASCT warrants clinical investigation. Given the expanding scope of oral therapeutic agents, patient engagement with long-term maintenance strategies is a real opportunity. This study will provide evidence to better define post-relapse treatment in MM