Integrating a sense of coherence into the neonatal environment

Background: Family centred care (FCC) is currently a valued philosophy within neonatal care; an approach that places the parents at the heart of all decision-making and engagement in the care of their infant. However, to date, there is a lack of clarity regarding the definition of FCC and limited evidence of FCCs effectiveness in relation to parental, infant or staff outcomes. Discussion: In this paper we present a new perspective to neonatal care based on Aaron Antonovksy’s Sense of Coherence (SOC) theory of well-being and positive health. Whilst the SOC was originally conceptualised as a psychological-based construct, the SOCs three underpinning concepts of comprehensibility, manageability and meaningfulness provide a theoretical lens through which to consider and reflect upon meaningful care provision in this particular care environment. By drawing on available FCC research, we consider how the SOC concepts considered from both a parental and professional perspective need to be addressed. The debate offered in this paper is not presented to reduce the importance or significance of FCC within neonatal care, but, rather, how consideration of the SOC offers the basis through which meaningful and effective FCC may be delivered. Practice based implications contextualised within the SOC constructs are also detailed. Summary: Consideration of the SOC constructs from both a parental and professional perspective need to be addressed in FCC provision. Service delivery and care practices need to be comprehensible, meaningful and manageable in order to achieve and promote positive well-being and health for all concerned

A meta-ethnographic study of health care staff perceptions of the WHO/UNICEF Baby Friendly Health Initiative

Background Implementation of the Baby Friendly Health Initiative (BFHI) is associated with increases in breastfeeding initiation and duration of exclusive breastfeeding and ‘any’ breastfeeding. However, implementation of the BFHI is challenging. Aim To identify and synthesise health care staff perceptions of the WHO/UNICEF BFHI and identify facilitators and barriers for implementation. Method Seven qualitative studies, published between 2003 and 2013 were analysed using meta-ethnographic synthesis. Findings Three overarching themes were identified. First the BFHI was viewed variously as a ‘desirable innovation or an unfriendly imposition’. Participants were passionate about supporting breastfeeding and improving consistency in the information provided. This view was juxtaposed against the belief that BFHI represents an imposition on women's choices, and is a costly exercise for little gain in breastfeeding rates. The second theme highlighted cultural and organisational constraints and obstacles to BFHI implementation including resource issues, entrenched staff practices and staff rationalisation of non-compliance. Theme three captured a level of optimism and enthusiasm amongst participants who could identify a dedicated and credible leader to lead the BFHI change process. Collaborative engagement with all key stakeholders was crucial. Conclusions Health care staff hold variant beliefs and attitudes towards BFHI, which can help or hinder the implementation process. The introduction of the BFHI at a local level requires detailed planning, extensive collaboration, and an enthusiastic and committed leader to drive the change process. This synthesis has highlighted the importance of thinking more creatively about the translation of this global policy into effective change at the local level

The effect of pre-service treatments on the long term properties of 9Cr steels strengthened by boron and nitrogen

Martensitic 9Cr steels have been developed which are strengthened by boron in order to stabilise the microstructure and improve their long-term creep strength. Boron plays a key role in these steels by stabilising the martensitic laths by decreasing the coarsening rate of M23C6 carbides, which act as pinning points in the microstructure. In this work two modified FB2 steel forgings are compared. Both forgings have similar compositions but one underwent an additional remelting process during manufacture. Creep tests showed that this additional processing step resulted in a significant increase in time to failure. In order to investigate the effect of the processing route on microstructural evolution during aging and creep, a range of advanced electron microscopy techniques have been used including ion beam induced secondary electron imaging and High Angle Annular Dark Field (HAADF) imaging in the Scanning Transmission Electron Microscope. These techniques have enabled the particle population characteristics of all the second phase particles (M23C6, Laves phase, BN and MX) to be quantified for materials from both forging processes. These quantitative data have enabled a better understanding of how the processing route affects the microstructural evolution of FB2 steels

Optimizing medication management for patients with cirrhosis: Evidence‐based strategies and their outcomes

Cirrhosis is a morbid condition associated with frequent hospitalizations and high mortality. Management of cirrhosis requires complex medication regimens to treat underlying liver disease, complications of cirrhosis and comorbid conditions. This review examines the complexities of medication management in cirrhosis, barriers to optimal medication use, and potential interventions to streamline medication regimens and avoid medication errors. A literature review was performed by searching PUBMED through December 2017 and article reference lists to identify articles relevant to medication management, complications, adherence, and interventions to improve medication use in cirrhosis. The structural barriers in cirrhosis include sheer medication complexity related to the number of medications and potential for cognitive impairment in this population, faulty medication reconciliation and limited adherence. Tested interventions have included patient self‐education, provider driven patient education, intensive case management including medication blister packs and smartphone applications. Initiatives are needed to improve patient, caregiver and provider education on appropriate use of medications in patients with cirrhosis. A multidisciplinary team should be established to coordinate care with close monitoring, address patient and caregiver concerns, and to provide timely access to outpatient evaluation of urgent/complex issues. Future studies evaluating the clinical outcomes and cost effectiveness of interventions are needed.Peer Reviewedhttps://deepblue.lib.umich.edu/bitstream/2027.42/146454/1/liv13892_am.pdfhttps://deepblue.lib.umich.edu/bitstream/2027.42/146454/2/liv13892.pd

Effect of selected plant species within biodiverse pasture on in vitro fatty acid biohydrogenation and tissue fatty acid composition of lamb

The effect of botanical diversity on supply of polyunsaturated fatty acids (PUFA) to ruminants in vitro, and the fatty acid (FA) composition of muscle in lambs was investigated. Six plant species, commonly grown as part of UK herbal ley mixtures (Trifolium pratense, Lotus corniculatus, Achillea millefolium, Centaurea nigra, Plantago lanceolata and Prunella vulgaris), were assessed for FA profile, and in vitro biohydrogenation of constituent PUFA, to estimate intestinal supply of PUFA available for absorption by ruminants. Modelling the in vitro data suggested that L. Corniculatus and P. Vulgaris had the greatest potential to increase 18:3 n-3 supply to ruminants, having the highest amounts escaping in vitro biohydrogenation . Biodiverse pastures were established using the six selected species, under-sown in a perennial ryegrass-based sward. Lambs were grazed (~50 days) on biodiverse or control pastures and the effects on the FA composition of m. longissimus thoracis (lean and subcutaneous fat) and m. semimembranosus (lean) were determined. Biodiverse pasture increased 18:2 n-6 and 18:3 n-3 contents of m. semimembranosus (+14.8 and +7.2 mg/100g tissue respectively) and the subcutaneous fat of m. l. thoracis (+158 and +166 mg/100g tissue respectively) relative to feeding a perennial ryegrass pasture. However, there was no effect on total concentrations of saturated FA in the tissues studied. It was concluded that enhancing biodiversity had a positive impact on muscle FA profile reflected by increased levels of total PUFA

The effect of varying proportion and chop length of lucerne silage in a maize silage-based total mixed ration on diet digestibility and milk yield in dairy cattle

The objective was to assess the effects of inclusion rate and chop length of lucerne silage, when fed in a total mixed ration (TMR), on milk yield, dry matter (DM) intake (DMI) and digestion in dairy cows. Diets were formulated to contain a 50:50 forage:concentrate ratio (DM basis) and to be isonitrogenous (170 g/kg CP). The forage portion of the offered diets was comprised of maize and lucerne silage in proportions (DM basis) of either 25:75 (HL) or 75:25 (LL). Lucerne was harvested and conserved as silage at either a long (L) or short (S) chop length. These variables were combined in a 2x2 factorial arrangement to give four treatments (HLL, HLS, LLL, LLS) which were fed in a Latin square design study to Holstein dairy cows in two separate experiments. Sixteen and 8 multiparous, mid-lactation, cows were used in experiments 1 and 2, respectively. To ensure sufficient silage for both experiments, different cuts of lucerne silage (taken from the same sward) were used for each experiment: first cut for experiment 1 (which was of poorer quality) and second cut for experiment 2. Dry matter intake, milk yield and milk composition where measured in both experiments, and total tract digestibility and nitrogen (N) balance were assessed using four cows in experiment 2. In experiment 1 cows fed LL had increased DMI (+3.2 kg/day), compared with those fed HL. In contrast, there was no difference in DMI due to lucerne silage inclusion rate in experiment 2. A reduction in milk yield was observed with the HL treatment in both experiment 1 and 2 (-3.0 and -2.9 kg/day, respectively). The HL diet had reduced digestibility of DM and organic matter (OM) (-3 and -4%, respectively), and also reduced the efficiency of intake N conversion into milk N (-4%). The S chop length increased total tract digestibility of DM and OM (both +4%), regardless of inclusion rate. Inclusion of lucerne silage at 25% of forage dry matter increased milk yield relative to 75% inclusion, but a S chop length partially mitigated adverse effects of HL on DMI and milk yield in experiment 1 and on DM digestibility in experiment 2

Incorporating grass-clover and lucerne silages into UK dairy systems: forage agronomy, silage analysis accuracy and lucerne feeding strategy

Red clover (trifolium pratense), white clover (trifolium repens) and lucerne (medicago sativa) are currently the most viable forage legumes for european farming systems. Knowing the agronomy and feeding strategies representing ‘best practice’ for these forages in livestock production systems is key as the industry turns to low input forages to meet sustainability targets. The research question addressed in this thesis was whether these forage legumes could be grown and fed more efficiently, with a focus on their use in the UK dairy sector. Limitations to their utilisation are discussed and potential practical solutions were assessed. This included investigations into the effects of sowing timing and plant maturity on yield and feeding value of lucerne, and the effect of chop length and inclusion rate of lucerne silage in a total mixed ration with maize silage on dry matter intake, milk yield, total tract digestibility, and rumen functionality in both ‘normal’ and ‘challenging’ rumen environments of dairy cattle. Furthermore, to ensure precise diet rationing, the method by which most legume-containing silage samples are analysed for nutritional content in the UK (Near Infra-Red Reflectance Spectroscopy) was tested for accuracy for both grass-clover and lucerne silages. Improved grass-clover prediction equations were calibrated from the data collated in the study, which will be adapted for commercial implementation in the future. Key findings from these studies which can be used to enhance best practice guidelines for farmers included: (i) it was advantageous to sow lucerne in spring rather than autumn for greater yield and reduced weed burden, (ii) including lucerne silage in a TMR diet with maize silage at 25% of forage DM and at a short chop length was beneficial to dry matter digestibility, and therefore metabolisable energy supply, relative to inclusion at 75% of forage DM and a long lucerne chop length, and (iii) a high inclusion rate of lucerne silage in the diet can mitigate against sub-acute rumen acidosis risk resulting from short-term feed deprivation followed by refeeding

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

Write Night: How a Writing Accountability Group (WAG) supports scholarly work and connection at a community residency program

Purpose: The purpose of this innovative endeavor was to improve scholarly output and collaboration at the Swedish First Hill Family Medicine residency by establishing a Writing Accountability Group (WAG). Background: While scholarly work during residency training is both required by the ACGME and important for producing physician leaders, many community-based residency programs have no formal structure to support such work and promote collaboration. At our program, faculty worked in functional silos and found it difficult to consistently involve residents in scholarly projects. WAGs have been studied in a variety of settings as a tool to increase scholarly output, improve writing habits, and provide mentorship for junior and senior faculty. Objectives: We aimed to analyze the effectiveness of a WAG in promoting scholarly work and resident scholarly mentorship in a community-based residency program. By reporting this work, we hope to provide inspiration and a roadmap for other faculty to increase scholarly productivity and joy in their work. Implementation/Design: After reviewing the literature regarding WAGs, a faculty member at Swedish First Hill Family Medicine invited other faculty to form a WAG at our community-based residency program. Over the next 18 months, a group of 4-6 faculty met every 2-3 weeks for 90-minute sessions to write, provide peer mentorship regarding scholarly pursuits, and collaborate on scholarly projects. Sessions were held on mutually convenient evenings at a faculty member’s home and over Zoom during the COVID-19 pandemic. Results/Outcomes: To assess the efficacy of the WAG, we measured total scholarly activity in an academic year for the five faculty participants both before (2018-2019) and after (2019-2020) the implementation of the WAG. We used the ACGME template for faculty scholarly activity to identify and categorize different types of activity. The total number of faculty scholarly activities increased from 20 to 44 after the formation of a WAG, representing a 120% increase in our total activity. For scholarly activity that required peer review or conference acceptance, our total number of submissions increased from 14 to 28, yet maintained a similar acceptance rate (79% in 2018-2019, 85% in 2019-2020). While the majority of our scholarly activity consisted of national conference submissions, we also noted increases in publications, podcasts, and other writing submissions. In addition to increased faculty scholarly productivity, our WAG was associated with increases in faculty job satisfaction, faculty collaboration, and resident scholarly activity. Significance: Creation of a WAG provided a structure for faculty scholarly collaboration and accountability for completion of scholarly projects. The WAG also provided a clear point of contact for other faculty and residents interested in scholarly work. In addition to increasing scholarly output and resident participation, our WAG improved wellness among faculty, providing a sense of collaboration and celebration of our scholarly work, particularly important during the COVID-19 pandemic. We plan to continue to evaluate the impact of the WAG in future years to look for sustained improvement.https://digitalcommons.psjhealth.org/swedish_learning_day_posters/1005/thumbnail.jp

Prediction of lignin content in ruminant diets and faecal samples using rapid analytical techniques

The measurement of lignin content in ruminant diet and faecal samples is important for 2 digestibility studies, but it is typically time consuming and costly. The work reported 3 involved correlation of traditional wet chemistry data with that from three rapid instrumental 4 techniques, Fourier Transform Infrared spectroscopy (FTIR), Conventional 5 Thermogravimteric Analysis (TGA) and High Resolution TGA (MaxRes TGA) to predict 6 lignin content of diets and faeces from digestibility trials. Calibration and performance data 7 indicated that the FTIR model was acceptable for screening whilst the Conventional and 8 MaxRes TGA predictions were of high accuracy for quantitative analysis. Cross validation 9 and model performance data revealed that MaxRes TGA provided the best performing 10 predictive model. This work showed that MaxRes TGA can accurately predict lignin content 11 in ruminant diet and faecal samples with distinct advantages over traditional wet chemistry, 12 namely the requirement for small sample size, ease of sample preparation, speed of analysis 13 and high sample throughput at considerably lower cost