The effect of a national ambulance Quality Improvement Collaborative on performance in care bundles for acute myocardial infarction and stroke

Background: National ambulance service indicators showed considerable variation in care for acute myocardial infarction (AMI) and stroke. We aimed to improve reliability of pre-hospital care processes for these conditions using a Quality Improvement Collaborative (QIC). The QIC involved educating ambulance staff in Quality Improvement (QI) methods, and the use of plan-do-study-act cycles (PDSA) to implement changes. Ambulance staff were provided with feedback on the effect of the PDSA cycles and the QIC provided an environment to share successful strategies within and across services to improve care bundles for AMI and stroke. Methods: We analysed change over time using logistic regression with three predictor variables: time (measured in weeks), sex, and age, to measure the effect of the national QIC on delivery of pre-hospital care bundles for AMI (aspirin, glyceryl trinitrate, pain assessment and analgesia) and stroke (face-arm-speech-test, blood pressure, blood glucose). The coefficient for time and its standard error were then extracted from each fit and plotted using forest plots. Results: There were statistically significant improvements in nine (of 12) participating trusts for the AMI care bundle (OR 2.06, 95% CI 1.88 to 2.07) and nine (of 12) for the stroke care bundle (OR 2.84, 95% CI 2.45 to 3.30). Eleven of 12 trusts showed a significant improvement in either the AMI or stroke care bundle, and seven (of 12) showed significant improvements for both AMI and stroke. Overall performance for the care bundle for AMI increased nationally in England from 43 to 79 percent and for stroke from 83 to 96 percent. Limitations: Our analysis was limited by lack of a comparison group. Conclusion and recommendations: Implementing care bundles as part of a national QIC led to significant improvements care for AMI and stroke provided by English ambulance services. We are using a multisite comparative case study to explain why and how the QIC changed care

Public perceptions of drinking water: A postal survey of residents with private water supplies

Background: In Canada, the legal responsibility for the condition of private water supplies, including private wells and cisterns, rests with their owners. However, there are reports that Canadians test these water supplies intermittently and that treatment of such water is uncommon. An estimated 45% of all waterborne outbreaks in Canada involve non-municipal systems. An understanding of the perceptions and needs of Canadians served by private water supplies is essential, as it would enable public health professionals to better target public education and drinking water policy. The purpose of this study was to investigate the public perceptions of private water supplies in the City of Hamilton, Ontario (Canada), with the intent of informing public education and outreach strategies within the population. Methods: A cross-sectional postal survey of 246 residences with private water supplies was conducted in May 2004. Questions pertained to the perceptions of water quality and alternative water sources, water testing behaviours and the self-identified need for further information. Results: Private wells, cisterns or both, were the source of household water for 71%, 16% and 13% of respondents, respectively. Although respondents rated their water quality highly, 80% also had concerns with its safety. The most common concerns pertained to bacterial and chemical contamination of their water supply and its potential negative effect on health. Approximately 56% and 61% of respondents used in-home treatment devices and bottled water within their homes, respectively, mainly due to perceived improvements in the safety and aesthetic qualities compared to regular tap water. Testing of private water supplies was performed infrequently: 8% of respondents tested at a frequency that meets current provincial guidelines. Two-thirds of respondents wanted more information on various topics related to private water supplies. Flyers and newspapers were the two media reported most likely to be used. Conclusion: Although respondents rated their water quality highly, the majority had concerns regarding the water from their private supply, and the use of bottled water and water treatment devices was extensive. The results of this study suggest important lines of inquiry and provide support and input for public education programs, particularly those related to private water testing, in this population

Arcuate fasciculus and pre-reading language development in children with prenatal alcohol exposure

IntroductionPrenatal alcohol exposure (PAE) contributes to widespread neurodevelopmental challenges, including reading, and has been associated with altered white matter. Here, we aimed to investigate whether arcuate fasciculus (AF) development is associated with pre-reading language skills in young children with PAE.MethodsA total of 51 children with confirmed PAE (25 males; 5.6 ± 1.1 years) and 116 unexposed controls (57 males; 4.6 ± 1.2 years) underwent longitudinal diffusion tensor imaging (DTI), for a total of 111 scans from participants with PAE and 381 scans in the unexposed control group. We delineated the left and right AF and extracted mean fractional anisotropy (FA) and mean diffusivity (MD). Pre-reading language ability was assessed using age-standardized phonological processing (PP) and speeded naming (SN) scores of the NEPSY-II. Linear mixed effects models were run to determine the relationship between diffusion metrics and age, group, sex, and age-by-group interactions, with subject modeled as a random factor. A secondary mixed effect model analysis assessed the influence of white matter microstructure and PAE on pre-reading language ability using diffusion metric-by-age-by-group interactions, with 51 age- and sex-matched unexposed controls.ResultsPhonological processing (PP) and SN scores were significantly lower in the PAE group (p < 0.001). In the right AF, there were significant age-by-group interactions for FA (p < 0.001) and MD (p = 0.0173). In the left AF, there was a nominally significant age-by-group interaction for MD that failed to survive correction (p = 0.0418). For the pre-reading analysis, a significant diffusion-by-age-by-group interaction was found for left FA (p = 0.0029) in predicting SN scores, and for the right FA (p = 0.00691) in predicting PP scores.DiscussionChildren with PAE showed altered developmental trajectories for the AF, compared with unexposed controls. Children with PAE, regardless of age, showed altered brain-language relationships that resembled those seen in younger typically developing children. Our findings support the contention that altered developmental trajectories in the AF may be associated with functional outcomes in young children with PAE

Deweyan tools for inquiry and the epistemological context of critical pedagogy

This article develops the notion of resistance as articulated in the literature of critical pedagogy as being both culturally sponsored and cognitively manifested. To do so, the authors draw upon John Dewey\u27s conception of tools for inquiry. Dewey provides a way to conceptualize student resistance not as a form of willful disputation, but instead as a function of socialization into cultural models of thought that actively truncate inquiry. In other words, resistance can be construed as the cognitive and emotive dimensions of the ongoing failure of institutions to provide ideas that help individuals both recognize social problems and imagine possible solutions. Focusing on Dewey\u27s epistemological framework, specifically tools for inquiry, provides a way to grasp this problem. It also affords some innovative solutions; for instance, it helps conceive of possible links between the regular curriculum and the study of specific social justice issues, a relationship that is often under-examined. The aims of critical pedagogy depend upon students developing dexterity with the conceptual tools they use to make meaning of the evidence they confront; these are background skills that the regular curriculum can be made to serve even outside social justice-focused curricula. Furthermore, the article concludes that because such inquiry involves the exploration and potential revision of students\u27 world-ordering beliefs, developing flexibility in how one thinks may be better achieved within academic subjects and topics that are not so intimately connected to students\u27 current social lives, especially where students may be directly implicated

From representation to emergence: complexity's challenge to the epistemology of schooling

In modern,Western societies the purpose of schooling is to ensure that school-goers acquire knowledge of pre-existing practices, events, entities and so on.The knowledge that is learned is then tested to see if the learner has acquired a correct or adequate understanding of it. For this reason, it can be argued that schooling is organised around a representational epistemology: one which holds that knowledge is an accurate representation of something that is separate from knowledge itself. Since the object of knowledge is assumed to exist separately from the knowledge itself, this epistemology can also be considered ‘spatial.’ In this paper we show how ideas from complexity have challenged the ‘spatial epistemology’ of representation and we explore possibilities for an alternative ‘temporal’ understanding of knowledge in its relationship to reality. In addition to complexity, our alternative takes its inspiration from Deweyan ‘transactional realism’ and deconstruction. We suggest that ‘knowledge’ and ‘reality’ should not be understood as separate systems which somehow have to be brought into alignment with each other, but that they are part of the same emerging complex system which is never fully ‘present’ in any (discrete) moment in time. This not only introduces the notion of time into our understanding of the relationship between knowledge and reality, but also points to the importance of acknowledging the role of the ‘unrepresentable’ or ‘incalculable’. With this understanding knowledge reaches us not as something we receive but as a response, which brings forth new worlds because it necessarily adds something (which was not present anywhere before it appeared) to what came before. This understanding of knowledge suggests that the acquisition of curricular content should not be considered an end in itself. Rather, curricular content should be used to bring forth that which is incalculable from the perspective of the present. The epistemology of emergence therefore calls for a switch in focus for curricular thinking, away from questions about presentation and representation and towards questions about engagement and response

Attendance of male partners to different reproductive health services in Shinyanga District, North western Tanzania

Background: Male involvement in reproductive health (RH) services in Africa has been associated with improved maternal and child health outcomes. The objective of this study was to determine the prevalence and factors affecting male partner attendance to available reproductive health services in Shinyanga district, north-western Tanzania.Methods: A house to house survey using a structured questionnaire was conducted among randomly selected married men. Additional in-depth interviews were conducted among married men found attending RH services. Factors that motivates the uptake of locally available RH services together with their partners were explored.Results: A total of 204 men participated in the study, 94.4 % (193/204) of them reported to have ever attended the RH service with their female partners at least once whereas 50.6% (103/204) of them attended at least thrice. Three quarters (154/204) attended HIV counselling and testing (VCT) and 63% (129/204) attended antenatal services (ANC). Reported attendance to sexually transmitted infections (STIs/STDs), prevention of HIV transmission from mother to child (PMTCT), and reproductive health cancer services were all less than 13%.  The male partners age group (25-34 years; χ2=9.347, df =3 p-value < 0.001), female partner invitation to HR services (χ2= 29.901, df=1, p-value <0.001) and having less than 2 children (χ2= 6.201, df= 2, p-value < 0.05) were associated with higher RH service attendance. Only 20% (4/20) of married men attended RH because they expected better health outcomes in their presence whilst majority attended because they were summoned or just happen to be at the clinic for other purposes.Conclusion: The male attendance to RH services together with their female partners’ in rural Shinyanga was mainly focused ANC and VCT. Most of men attended because were verbally invited by their partners. Education on couple communication empowerment among women attending RH clinics could sustainably improve attendance to all RH services.

The association between subcortical and cortical fMRI and lifetime noise exposure in listeners with normal hearing thresholds

In animal models, exposure to high noise levels can cause permanent damage to hair-cell synapses (cochlear synaptopathy) for high-threshold auditory nerve fibers without affecting sensitivity to quiet sounds. This has been confirmed in several mammalian species, but the hypothesis that lifetime noise exposure affects auditory function in humans with normal audiometric thresholds remains unconfirmed and current evidence from human electrophysiology is contradictory. Here we report the auditory brainstem response (ABR), and both transient (stimulus onset and offset) and sustained functional magnetic resonance imaging (fMRI) responses throughout the human central auditory pathway across lifetime noise exposure. Healthy young individuals aged 25–40 years were recruited into high (n = 32) and low (n = 30) lifetime noise exposure groups, stratified for age, and balanced for audiometric threshold up to 16 kHz fMRI demonstrated robust broadband noise-related activity throughout the auditory pathway (cochlear nucleus, superior olivary complex, nucleus of the lateral lemniscus, inferior colliculus, medial geniculate body and auditory cortex). fMRI responses in the auditory pathway to broadband noise onset were significantly enhanced in the high noise exposure group relative to the low exposure group, differences in sustained fMRI responses did not reach significance, and no significant group differences were found in the click-evoked ABR. Exploratory analyses found no significant relationships between the neural responses and self-reported tinnitus or reduced sound-level tolerance (symptoms associated with synaptopathy). In summary, although a small effect, these fMRI results suggest that lifetime noise exposure may be associated with central hyperactivity in young adults with normal hearing thresholds

A Cross-Sectional Survey on Knowledge and Perceptions of Health Risks Associated with Arsenic and Mercury Contamination from Artisanal Gold mining in Tanzania.

An estimated 0.5 to 1.5 million informal miners, of whom 30-50% are women, rely on artisanal mining for their livelihood in Tanzania. Mercury, used in the processing gold ore, and arsenic, which is a constituent of some ores, are common occupational exposures that frequently result in widespread environmental contamination. Frequently, the mining activities are conducted haphazardly without regard for environmental, occupational, or community exposure. The primary objective of this study was to assess community risk knowledge and perception of potential mercury and arsenic toxicity and/or exposure from artisanal gold mining in Rwamagasa in northwestern Tanzania. A cross-sectional survey of respondents in five sub-villages in the Rwamagasa Village located in Geita District in northwestern Tanzania near Lake Victoria was conducted. This area has a history of artisanal gold mining and many of the population continue to work as miners. Using a clustered random selection approach for recruitment, a total of 160 individuals over 18 years of age completed a structured interview. The interviews revealed wide variations in knowledge and risk perceptions concerning mercury and arsenic exposure, with 40.6% (n=65) and 89.4% (n=143) not aware of the health effects of mercury and arsenic exposure respectively. Males were significantly more knowledgeable (n=59, 36.9%) than females (n=36, 22.5%) with regard to mercury (x²=3.99, p<0.05). An individual's occupation category was associated with level of knowledge (x²=22.82, p=<0.001). Individuals involved in mining (n=63, 73.2%) were more knowledgeable about the negative health effects of mercury than individuals in other occupations. Of the few individuals (n=17, 10.6%) who knew about arsenic toxicity, the majority (n=10, 58.8%) were miners. The knowledge of individuals living in Rwamagasa, Tanzania, an area with a history of artisanal gold mining, varied widely with regard to the health hazards of mercury and arsenic. In these communities there was limited awareness of the threats to health associated with exposure to mercury and arsenic. This lack of knowledge, combined with minimal environmental monitoring and controlled waste management practices, highlights the need for health education, surveillance, and policy changes

The effect of a national quality improvement collaborative on prehospital care for acute myocardial infarction and stroke in England

Background Previous studies have shown wide variations in prehospital ambulance care for acute myocardial infarction (AMI) and stroke. We aimed to evaluate the effectiveness of implementing a Quality Improvement Collaborative (QIC) for improving ambulance care for AMI and stroke. Methods We used an interrupted time series design to investigate the effect of a national QIC on change in delivery of care bundles for AMI (aspirin, glyceryl trinitrate [GTN], pain assessment and analgesia) and stroke (face-arm-speech test, blood pressure and blood glucose recording) in all English ambulance services between January 2010 and February 2012. Key strategies for change included local quality improvement (QI) teams in each ambulance service supported by a national coordinating expert group that conducted workshops educating staff in QI methods to improve AMI and stroke care. Expertise and ideas were shared between QI teams who met together at three national workshops, between QI leads through monthly teleconferences, and between the expert group and participants. Feedback was provided to services using annotated control charts. Results We analyzed change over time using logistic regression with three predictor variables: time, gender, and age. There were statistically significant improvements in care bundles in nine (of 12) participating trusts for AMI (OR 1.04, 95% CI 1.04, 1.04), nine for stroke (OR 1.06, 95% CI 1.05, 1.07), 11 for either AMI or stroke, and seven for both conditions. Overall care bundle performance for AMI increased in England from 43 to 79% and for stroke from 83 to 96%. Successful services all introduced provider prompts and individualized or team feedback. Other determinants of success included engagement with front-line clinicians, feedback using annotated control charts, expert support, and shared learning between participants and organizations. Conclusions This first national prehospital QIC led to significant improvements in ambulance care for AMI and stroke in England. The use of care bundles as measures, clinical engagement, application of quality improvement methods, provider prompts, individualized feedback and opportunities for learning and interaction within and across organizations helped the collaborative to achieve its aims

Cross-Sectional Study Protocol for the COVID-19 Impact Survey of Mothers and Their 7–11 Year Old Children in Alberta, Canada

Objectives: Our aim is to understand the effect of the COVID-19 pandemic on families who have been followed longitudinally in two cohorts studied in Alberta, Canada. We will examine household infections during the COVID-19 pandemic, financial impact, domestic violence, substance use, child school and daily life and relationships in the home. We will identify risk and protective factors for maternal mental health outcomes using longitudinal data that can inform policy and government resource allocation in future disasters.Methods: Mothers who are currently participating in two longitudinal studies, Alberta Pregnancy Outcomes and Nutrition (APrON; N = 1,800) and All Our Families (AOF: N = 2,534) were eligible to participate. Mothers were invited to complete the baseline COVID-19 Impact Survey (20–30 min) within 4 months of March 15, 2020, which was when the province of Alberta, Canada, implemented school closures and physical-distancing measures to prevent the spread of COVID-19. Mothers were asked to report on their own, their child's and their family's functioning. Mothers were re-surveyed at 6 months after completion of the initial COVID-19 Impact Survey, and will be re-surveyed again at 12 months.Results: Responses from participants in both cohorts will be examined in harmonized analyses as well as separately. Descriptive, multivariable analysis will be undertaken to examine risk and resiliency over time and factors that predict mental health and well-being.Conclusions: This study will provide timely information on the impact of COVID-19 for Albertan families. It will identify risk and protective factors for mental health and well-being among contemporary urban families supported by a publicly funded health care system to inform allocation of resources to support those most vulnerable during a global pandemic