Neurophysiology

Contains reports on two research projects.National Institutes of Health (Grant 5 PO1 GM14940-07

Transfer of training from an internal medicine boot camp to the workplace:enhancing and hindering factors

Background: The transfer of training to the workplace is the aim of training interventions. Three primary factors influence transfer: trainee characteristics, training design and work environment influences. Within medical education, the work environment factors influencing transfer of training remain underexplored. Burke and Hutchins’ review of training transfer outlined five work environment influences: opportunity to perform, supervisor/peer support, strategic link, transfer climate and accountability. This study aimed to explore the ways in which work environment factors influence the transfer of training for medical trainees. Methods: Internal Medicine Training in Scotland includes a three-day boot camp involving simulation-based mastery learning of procedural skills, immersive simulation scenarios and communication workshops. Following ethical approval, trainees were invited to take part in interviews at least three months after following their boot camp. Interviews were semi-structured, anonymised, transcribed verbatim and analysed using template analysis. Member checking interviews were performed to verify findings. Results: A total of 26 trainees took part in interviews between January 2020 and January 2021. Trainees reported a lack of opportunities to perform procedures in the workplace and challenges relating to the transfer climate, including a lack of appropriate equipment and resistance to change in the workplace. Trainees described a strong sense of personal responsibility to transfer and they felt empowered to change practice in response to the challenges faced. Conclusions: This study highlights barriers to transfer of training within the clinical workplace including procedural opportunities, a transfer climate with challenging equipment availability and, at times, an unsupportive workplace culture. Trainees are driven by their own sense of personal responsibility; medical educators and healthcare leaders must harness this enthusiasm and take heed of the barriers to assist in the development of strategies to overcome them.</p

The impact of simulation-based mastery learning, booster session timing and clinical exposure on confidence in intercostal drain insertion:a survey of internal medicine trainees in Scotland

Background: Intercostal chest drain (ICD) insertion is a skill that medical trainees lack confidence in performing. This study explores the impact of a national programme of Simulation-Based Mastery Learning (SBML) on procedural confidence, including the impact of time intervals between booster sessions and interim clinical experience. Methods: Internal Medicine Trainees in Scotland were surveyed about confidence and clinical experience with ICD insertion before and immediately after SBML and booster session. Data were matched and analysed using paired sample t-tests. Short interval and long interval groups were compared using Student’s unpaired t-test. The impact of interim clinical experience was assessed using Analysis of Variance. Results: Mean confidence in ICD insertion rose following SBML, fell between initial and booster session, and increased again following booster session (P = &lt; 0.001). 33 of 74 trainees had successfully inserted an ICD between sessions. Fall in confidence was unaffected by the time interval between training sessions, but was mitigated by interim clinical experience. Conclusions: SBML boosts trainee confidence in ICD insertion. However, there is evidence of confidence decay, possibly due to a lack of clinical experience between sessions. More research is needed to explore barriers to transfer of skills from simulated to real-world environments.</p

Distribution and thermal niche of the common skate species complex in the north-east Atlantic

Temperature is one of the most significant variables affecting the geographic distribution and physiology of elasmobranchs. Differing thermal gradients across a species' range can lead to adaptive divergence and differing developmental times, an important consideration for recruitment rates of exploited species. The Critically Endangered common skate (formerly Dipturus batis) has been divided into 2 species, the flapper skate D. intermedius and blue skate D. batis, both of which have undergone dramatic population declines. Here we examine the environmental thermal and geographic distribution of these species, using observations from scientific trawling surveys and recreational angling around the British Isles. As similar-sized specimens of the 2 species can be confused, we validated species identity using molecular genetic techniques. Both species had more extensive geographic ranges than previously reported and different spatial patterns of abundance. The distribution of the blue skate appears to reflect its partiality to thermally less variable and warmer waters, while flapper skate were found in more variable and notably colder areas. The thermal range and current geographic distribution of these species indicate that future projected climate change could have a differential impact on distribution of flapper and blue skate in the north-east Atlantic

Population and seascape genomics of a critically endangered benthic elasmobranch, the blue skate Dipturus batis

The blue skate (Dipturus batis) has a patchy distribution across the North-East Atlantic Ocean, largely restricted to occidental seas around the British Isles following fisheries-induced population declines and extirpations. The viability of remnant populations remains uncertain, and could be impacted by continued fishing and bycatch pressure and the projected impacts of climate change. We genotyped 503 samples of D. batis, obtained opportunistically from the widest available geographic range, across 6,350 single nucleotide polymorphisms (SNPs) using a reduced-representation sequencing approach. Genotypes were used to assess the species’ contemporary population structure, estimate effective population sizes, and identify putative signals of selection in relation to environmental variables using a seascape genomics approach. We identified genetic discontinuities between inshore (British Isles) and offshore (Rockall and Faroe Island) populations, with differentiation most pronounced across the deep waters of the Rockall Trough. Effective population sizes were largest in the Celtic Sea and Rockall, but low enough to be of potential conservation concern among Scottish and Faroese sites. Among the 21 candidate SNPs under positive selection was one significantly correlated with environmental variables predicted to be affected by climate change, including bottom temperature, salinity, and pH. The paucity of well annotated elasmobranch genomes precluded us from identifying a putative function for this SNP. Nevertheless, our findings suggest that climate change could inflict a strong selective force upon remnant populations of D. batis, further constraining its already restricted habitat. Furthermore, the results provide fundamental insights on the distribution, behaviour, and evolutionary biology of D. batis in the North-East Atlantic that will be useful for the establishment of conservation actions for this and other critically endangered elasmobranchs

Present and Future CP Measurements

We review theoretical and experimental results on CP violation summarizing the discussions in the working group on CP violation at the UK phenomenology workshop 2000 in Durham.Comment: 104 pages, Latex, to appear in Journal of Physics

Parental experiences of supporting children with clinically significant post-traumatic distress: a qualitative study of families accessing psychological services

The aim of this study was to investigate the experiences of parents in providing support to their child following trauma exposure in cases where children are experiencing clinically significant levels of post-traumatic distress. Qualitative interviews were conducted with parents whose child was exposed to a trauma and referred for psychological treatment. Parents reported considerable anxiety in coping with their child’s post-traumatic distress. Avoidance of trauma-related discussions was encouraged due to concerns that non-avoidant approaches may worsen children’s post-trauma difficulties. Nonetheless, parents were often sensitive to their child’s distress and offered reassurance and other forms of support. Many barriers existed to accessing psychological treatment, and perceptions of inadequate guidance from therapists on supporting child adjustment contributed to parental distress. The results illustrate the strategies used by parents in supporting their child post-trauma and may assist mental health professionals in providing acceptable guidance to parents following child trauma

COSMOS: COmparing Standard Maternity care with One-to-one midwifery Support: a randomised controlled trial

Background: In Australia and internationally, there is concern about the growing proportion of women giving birth by caesarean section. There is evidence of increased risk of placenta accreta and percreta in subsequent pregnancies as well as decreased fertility; and significant resource implications. Randomised controlled trials (RCTs) of continuity of midwifery care have reported reduced caesareans and other interventions in labour, as well as increased maternal satisfaction, with no statistically significant differences in perinatal morbidity or mortality. RCTs conducted in the UK and in Australia have largely measured the effect of teams of care providers (commonly 6&ndash;12 midwives) with very few testing caseload (one-to-one) midwifery care. This study aims to determine whether caseload (one-to-one) midwifery care for women at low risk of medical complications decreases the proportion of women delivering by caesarean section compared with women receiving \u27standard\u27 care. This paper presents the trial protocol in detail.Methods/design: A two-arm RCT design will be used. Women who are identified at low medical risk will be recruited from the antenatal booking clinics of a tertiary women\u27s hospital in Melbourne, Australia. Baseline data will be collected, then women randomised to caseload midwifery or standard low risk care. Women allocated to the caseload intervention will receive antenatal, intrapartum and postpartum care from a designated primary midwife with one or two antenatal visits conducted by a \u27back-up\u27 midwife. The midwives will collaborate with obstetricians and other health professionals as necessary. If the woman has an extended labour, or if the primary midwife is unavailable, care will be provided by the back-up midwife. For women allocated to standard care, options include midwifery-led care with varying levels of continuity, junior obstetric care and community based general medical practitioner care. Data will be collected at recruitment (self administered survey) and at 2 and 6 months postpartum by postal survey. Medical/obstetric outcomes will be abstracted from the medical record. The sample size of 2008 was calculated to identify a decrease in caesarean birth from 19 to 14% and detect a range of other significant clinical differences. Comprehensive process and economic evaluations will be conducted.Trial registration: Australian New Zealand Clinical Trials Registry ACTRN012607000073404.<br /

Increasing frailty is associated with higher prevalence and reduced recognition of delirium in older hospitalised inpatients: results of a multi-centre study

Purpose: Delirium is a neuropsychiatric disorder delineated by an acute change in cognition, attention, and consciousness. It is common, particularly in older adults, but poorly recognised. Frailty is the accumulation of deficits conferring an increased risk of adverse outcomes. We set out to determine how severity of frailty, as measured using the CFS, affected delirium rates, and recognition in hospitalised older people in the United Kingdom. Methods: Adults over 65 years were included in an observational multi-centre audit across UK hospitals, two prospective rounds, and one retrospective note review. Clinical Frailty Scale (CFS), delirium status, and 30-day outcomes were recorded. Results: The overall prevalence of delirium was 16.3% (483). Patients with delirium were more frail than patients without delirium (median CFS 6 vs 4). The risk of delirium was greater with increasing frailty [OR 2.9 (1.8–4.6) in CFS 4 vs 1–3; OR 12.4 (6.2–24.5) in CFS 8 vs 1–3]. Higher CFS was associated with reduced recognition of delirium (OR of 0.7 (0.3–1.9) in CFS 4 compared to 0.2 (0.1–0.7) in CFS 8). These risks were both independent of age and dementia. Conclusion: We have demonstrated an incremental increase in risk of delirium with increasing frailty. This has important clinical implications, suggesting that frailty may provide a more nuanced measure of vulnerability to delirium and poor outcomes. However, the most frail patients are least likely to have their delirium diagnosed and there is a significant lack of research into the underlying pathophysiology of both of these common geriatric syndromes