“Even if You Know Everything You Can Forget”: Health Worker Perceptions of Mobile Phone Text-Messaging to Improve Malaria Case-Management in Kenya

This paper presents the results of a qualitative study to investigate the perceptions and experiences of health workers involved in a a cluster-randomized controlled trial of a novel intervention to improve health worker malaria case-management in 107 government health facilities in Kenya. The intervention involved sending text-messages about paediatric outpatient malaria case-management accompanied by “motivating” quotes to health workers’ mobile phones. Ten malaria messages were developed reflecting recommendations from the Kenyan national guidelines. Two messages were delivered per day for 5 working days and the process was repeated for 26 weeks (May to October 2009). The accompanying quotes were unique to each message. The intervention was delivered to 119 health workers and there were significant improvements in correct artemether-lumefantrine (AL) management both immediately after the intervention (November 2009) and 6 months later (May 2010). In-depth interviews with 24 health workers were undertaken to investigate the possible drivers of this change. The results suggest high acceptance of all components of the intervention, with the active delivery of information in an on the job setting, the ready availability of new and stored text messages and the perception of being kept ‘up to date’ as important factors influencing practice. Applying the construct of stages of change we infer that in this intervention the SMS messages were operating primarily at the action and maintenance stages of behaviour change achieving their effect by creating an enabling environment and providing a prompt to action for the implementation of case management practices that had already been accepted as the clinical norm by the health workers. Future trials testing the effectiveness of SMS reminders in creating an enabling environment for the establishment of new norms in clinical practice as well as in providing a prompt to action for the implementation of the new case-management guidelines are justified

Integration of Large-Scale Genomic Data Sources With Evolutionary History Reveals Novel Genetic Loci for Congenital Heart Disease

Background: Most cases of congenital heart disease (CHD) are sporadic and nonsyndromic, with poorly understood etiology. Rare genetic variants have been found to affect the risk of sporadic, nonsyndromic CHD, but individual studies to date are of only moderate sizes, and none to date has incorporated the ohnolog status of candidate genes in the analysis. Ohnologs are genes retained from ancestral whole-genome duplications during evolution; multiple lines of evidence suggest ohnologs are overrepresented among dosage-sensitive genes. We integrated large-scale data on rare variants with evolutionary information on ohnolog status to identify novel genetic loci predisposing to CHD. Methods: We compared copy number variants present in 4634 nonsyndromic CHD cases derived from publicly available data resources and the literature, and >27 000 healthy individuals. We analyzed deletions and duplications independently and identified copy number variant regions exclusive to cases. These data were integrated with whole-exome sequencing data from 829 sporadic, nonsyndromic patients with Tetralogy of Fallot. We placed our findings in an evolutionary context by comparing the proportion of vertebrate ohnologs in CHD cases and controls. Results: Novel genetic loci in CHD cases were significantly enriched for ohnologs compared with the genome (χ2 test, P<0.0001, OR =1.253 [95% CI, 1.199–1.309]). We identified 54 novel candidate protein-coding genes supported by both: (1) copy number variant and whole-exome sequencing data; and (2) ohnolog status. Conclusions: We have identified new CHD candidate loci, and show for the first time that ohnologs are overrepresented among CHD genes. Incorporation of evolutionary metrics may be useful in refining candidate genes emerging from large-scale genetic evaluations of CHD

Strategies Addressing Barriers to the Implementation of a Pediatric Hand Fracture Care Pathway

Background:. We recently highlighted shortcomings in the care of pediatric hand fractures in our local context. The Calgary Kids’ Hand Rule (CKHR) was developed to predict hand fractures that require referral to a hand surgeon. The aims of this study were to identify barriers to a new care pathway for pediatric hand fractures, based on the CKHR and to generate tailored strategies to support its implementation. Methods:. We performed a conventional content analysis of transcripts from four focus groups (parents, emergency/urgent care physicians, plastic surgeons, and hand therapists) to identify relevant concepts (facilitators and barriers). These concepts were mapped to two frameworks. Generic strategies to address the barriers were identified, and further discussions with key stakeholders resulted in tailored strategies for implementation. Results:. Five facilitators to implementation of a CKHR-based hand fracture care pathway included established rapport between hand therapists and surgeons, potential for more streamlined care, agreement on identifying another care provider, positive perceptions of hand therapist expertise, and opportunity for patient education. Two individual barriers were concern for poor outcomes and trust. Three systemic barriers were awareness and usability, referral process, and cost and resources. Strategies to address these barriers include pilot-testing of the new care pathway, ensuring closed loop communication, multiple knowledge translation activities, integration of CKHR into the clinical information system, coordinating care and development of parent handouts. Conclusion:. Mapping barriers to established implementation frameworks has informed tailored implementation strategies, bringing us one step closer to successfully implementing a new pediatric hand fracture pathway

Hospital-acquired acute hyponatremia and reports of pediatric deaths

Abstract Information from four voluntary reports of hospital-acquired acute hyponatremia leading to the death of otherwise healthy children is highlighted. In this column, we present two cases and information from a recent ISMP Canada Safety Bulletin, as well as two cases reported to ISMP United States. Information is shared to enhance health care practitioners' awareness of the potential for acute hyponatremia and to provide an overview of some of the potential underlying factors. Hospital-acquired acute hyponatremia and reports of pediatric deaths Four pediatric deaths due to acute hyponatremia associated with intravenous (IV) administration of hypotonic solutions, three in a postsurgical setting and the other in a medical setting were voluntarily reported (two to the Institute for Safe Medication Practices Canada [ISMP Canada] and two to the Institute for Safe Medication Practices [ISMP] in the United States). Acute hyponatremia is defined as a decline in serum sodium to less than 130 mmol/L within a 48-hour period. This abrupt change can lead to cerebral edema as a result of electrolyte-free water moving into the brain cells. Acute hyponatremia can be fatal for both children and adults. However, children are more vulnerable to the effects of fluid and electrolyte imbalance. The early signs of acute hyponatremia and rising intracranial pressure are often nonspecific and include nausea, vomiting, headache, and decreasing level of consciousness. Information from the voluntary incident reports is shared here to enhance health care practitioners' awareness of the potential for acute hyponatremia and to provide an overview of some of the potential underlying factors. Incident reports received by ISMP Canad

Healthcare Providers and Parents Highlight Challenges of Pediatric Hand Fracture Care

Background:. Pediatric hand fractures are common, and many are referred to hand surgeons despite less than 10% of referrals requiring surgical intervention. We explored healthcare provider and parent perspectives to inform a new care pathway. Methods:. We conducted a qualitative descriptive study using virtual focus groups. Emergency physicians, hand therapists, plastic surgeons, and parents of children treated for hand fractures were asked to discuss their experiences with existing care for pediatric hand fractures, and perceptions surrounding the implementation of a new care pathway. Data were analyzed using directed content analysis with an inductive approach. Results:. Four focus groups included 24 participants: 18 healthcare providers and six parents. Four themes were identified: educating parents throughout the hand fracture journey, streamlining the referral process for simple hand fractures, identifying the most appropriate care provider for simple hand fractures, and maintaining strong multidisciplinary connections to facilitate care. Participants described gaps in the current care, including a need to better inform parents, and elucidated the motivations behind emergency medicine physicians’ existing referral practices. Participants also generally agreed on the need for more efficient management of simple hand fractures that do not require surgical care. Healthcare providers believed the strong preexisting relationship between surgeons and hand therapists would facilitate the changes brought forward by the new care pathway. Conclusion:. These findings highlighted shortcomings of existing care for pediatric hand fractures and will inform the co-development and implementation of a new care pathway to enable more efficient management while preserving good patient outcomes

Haptophyta

Haptophyta are predominantly planktonic and phototrophic organisms that have their main distribution in marine environments worldwide. They are a major component of the microbial ecosystem, some form massive blooms and some are toxic. Haptophytes are significant players in the global carbonate cycle through photosynthesis and calcification. They are characterized by the haptonema, a third appendage used for attachment and food handling, two similar flagella, two golden-brown chloroplasts, and organic body scales that serve in species identification. Coccolithophores have calcified scales termed coccoliths. Phylogenetically Haptophyta form a well-defined group and are divided into two classes Pavlovophyceae and Coccolithophyceae (Prymnesiophyceae). Currently, about 330 species are described. Environmental DNA sequencing shows high haptophyte diversity in the marine pico- and nanoplankton, of which many likely represent novel species and lineages. Haptophyte diversity is believed to have peaked in the past and their presence is documented in the fossil record back to the Triassic, approximately 225 million years ago. Some biomolecules of haptophyte origin are extraordinarily resistant to decay and are thus used by geologists as sedimentary proxies of past climatic conditions