Evaluation of video reflexive ethnography as a tool for improvement of teamwork and communication at the multi-disciplinary maternity unit handover

The implementation of video reflexive ethnography (VRE) is suggested to be a successful tool through which to prompt change and improvement at the inter-professional handover in acute healthcare. This thesis was designed to evaluate VRE as an improvement approach, focused on prompting improvement at the inter-professional clinical handover in an acute maternity team. The main aims of the work were to: 1) understand how team reflexivity has been implemented as a tool for improvement in inter-professional hospital-based healthcare teams, 2) to understand whether VRE is feasible and acceptable as a tool for improvement in an acute maternity unit, 3) the role of the facilitator in the successful delivery of VRE and 4) whether and how VRE was successful in prompting change and improvement. A mixed-methods approach was taken to address these main objectives, and a systematic review of the literature was conducted. Semi-structured interviews and ethnographic field notes were employed to gather data on the feasibility and acceptability of VRE, staff perceptions of the VRE process, and the contextual factors important in the successful delivery of VRE. Qualitative data from the reflexive feedback sessions was explored to understand how staff discovered potential issues from the video footage and collectively developed potential solutions. A short before and after survey was employed to gather the perceptions of the wider staff group on the changes to the handover process. The quantitative data generated was assessed using independent samples t-tests, and suggested significant perceived improvement in communication at the inter-professional handover. Qualitative data was assessed using a combination of inductive and deductive thematic analysis and adapted framework analysis, and illustrated the specific discoveries and solutions identified in the reflexive feedback sessions, as well as information about feasibility, acceptability and salient contextual factors in the delivery of VRE. The qualitative data was used to develop an initial logic model to map the process of VRE. The thesis also considers the implications of the research and potential for future work, as well as limitations and the challenges of undertaking applied research in an acute healthcare environment

The Muses and Creative Inspiration: Homer to Milton

Tracing the influences and references to the Muses in written language from Ancient Greece through the end of the English Renaissance, I discover transformations and revivals in their usage. There are shifts from dependence on deified inspiration to the development of personal insight. Also, there appears to be a conscious substituting of the Muses with the beloved and Cupid or Apollo. But the Muses\u27 religious significance returns in Paradise Lost. The first part of this thesis focuses on the early Greek writers: Homer, Hesiod, Pindar, Plato, and the Latin writers: Ovid, Virgil, Boethius. The second part addresses the English poetic tradition from Chaucer through Milton. The poets cited for this section are Chaucer, Spenser, Sidney, Shakespeare, Donne, Marlowe and Milton. Presentations of the Muses or a personally chosen muse during these literary periods display conceptions of what originally motivates literary creation. I cover both the epic and lyric poetic traditions

Verbal Learning and Transfer of Function in Anxiety

Objective: To evaluate the clinical psychology service provided to South Ayrshire and Arran Trust, to gain an in-depth and accurate analysis of service usage in order to assist future planning and organisation of such a service. Design: Part I involved a casenote review of all patients referred to clinical psychology in year January - December 1997. Part II of the study used a postal questionnaire to survey staff opinions on the service. Setting: Ayr Hospital, South Ayrshire and Arran Trust. Subjects: The casenotes of seventy-eight patients were reviewed for the first part of the study. All potential referrers were surveyed in Part II, including medical consultants & associated specialities, nursing specialists and heads of department of professions allied to medicine. Results: Casenote review revealed the majority of patients are referred for somatoform complaints, although this did not necessarily correspond with the psychologist's diagnosis and formulation following assessment. Questionnaire responses revealed that the majority of referrers were satisfied with the quality of service but dissatisfied with the length of waiting lists and resultant problems in accessing clinical psychology generally. Conclusion: Expansion to the Clinical Psychology service is desirable and this should preferably take the form of dedicated clinical psychology time to specific services, with allocated sessions for indirect work which is currently neglected. The lack of priority attached to such a service, however, means expansion is unlikely to take place in the foreseeable future

Does team reflexivity impact teamwork and communication in interprofessional hospital-based healthcare teams? : A systematic review and narrative synthesis

BACKGROUND: Teamwork and communication are recognised as key contributors to safe and high-quality patient care. Interventions targeting process and relational aspects of care may therefore provide patient safety solutions that reflect the complex nature of healthcare. Team reflexivity is one such approach with the potential to support improvements in communication and teamwork, where reflexivity is defined as the ability to pay critical attention to individual and team practices with reference to social and contextual information. OBJECTIVE: To systematically review articles that describe the use of team reflexivity in interprofessional hospital-based healthcare teams. METHODS: Following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, six electronic databases were searched to identify literature investigating the use of team reflexivity in interprofessional hospital-based healthcare teams.The review includes articles investigating the use of team reflexivity to improve teamwork and communication in any naturally occurring hospital-based healthcare teams. Articles' eligibility was validated by two second reviewers (5%). RESULTS: Fifteen empirical articles were included in the review. Simulation training and video-reflexive ethnography (VRE) were the most commonly used forms of team reflexivity. Included articles focused on the use of reflexive interventions to improve teamwork and communication within interprofessional healthcare teams. Communication during interprofessional teamworking was the most prominent focus of improvement methods. The nature of this review only allows assessment of team reflexivity as an activity embedded within specific methods. Poorly defined methodological information relating to reflexivity in the reviewed studies made it difficult to draw conclusive evidence about the impact of reflexivity alone. CONCLUSION: The reviewed literature suggests that VRE is well placed to provide more locally appropriate solutions to contributory patient safety factors, ranging from individual and social learning to improvements in practices and systems. TRIAL REGISTRATION NUMBER: CRD42017055602

Hospital Costs Related to Early Extubation after Infant Cardiac Surgery

Background The Pediatric Heart Network Collaborative Learning Study (PHN CLS) increased early extubation rates after infant Tetralogy of Fallot (TOF) and coarctation (CoA) repair across participating sites by implementing a clinical practice guideline (CPG). The impact of the CPG on hospital costs has not been studied. Methods PHN CLS clinical data were linked to cost data from Children’s Hospital Association by matching on indirect identifiers. Hospital costs were evaluated across active and control sites in the pre- and post-CPG periods using generalized linear mixed effects models. A difference-in-difference approach was used to assess whether changes in cost observed in active sites were beyond secular trends in control sites. Results Data were successfully linked on 410/428 (96%) of eligible patients from 4 active and 4 control sites. Mean adjusted cost/case for TOF repair was significantly reduced in the post-CPG period at active sites ($42,833 vs.$56,304, p<0.01) and unchanged at control sites ($47,007 vs.$46,476, p=0.91), with an overall cost reduction of 27% in active vs. control sites (p=0.03). Specific categories of cost reduced in the TOF cohort included clinical (-66%, p<0.01), pharmacy (-46%, p=0.04), lab (-44%, p<0.01), and imaging (-32%, p<0.01). There was no change in costs for CoA repair at active or control sites. Conclusions The early extubation CPG was associated with a reduction in hospital costs for infants undergoing repair of TOF, but not CoA repair. This CPG represents an opportunity to both optimize clinical outcome and reduce costs for certain infant cardiac surgeries

Clinical outcomes of patients with corticosteroid refractory immune checkpoint inhibitor induced enterocolitis treated with infliximab

Introduction Immune Checkpoint Inhibitors (CPI) have changed the treatment landscape for many cancers, but also cause severe inflammatory side effects including enterocolitis. CPI-induced enterocolitis is treated empirically with corticosteroids, and infliximab (IFX) is used in corticosteroid-refractory cases. However, robust outcome data for these patients are scarce. Methods We conducted a multi-centre (six cancer centres), cohort study of outcomes in patients treated with IFX for corticosteroid-refractory CPI-induced enterocolitis between 2007 and 2020. The primary outcome was corticosteroid-free clinical remission (CFCR) with CTCAE grade 0 for diarrhoea at 12 weeks after IFX initiation. We also assessed cancer outcomes at one year using RECIST criteria. Results 127 patients (73 male; median age 59 years) were treated with IFX for corticosteroid-refractory CPI-induced enterocolitis. Ninety-six (75.6%) patients had diarrhoea CTCAE grade >2 and 115 (90.6%) required hospitalisation for colitis. CFCR was 41.2% at 12 weeks and 50.9% at 26 weeks. In multivariable logistical regression, IFX-resistant enterocolitis was associated with rectal bleeding (OR 0.19; 95% CI 0.04-0.80; p=0.03) and absence of colonic crypt abscesses (OR 2.16; 95% CI 1.13-8.05; p=0.03). Cancer non-progression was significantly more common in patients with IFX-resistant enterocolitis (64.4%) as compared to patients with IFX-responsive enterocolitis (37.5%; p=0.013). Conclusion This is the largest study to date reporting outcomes of IFX therapy in patients with corticosteroid-refractory CPI-induced enterocolitis. Utilizing pre-defined robust endpoints, we have demonstrated that fewer than half of patients achieved CFCR. Our data also indicate that cancer outcomes may be better in patients developing prolonged and severe inflammatory side effects of CPI-therapy

Transplacental Transmission of Leishmania infantum as a Means for Continued Disease Incidence in North America

Dogs are a favored feeding source for sand flies that transmit human L. infantum infection. Zoonotic visceral leishmaniasis (ZVL) is an emerging problem in some U.S. dog breeds, with over 20% of at-risk Foxhounds infected. Although classically Leishmania is transmitted by infected sand flies which exist in the United States, no role has yet been determined for vector-borne transmission. Means of ongoing L. infantum transmission in U.S. dogs is unknown. Possibilities include transplacental and horizontal/venereal transmission. Aims for this study were to establish whether transplacental transmission occurred in Leishmania-infected U.S. dogs and determine the effect of this transmission on immune recognition of Leishmania. This novel report describes wide-spread infection as identified by kqPCR in 8 day-old pups born to a naturally-infected, seropositive U.S. dog with no travel history. This is the first report of transplacental transmission of L. infantum in naturally-infected dogs in North America. Evidence that mom-to-pup transmission of ZVL may continue disease in an otherwise non-endemic region has significant implications on current control strategies for ZVL. Determining frequency of vertical transmission and incorporating canine sterilization with vector control may have a more significant impact on ZVL transmission to people in endemic areas than current control efforts

Shopping, sex, and lies: Mimong/Sweet Dreams (1936) and the disruptive process of colonial girlhood

In the early Korean film we follow the melodramatic life of an unfaithful housewife. Sweet Dreams situates itself at the heart of the Korean colonial experience with urban Seoul as the backdrop to a narrative of deceit, adultery and consumerism. This article will explore how Sweet Dreams functions both as a warning about the perils of modern womanhood and, simultaneous to this, a vision of consumerist pleasure and delight. This article examines how the actions of lead character Ae-soon constitute a process by which the adult women is rendered girl via her positioning at the locus of female visual pleasure. I use the term girl as a process rather than a static category since, as will be explored, the attributes of girlhood with relation to Sweet Dreams are both expansive and fluid. In this way girlhood can be appropriated for transgressive purposes, not only in terms of a visualization of a desiring femininity, but also as a marker of colonial dissent. I argue that Sweet Dreams uses the interplay between the categories of woman and girl to disrupt the colonial drive towards a productive body in favour of the delights of consumption

State Policy Responses to COVID-19 in Nursing Homes

Context: COVID-19 has a high case fatality rate in high-risk populations and can cause severe morbidity and high healthcare resource use. Nursing home residents are a high-risk population; they live in congregate settings, often with shared rooms, and require hands-on care. Objectives: To assess state responses to the coronavirus pandemic related to nursing homes in the first half of 2020. Methods: An in-depth examination of 12 states’ responses to the COVID-19 pandemic in nursing homes through June 2020, using publicly reported information such as government decrees, health department guidance, and news reports. Findings: No state emerged as a model of care. All states faced difficulty with limited availability of testing and Personal Protective Equipment (PPE). State-level efforts to increase pay and benefits as a strategy to enable infected staff to quickly physically separate from residents were minimal, and other separation strategies depended on the ability to obtain test results rapidly and on state rules regarding accepting discharged COVID-19 patients into nursing homes. Visitor restrictions to reduce risk were ubiquitous, though based on a slim evidence-base. Limitations: The information used was limited to that which was publicly available. Implications: Overall, the results suggest that the states that handle the ongoing pandemic in nursing homes best will be those that find ways to make sure nursing homes have the resources to follow best practices for testing, PPE, separation, and staffing. Evidence is needed on visitor restrictions and transmission, as states and their citizens would benefit from finding safe ways to relax visitor restrictions

NIK Stabilization in Osteoclasts Results in Osteoporosis and Enhanced Inflammatory Osteolysis

Maintenance of healthy bone requires the balanced activities of osteoclasts (OCs), which resorb bone, and osteoblasts, which build bone. Disproportionate action of OCs is responsible for the bone loss associated with postmenopausal osteoporosis and rheumatoid arthritis. NF-κB inducing kinase (NIK) controls activation of the alternative NF-κB pathway, a critical pathway for OC differentiation. Under basal conditions, TRAF3-mediated NIK degradation prevents downstream signaling, and disruption of the NIK:TRAF3 interaction stabilizes NIK leading to constitutive activation of the alternative NF-κB pathway.Using transgenic mice with OC-lineage expression of NIK lacking its TRAF3 binding domain (NT3), we now find that alternative NF-κB activation enhances not only OC differentiation but also OC function. Activating NT3 with either lysozyme M Cre or cathepsinK Cre causes high turnover osteoporosis with increased activity of OCs and osteoblasts. In vitro, NT3-expressing precursors form OCs more quickly and at lower doses of RANKL. When cultured on bone, they exhibit larger actin rings and increased resorptive activity. OC-specific NT3 transgenic mice also have an exaggerated osteolytic response to the serum transfer model of arthritis.Constitutive activation of NIK drives enhanced osteoclastogenesis and bone resorption, both in basal conditions and in response to inflammatory stimuli