Identifying barriers and facilitators to improving prehospital care of asthma: views of ambulance clinicians

Background: In 2008/09 there were nearly 80,000 emergency hospital admissions for asthma. Current UK guidelines emphasise the importance of evidence-based prehospital assessment and treatment of asthma for improving patient outcomes and reducing hospitalisation, morbidity and mortality. National benchmarking of ambulance clinical performance indicators for asthma has revealed important unexplained variations in care across ambulance services. Little research has been undertaken to understand the reasons for poor levels of care. Objective: The aim of this study was to gather data on ambulance clinicians’ perceptions and beliefs around prevailing and best practice for management of asthma. This was used to identify the factors which prevent or enable better asthma care in ambulance services. Methods: We used a phenomenological qualitative approach, which addresses how individuals use their experiences to make sense of their world, focusing on participants’ lived experiences of care delivery for asthma. We used focus groups of ambulance clinicians to gather data on barriers and facilitators to better asthma care. Recordings and notes were taken, transcribed and then analysed using QSR NVivo 8. A coding framework was developed based on a priori concepts but with emergent themes added during the analysis. Results: Two focus groups were conducted with eight and five participants respectively. A number of preliminary themes and subthemes were identified. The study identified issues relating to clarity of ambulance guidelines, conflicts between training and guidance, misconceptions about the importance of objective assessment and over reliance on non-objective assessment. Some practitioners believed that hospital staff were not interested in prehospital peak flow assessments. Conclusion: Our findings will inform improved systems of care for asthma and the effect on indicators will be measured using time series methods. This approach could be used more widely to improve management of specific clinical conditions where quality of care is demonstrated to be suboptimal

Identifying barriers and facilitators to improve prehospital care of asthma

Context: The National Ambulance Services Clinical Quality Group is responsible for benchmarking and driving improvement in the quality of clinical care provided by front line ambulance staff (paramedics and ambulance clinicians) across all twelve ambulance services in England. Problem: In 2008/09 there were nearly 80,000 emergency hospital admissions for asthma. Current UK guidelines emphasise the importance of evidence-based prehospital assessment and treatment of asthma for improving patient outcomes and reducing hospitalisation, morbidity and mortality. Assessment of problem and analysis of its causes: National benchmarking of ambulance clinical performance indicators for asthma, with performance analysed and compared using funnel plots, revealed important unexplained variations in care across ambulance services. Despite gradual improvements in care quality poor levels of prehospital assessment of asthma persist, particularly in recording of peak expiratory flow rates (PEFR: mean 42%, range 8-50% recorded) and saturation of peripheral oxygen (SpO2: mean 90%, range 66-100% recorded). Intervention: We aimed to collect data about ambulance clinicians’ perceptions and beliefs around asthma management, the barriers and facilitators to implementing current guidelines and what measures would improve prehospital care and pathways for asthma. Study design: We used a phenomenological qualitative approach focusing on participants’ lived experiences of care delivery for asthma. We used focus groups of ambulance clinicians to gather data on of barriers and facilitators to better asthma care. Recordings and notes were taken, transcribed and then analysed using QSR NVivo 8. A coding framework was developed based on a priori concepts but with emergent themes added during the analysis. Strategy for change: A number of preliminary themes were identified: 1. perceptions and beliefs of paramedics on the management of asthma, 2. barriers and facilitators to following asthma guidelines, 3 measures to improve prehospital asthma care and pathways. Measurement of improvement: Ambulance clinicians believed that asthma guidelines were usually followed with the exception of PEFR recording. They felt the guidelines were more suitable for the hospital environment, and that they were confusing or not always practical in the prehospital environment. Pre-treatment objective assessments were not seen as a priority where airway or breathing difficulty was apparent and where these were not thought to affect patient outcome. Oxygen measurement was more likely to be carried out where equipment was readily to hand. Peak flow measurement was believed by some to be detrimental to patients in respiratory distress and sometimes difficult to obtain. Reasons for not carrying out objective assessment were not always recorded. Ambulance guidelines and training were seen as barriers to pre-treatment assessment as the emphasis is on correcting breathing difficulties before carrying out other assessments. Development of better pathways and co-operation between health agencies was advocated. Effects of changes: Our findings will inform system interventions to address current deficiencies in care. Improvements will be measured using control charts. Lessons learnt: Important barriers to improving care are often not evident without involving front line clinicians, gathering information from them in order to understand the issues affecting care delivery from their perspective. Perceptions and beliefs held by ambulance clinicians for asthma management need to be addressed in order to change practice. Ambulance training and guidelines need to reinforce the reasons for taking objective assessments, reinforcing the place of pre-treatment assessment in the overall patient journey and highlighting the dangers of overreliance on non-objective assessment. Message for others: Detailed analysis of barriers and facilitators is an important precursor to real, sustained and systematic improvements in care

Scholarly Concentrations: A Novel Platform for Delivery of Health Systems Science Exposure and Highlight Unique Learning Environments Across the Nine Campuses of Indiana University School of Medicine

Presented as a Poster at 2020 IUSM Education Day.Rapidly evolving challenges in health care mandate changes in the way health care professionals are educated. How do we integrate the need for new and different content into the medical school curriculum? One area of particular focus is called Health Systems Science. Health Systems Science is being called the 3rd leg of modern medical education to complement the foundational and clinical sciences curricula. IU School of Medicine is integrating Health Systems Science content into Scholarly Concentrations. Scholarly Concentrations is a program offering students longitudinal educational enhancement through coursework and scholarly work

Oxidation of primary amines to ketones

A simple method for the oxidn. of primary amines to the corresponding ketones in the presence of both moisture and air is described. Treatment of an amine with benzoyl peroxide in the presence of Cs2CO3, followed by warming of the hydroxylamine product to 50-70° leads directly to the ketone. The method is shown to be effective for both benzylic and aliph. substrates. [on SciFinder(R)

The Ursinus Weekly, May 16, 1974

Women\u27s hours abolished; Board votes rule change for next Fall • Show Boat and band Parent\u27s Day hits • Will rates go up? • Student writes play • Marsteller to publish constellation slides • New special students to take part in upcoming Summer School session • Yearbook trouble • The ghost of Ursinus past • Editorial: New rules = new responsibilities • Wanted: Fearless leader • Alumni Corner: What happens to Weekly editors? • Meistersingers tour • Art review • In praise of ProTheatre • The Zodiac: The Earth signs: Taurus, Virgo, Capricorn • Record review: Robin Trower: Bridge of Sighs • Seasons are near end • The Cinder scene wrap-uphttps://digitalcommons.ursinus.edu/weekly/1017/thumbnail.jp

Seeing the way: visual sociology and the distance runner's perspective

Employing visual and autoethnographic data from a two‐year research project on distance runners, this article seeks to examine the activity of seeing in relation to the activity of distance running. One of its methodological aims is to develop the linkage between visual and autoethnographic data in combining an observation‐based narrative and sociological analysis with photographs. This combination aims to convey to the reader not only some of the specific subcultural knowledge and particular ways of seeing, but also something of the runner's embodied feelings and experience of momentum en route. Via the combination of narrative and photographs we seek a more effective way of communicating just how distance runners see and experience their training terrain. The importance of subjecting mundane everyday practices to detailed sociological analysis has been highlighted by many sociologists, including those of an ethnomethodological perspective. Indeed, without the competence of social actors in accomplishing these mundane, routine understandings and practices, it is argued, there would in fact be no social order

Strengthening patient-centred communication in rural Ugandan health centres: A theory-driven evaluation within a cluster randomized trial.

This article describes a theory-driven evaluation of one component of an intervention to improve the quality of health care at Ugandan public health centres. Patient-centred services have been advocated widely, but such approaches have received little attention in Africa. A cluster randomized trial is evaluating population-level outcomes of an intervention with multiple components, including 'patient-centred services.' A process evaluation was designed within this trial to articulate and evaluate the implementation and programme theories of the intervention. This article evaluates one hypothesized mechanism of change within the programme theory: the impact of the Patient Centred Services component on health-worker communication. The theory-driven approach extended to evaluation of the outcome measures. The study found that the proximal outcome of patient-centred communication was rated 10 percent higher (p < 0.008) by care seekers consulting with the health workers who were at the intervention health centres compared with those at control health centres. This finding will strengthen interpretation of more distal trial outcomes

Patient engagement in designing, conducting, and disseminating clinical pain research : IMMPACT recommended considerations

The consensus recommendations are based on the views of IMMPACT meeting participants and do not necessarily represent the views of the organizations with which the authors are affiliated. The following individuals made important contributions to the IMMPACT meeting but were not able to participate in the preparation of this article: David Atkins, MD (Department of Veterans Affairs), Rebecca Baker, PhD (National Institutes of Health), Allan Basbaum, PhD (University of California San Francisco), Robyn Bent, RN, MS (Food and Drug Administration), Nathalie Bere, MPH (European Medicines Agency), Alysha Croker, PhD (Health Canada), Stephen Bruehl, PhD (Vanderbilt University), Michael Cobas Meyer, MD, MBS (Eli Lilly), Scott Evans, PhD (George Washington University), Gail Graham (University of Maryland), Jennifer Haythornthwaite, PhD (Johns Hopkins University), Sharon Hertz, MD (Hertz and Fields Consulting), Jonathan Jackson, PhD (Harvard Medical School), Mark Jensen, PhD (University of Washington), Francis Keefe, PhD (Duke University), Karim Khan, MD, PhD, MBA (Canadian Institutes of Health Research), Lynn Laidlaw (University of Aberdeen), Steven Lane (Patient-Centered Outcomes Research Institute), Karen Morales, BS (University of Maryland), David Leventhal, MBA (Pfizer), Jeremy Taylor, OBE (National Institute for Health Research), and Lena Sun, MD (Columbia University). The manuscript has not been submitted, presented, or published elsewhere. Parts of the manuscript have been presented in a topical workshop at IASP World Congress on Pain in Toronto, in 2022.Peer reviewedPublisher PD

Pleiotropic meta-analysis of cognition, education, and schizophrenia differentiates roles of early neurodevelopmental and adult synaptic pathways

Susceptibility to schizophrenia is inversely correlated with general cognitive ability at both the phenotypic and the genetic level. Paradoxically, a modest but consistent positive genetic correlation has been reported between schizophrenia and educational attainment, despite the strong positive genetic correlation between cognitive ability and educational attainment. Here we leverage published genome-wide association studies (GWASs) in cognitive ability, education, and schizophrenia to parse biological mechanisms underlying these results. Association analysis based on subsets (ASSET), a pleiotropic meta-analytic technique, allowed jointly associated loci to be identified and characterized. Specifically, we identified subsets of variants associated in the expected (“concordant”) direction across all three phenotypes (i.e., greater risk for schizophrenia, lower cognitive ability, and lower educational attainment); these were contrasted with variants that demonstrated the counterintuitive (“discordant”) relationship between education and schizophrenia (i.e., greater risk for schizophrenia and higher educational attainment). ASSET analysis revealed 235 independent loci associated with cognitive ability, education, and/or schizophrenia at p < 5 × 10−8. Pleiotropic analysis successfully identified more than 100 loci that were not significant in the input GWASs. Many of these have been validated by larger, more recent single-phenotype GWASs. Leveraging the joint genetic correlations of cognitive ability, education, and schizophrenia, we were able to dissociate two distinct biological mechanisms—early neurodevelopmental pathways that characterize concordant allelic variation and adulthood synaptic pruning pathways—that were linked to the paradoxical positive genetic association between education and schizophrenia. Furthermore, genetic correlation analyses revealed that these mechanisms contribute not only to the etiopathogenesis of schizophrenia but also to the broader biological dimensions implicated in both general health outcomes and psychiatric illness

Whole-Exome Capture and Sequencing Identifies HEATR2 Mutation as a Cause of Primary Ciliary Dyskinesia

Motile cilia are essential components of the mucociliary escalator and are central to respiratory-tract host defenses. Abnormalities in these evolutionarily conserved organelles cause primary ciliary dyskinesia (PCD). Despite recent strides characterizing the ciliome and sensory ciliopathies through exploration of the phenotype-genotype associations in model organisms, the genetic bases of most cases of PCD remain elusive. We identified nine related subjects with PCD from geographically dispersed Amish communities and performed exome sequencing of two affected individuals and their unaffected parents. A single autosomal-recessive nonsynonymous missense mutation was identified in HEATR2, an uncharacterized gene that belongs to a family not previously associated with ciliary assembly or function. Airway epithelial cells isolated from PCD-affected individuals had markedly reduced HEATR2 levels, absent dynein arms, and loss of ciliary beating. MicroRNA-mediated silencing of the orthologous gene in Chlamydomonas reinhardtii resulted in absent outer dynein arms, reduced flagellar beat frequency, and decreased cell velocity. These findings were recapitulated by small hairpin RNA-mediated knockdown of HEATR2 in airway epithelial cells from unaffected donors. Moreover, immunohistochemistry studies in human airway epithelial cells showed that HEATR2 was localized to the cytoplasm and not in cilia, which suggests a role in either dynein arm transport or assembly. The identification of HEATR2 contributes to the growing number of genes associated with PCD identified in both individuals and model organisms and shows that exome sequencing in family studies facilitates the discovery of novel disease-causing gene mutations