The fatigue paradox: Team perceptions of physician fatigue

OBJECTIVES: Ongoing calls to implement fatigue risk management in residency education assume a shared understanding of physician fatigue as a workplace hazard, yet we lack empirical evidence that all health care team members maintain this assumption. Thus, this study seeks to explore how health care team members understand the role of physician fatigue in an effort to inform the implementation of fatigue risk management in residency training and medical practice. METHODS: This study uses constructivist grounded theory to explore perceptions of workplace fatigue and its impact on clinical practice. We conducted individual semi-structured interviews with physicians, nurses and senior residents across four hospitals in 8 different specialties for a total of 40 participants. Constant comparative analysis guided data analysis and led to the final grounded theory. RESULTS: While participants outlined multiple problematic manifestations of physician fatigue on clinical performance, they were reluctant to acknowledge any negative impact of fatigue on patient care. We refer to these contradictions as the fatigue paradox. Four key themes sustain the fatigue paradox: the indefatigable physician, blind spots, faith in safety nets and the minimisation of fatigue-related events. CONCLUSIONS: This study suggests that health care team members do not universally feel that physician fatigue is problematic for patient care, despite providing multiple examples to the contrary. This paradoxical understanding of fatigue likely exists because the system relies on fatigued physicians, particularly trainees, and provides few mechanisms to critically examine fatigue. Successful implementation of fatigue risk management in residency training may prove elusive if clinical supervisors are skeptical of the potentially negative impact of workplace fatigue

Analysis of UK and European NOx and VOC emission scenarios in the Defra model intercomparison exercise

This is a PDF file of an unedited manuscript that has been accepted for publication. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertainSimple emission scenarios have been implemented in eight United Kingdom air quality models with the aim of assessing how these models compared when addressing whether photochemical ozone formation in southern England was NOx- or VOC-sensitive and whether ozone precursor sources in the UK or in the Rest of Europe (RoE) were the most important during July 2006. The suite of models included three Eulerian-grid models (three implementations of one of these models), a Lagrangian atmospheric dispersion model and two moving box air parcel models. The assignments as to NOx- or VOC-sensitive and to UK- versus RoE-dominant, turned out to be highly variable and often contradictory between the individual models. However, when the assignments were filtered by model performance on each day, many of the contradictions could be eliminated. Nevertheless, no one model was found to be the 'best' model on all days, indicating that no single air quality model could currently be relied upon to inform policymakers robustly in terms of NOx- versus VOC-sensitivity and UK- versus RoE-dominance on each day. It is important to maintain a diversity in model approaches.Peer reviewedFinal Accepted Versio

Neolithic pits and Late Bronze Age roundhouses in the Upper Ury Valley, Aberdeenshire

Archaeological monitoring of works on a gas pipeline route in Aberdeenshire, north-west of Inverurie, resulted in the discovery and excavation of several groups of Neolithic pits and four Bronze Age roundhouses. The Neolithic pits were concentrated around the Shevock Burn, a small tributary of the Ury, and in the East and North Lediken areas to the north. They produced significant assemblages of Early Neolithic Impressed Ware and of Modified Carinated Bowl. The Bronze Age roundhouses included the heavily truncated remains of a post-built structure near Pitmachie, the remains of a pair of ring ditch structures near Little Lediken Farm, and another ring ditch structure close to Wrangham village

Decline in Health-Related Quality of Life reported by more than half of those waiting for joint replacement surgery: a prospective cohort study

<p>Abstract</p> <p>Background</p> <p>In many healthcare systems, people with severe joint disease wait months to years for joint replacement surgery. There are little empirical data on the health consequences of this delay and it is unclear whether people with substantial morbidity at entry to the waiting list continue to deteriorate further while awaiting surgery. This study investigated changes in Health-Related Quality of Life (HRQoL), health status and psychological distress among people waiting for total hip (THR) and knee replacement (TKR) surgery at a major metropolitan Australian public hospital.</p> <p>Methods</p> <p>134 patients completed questionnaires including the Assessment of Quality of Life (AQoL) instrument, Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) and Kessler Psychological Distress Scale after entering an orthopaedic waiting list (baseline) and before surgery (preadmission). To quantify potential decline in wellbeing, we calculated the proportion of people experiencing clinically important deterioration using published guidelines and compared HRQoL and psychological distress outcomes with population norms.</p> <p>Results</p> <p>Most participants (69%) waited ≥6 months for surgery (median 286 days, IQR 169-375 days). Despite poor physical and psychological wellbeing at baseline, there was an overall deterioration in HRQoL during the waiting period (mean AQoL change -0.04, 95%CI -0.08 to -0.01), with 53% of participants experiencing decline in HRQoL (≥0.04 AQoL units). HRQoL prior to surgery remained substantially lower than Australian population norms (mean sample AQoL 0.37, 95%CI 0.33 to 0.42 vs mean population AQoL 0.83, 95%CI 0.82 to 0.84). Twenty-five per cent of participants showed decline in health status (≥9.6 WOMAC units) over the waiting period and prevalence of high psychological distress remained high at preadmission (RR 3.5, 95%CI 2.8 to 4.5). Most participants considered their pain (84%), fatigue (76%), quality of life (73%) and confidence in managing their health (55%) had worsened while waiting for surgery.</p> <p>Conclusions</p> <p>Despite substantial initial morbidity, over half of the participants awaiting joint replacement experienced deterioration in HRQoL during the waiting period. These data provide much-needed evidence to guide health professionals and policymakers in the design of care pathways and resource allocation for people who require joint replacement surgery.</p

Coordinating government and community support for community language teaching in Australia: Overview with special attention to New South Wales

An overview of formal government language-in-education planning for community languages (CLs) that has been undertaken in Australia and New South Wales is provided, moving from the more informal programmes provided in the 1980s to school-oriented programmes and training at the turn of the century. These programmes depend on community support; for many of the teachers from the communities, methodological training is needed to complement their language and cultural skills. At the same time, Commonwealth (Federal) and State support for CL programmes has improved their quality and provides students with opportunities to study CLs at the senior secondary matriculation level. The paper concludes with specific recommendations for greater recognition of CL schools and for greater attention to CL teacher preparation

Tyrosine 331 and phenylalanine 334 in Clostridium perfringens α-toxin are essential for cytotoxic activity

AbstractDifferences in the biological properties of the Clostridium perfringens phospholipase C (α-toxin) and the C. bifermentans phospholipase C (Cbp) have been attributed to differences in their carboxy-terminal domains. Three residues in the carboxy-terminal domain of α-toxin, which have been proposed to play a role in membrane recognition (D269, Y331 and F334), are not conserved in Cbp (Y, L and I respectively). We have characterised D269Y, Y331L and F334I variant forms of α-toxin. Variant D269Y had reduced phospholipase C activity towards aggregated egg yolk phospholipid but increased haemolytic and cytotoxic activity. Variants Y331L and F334I showed a reduction in phospholipase C, haemolytic and cytotoxic activities indicating that these substitutions contribute to the reduced haemolytic and cytotoxic activity of Cbp

Analysis of Known Bacterial Protein Vaccine Antigens Reveals Biased Physical Properties and Amino Acid Composition

Many vaccines have been developed from live attenuated forms of bacterial pathogens or from killed bacterial cells. However, an increased awareness of the potential for transient side-effects following vaccination has prompted an increased emphasis on the use of sub-unit vaccines, rather than those based on whole bacterial cells. The identification of vaccine sub-units is often a lengthy process and bioinformatics approaches have recently been used to identify candidate protein vaccine antigens. Such methods ultimately offer the promise of a more rapid advance towards preclinical studies with vaccines. We have compared the properties of known bacterial vaccine antigens against randomly selected proteins and identified differences in the make-up of these two groups. A computer algorithm that exploits these differences allows the identification of potential vaccine antigen candidates from pathogenic bacteria on the basis of their amino acid composition, a property inherently associated with sub-cellular location

Demonstration of a Hybrid Space Architecture During RIMPAC 2020

The Micro-Satellite Military Utility (MSMU) Project Arrangement (PA) is an agreement under the Responsive Space Capabilities (RSC) Memorandum of Understanding (MOU) that involves the Departments and Ministries of Defence of Australia, Canada, Germany, Italy, the Netherlands, New Zealand, Norway, United Kingdom and United States. MSMU’s charter is to inform a space enterprise that provides military users with reliable access to a broad spectrum of information in an opportunistic environment. Research and Development teams from MSMU partner nations supported Exercise Rim of the Pacific (RIMPAC) 2020 which took place 17 to 31 August 2020 in the Hawaiian region. RIMPAC 2020 provided an opportunity to explore the military utility of a Hybrid Space Architecture (HSA) of satellites including traditional government and commercial satellites, as well as micro-satellites and nanosatellites, by leveraging contributions across the MSMU partner nations. The objective was to continue testing the hypothesis that an HSA, mostly composed of small satellites, can bring significant value to the operational theatre. The MSMU PA partner nations have leveraged several multi-national exercises, with the first being the Exercise RIMPAC 2018. Previous exercises enabled multinational technology advancements, interoperability testing, process refinement, and capability developments to make advancements towards MSMU’s goal to address the warfighter’s need for diverse ISR capabilities. The most recent accomplishment was a major integration effort across mission planning tools, space-based Intelligence, Surveillance and Reconnaissance (ISR) data providers, and exploitation tools. The MSMU team accessed ~256 space-based sensors (EO – Electro Optical, SAR – Synthetic Aperture Radar, AIS – Automatic Identification System) to collect maritime domain and ISR data over a harbor, airfields and open sea. Data was exploited via international channels in order to determine the success rate of capturing pertinent data to be later exploited and disseminated. This paper describes results from the experiment and offers insights into the HSA military utility

Functional antibody and T-cell immunity following SARS-CoV-2 infection, including by variants of concern, in patients with cancer: the CAPTURE study

Patients with cancer have higher COVID-19 morbidity and mortality. Here we present the prospective CAPTURE study (NCT03226886) integrating longitudinal immune profiling with clinical annotation. Of 357 patients with cancer, 118 were SARS-CoV-2-positive, 94 were symptomatic and 2 patients died of COVID-19. In this cohort, 83% patients had S1-reactive antibodies, 82% had neutralizing antibodies against WT, whereas neutralizing antibody titers (NAbT) against the Alpha, Beta, and Delta variants were substantially reduced. Whereas S1-reactive antibody levels decreased in 13% of patients, NAbT remained stable up to 329 days. Patients also had detectable SARS-CoV-2-specific T cells and CD4+ responses correlating with S1-reactive antibody levels, although patients with hematological malignancies had impaired immune responses that were disease and treatment-specific, but presented compensatory cellular responses, further supported by clinical. Overall, these findings advance the understanding of the nature and duration of immune response to SARS-CoV-2 in patients with cancer

The contributions to long-term health-relevant particulate matter at the UK EMEP supersites between 2010 and 2013: Quantifying the mitigation challenge

Human health burdens associated with long-term exposure to particulate matter (PM) are substantial. The metrics currently recommended by the World Health Organization for quantification of long-term health-relevant PM are the annual average PM10 and PM2.5 mass concentrations, with no low concentration threshold. However, within an annual average, there is substantial variation in the composition of PM associated with different sources. To inform effective mitigation strategies, therefore, it is necessary to quantify the conditions that contribute to annual average PM10 and PM2.5 (rather than just short-term episodic concentrations). PM10, PM2.5, and speciated water-soluble inorganic, carbonaceous, heavy metal and polycyclic aromatic hydrocarbon components are concurrently measured at the two UK European Monitoring and Evaluation Programme (EMEP) ‘supersites’ at Harwell (SE England) and Auchencorth Moss (SE Scotland). In this work, statistical analyses of these measurements are integrated with air-mass back trajectory data to characterise the ‘chemical climate’ associated with the long-term health-relevant PM metrics at these sites. Specifically, the contributions from different PM concentrations, months, components and geographic regions are detailed. The analyses at these sites provide policy-relevant conclusions on mitigation of (i) long-term health-relevant PM in the spatial domain for which these sites are representative, and (ii) the contribution of regional background PM to long-term health-relevant PM. At Harwell the mean (±1 sd) 2010–2013 annual average concentrations were PM10 = 16.4 ± 1.4 μg m−3 and PM2.5 = 11.9 ± 1.1 μg m−3 and at Auchencorth PM10 = 7.4 ± 0.4 μg m−3 and PM2.5 = 4.1 ± 0.2 μg m−3. The chemical climate state at each site showed that frequent, moderate hourly PM10 and PM2.5 concentrations (defined as approximately 5–15 μg m−3 for PM10 and PM2.5 at Harwell and 5–10 μg m−3 for PM10 at Auchencorth) determined the magnitude of annual average PM10 and PM2.5 to a greater extent than the relatively infrequent high, episodic PM10 and PM2.5 concentrations. These moderate PM10 and PM2.5 concentrations were derived across the range of chemical components, seasons and air-mass pathways, in contrast to the highest PM concentrations which tended to associate with specific conditions. For example, the largest contribution to moderate PM10 and PM2.5 concentrations – the secondary inorganic aerosol components, specifically NO3− – were accumulated during the arrival of trajectories traversing the spectrum of marine, UK, and continental Europe areas. Mitigation of the long-term health-relevant PM impact in the regions characterised by these two sites requires multilateral action, across species (and hence source sectors), both nationally and internationally; there is no dominant determinant of the long-term PM metrics to target