Scratching beneath the surface : how organisational culture influences curricular reform

Funding information: This work was supported by the Royal College of Surgeons of Edinburgh [Grant number RG-15026]. ACKNOWLEDGEMENTS We would like to thank Graham Haddock, Satheesh Yalamarthi and Mark Vella for their assistance with participant recruitment, and all the surgical trainees and trainers who took part in the study.Peer reviewedPublisher PD

It's making me think outside the box at times : a qualitative study of dynamic capabilities in surgical training.

Acknowledgements The authors would like to thank Graham Haddock, Satheesh Yalamarthi, and Mark Vella for their assistance with participant recruitment. Funding Information: This work was supported by the Royal College of Surgeons of Edinburgh [Grant number RG-15026].Peer reviewedPublisher PD

Programming Protocol-Independent Packet Processors

P4 is a high-level language for programming protocol-independent packet processors. P4 works in conjunction with SDN control protocols like OpenFlow. In its current form, OpenFlow explicitly specifies protocol headers on which it operates. This set has grown from 12 to 41 fields in a few years, increasing the complexity of the specification while still not providing the flexibility to add new headers. In this paper we propose P4 as a strawman proposal for how OpenFlow should evolve in the future. We have three goals: (1) Reconfigurability in the field: Programmers should be able to change the way switches process packets once they are deployed. (2) Protocol independence: Switches should not be tied to any specific network protocols. (3) Target independence: Programmers should be able to describe packet-processing functionality independently of the specifics of the underlying hardware. As an example, we describe how to use P4 to configure a switch to add a new hierarchical label

Development of improved inhibitors of wall teichoic acid biosynthesis with potent activity against Staphylococcus aureus

A small molecule (1835F03) that inhibits Staphylococcus aureus wall teichoic acid biosynthesis, a proposed antibiotic target, has been discovered. Rapid, parallel, solution-phase synthesis was employed to generate a focused library of analogs, providing detailed information about structure–activity relationships and leading to the identification of targocil, a potent antibiotic

The CRISP colorectal cancer risk prediction tool: an exploratory study using simulated consultations in Australian primary care

Abstract Background In Australia, screening for colorectal cancer (CRC) with colonoscopy is meant to be reserved for people at increased risk, however, currently there is a mismatch between individuals’ risk of CRC and the type of CRC screening they receive. This paper describes the development and optimisation of a Colorectal cancer RISk Prediction tool (‘CRISP’) for use in primary care. The aim of the CRISP tool is to increase risk-appropriate CRC screening. Methods CRISP development was informed by previous experience with developing risk tools for use in primary care and a systematic review of the evidence. A CRISP prototype was used in simulated consultations by general practitioners (GPs) with actors as patients. GPs were interviewed to explore their experience of using CRISP, and practice nurses (PNs) and practice managers (PMs) were interviewed after a demonstration of CRISP. Transcribed interviews and video footage of the ‘consultations’ were qualitatively analyzed. Themes arising from the data were mapped onto Normalization Process Theory (NPT). Results Fourteen GPs, nine PNs and six PMs were recruited from 12 clinics. Results were described using the four constructs of NPT: 1) Coherence: Clinicians understood the rationale behind CRISP, particularly since they were familiar with using risk tools for other conditions; 2) Cognitive participation: GPs welcomed the opportunity CRISP provided to discuss healthy and unhealthy behaviors with their patients, but many GPs challenged the screening recommendation generated by CRISP; 3) Collective Action: CRISP disrupted clinician-patient flow if the GP was less comfortable with computers. GP consultation time was a major implementation barrier and overall consensus was that PNs have more capacity and time to use CRISP effectively; 4) Reflexive monitoring: Limited systematic monitoring of new interventions is a potential barrier to the sustainable embedding of CRISP. Conclusions CRISP has the potential to improve risk-appropriate CRC screening in primary care but was considered more likely to be successfully implemented as a nurse-led intervention

Organization of Subunits in the Membrane Domain of the Bovine F-ATPase Revealed by Covalent Cross-linking.

The F-ATPase in bovine mitochondria is a membrane-bound complex of about 30 subunits of 18 different kinds. Currently, ∼85% of its structure is known. The enzyme has a membrane extrinsic catalytic domain, and a membrane intrinsic domain where the turning of the enzyme's rotor is generated from the transmembrane proton-motive force. The domains are linked by central and peripheral stalks. The central stalk and a hydrophobic ring of c-subunits in the membrane domain constitute the enzyme's rotor. The external surface of the catalytic domain and membrane subunit a are linked by the peripheral stalk, holding them static relative to the rotor. The membrane domain contains six additional subunits named ATP8, e, f, g, DAPIT (diabetes-associated protein in insulin-sensitive tissues), and 6.8PL (6.8-kDa proteolipid), each with a single predicted transmembrane α-helix, but their orientation and topography are unknown. Mutations in ATP8 uncouple the enzyme and interfere with its assembly, but its roles and the roles of the other five subunits are largely unknown. We have reacted accessible amino groups in the enzyme with bifunctional cross-linking agents and identified the linked residues. Cross-links involving the supernumerary subunits, where the structures are not known, show that the C terminus of ATP8 extends ∼70 Å from the membrane into the peripheral stalk and that the N termini of the other supernumerary subunits are on the same side of the membrane, probably in the mitochondrial matrix. These experiments contribute significantly toward building up a complete structural picture of the F-ATPase.This work was supported by the intramural program of the Medical Research Council (MRC Grant U105663150 (to J. E. W.)

Incorporating temporal and spatial variability of salt-marsh foraminifera into sea-level reconstructions

Foraminifera from salt-marsh environments have been used extensively in quantitative relative sea-level reconstructions due to their strong relationship with tidal level. However, the influence of temporal and spatial variability of salt-marsh foraminifera on quantitative reconstructions remains unconstrained. Here, we conducted a monitoring study of foraminifera from four intertidal monitoring stations in New Jersey from high marsh environments over three years that included several extreme weather (temperature, precipitation, and storm surge) events. We sampled four replicates from each station seasonally (four times per year) for a total of 188 samples. The dead foraminiferal assemblages were separated into four site-specific assemblages. After accounting for systematic trends in changes in foraminifera over time among stations, the distribution of foraminiferal assemblages across monitoring stations explained ~87% of the remaining variation, while ~13% can be explained by temporal and/or spatial variability among the replicate samples. We applied a Bayesian transfer function to estimate the elevation of the four monitoring stations. All samples from each station predicted an elevation estimate within a 95% uncertainty interval consistent with the observed elevation of that station. Combining samples into replicate- and seasonal-aggregate datasets decreased elevation estimate uncertainty, with the greatest decrease in aggregate datasets from Fall and Winter. Information about the temporal and spatial variability of modern foraminiferal distributions was formally incorporated into the Bayesian transfer function through informative foraminifera variability priors and was applied to a Common Era relative sea-level record in New Jersey. The average difference in paleomarsh elevation estimates and uncertainties using an informative vs uninformative prior was minimal

Euthanasia-related strain and coping strategies in animal shelter employees

Objective—To identify and evaluate coping strategies advocated by experienced animal shelter workers who directly engaged in euthanizing animals. Design—Cross-sectional study. Sample Population—Animal shelters across the United States in which euthanasia was conducted (5 to 100 employees/shelter). Procedures—With the assistance of experts associated with the Humane Society of the United States, the authors identified 88 animal shelters throughout the United States in which animal euthanasia was actively conducted and for which contact information regarding the shelter director was available. Staff at 62 animal shelters agreed to participate in the survey. Survey packets were mailed to the 62 shelter directors, who then distributed them to employees. The survey included questions regarding respondent age, level of education, and role and asked those directly involved in the euthanasia of animals to provide advice on strategies for new euthanasia technicians to deal with the related stress. Employees completed the survey and returned it by mail. Content analysis techniques were used to summarize survey responses. Results—Coping strategies suggested by 242 euthanasia technicians were summarized into 26 distinct coping recommendations in 8 categories: competence or skills strategies, euthanasia behavioral strategies, cognitive or self-talk strategies, emotional regulation strategies, separation strategies, get-help strategies, seek long-term solution strategies, and withdrawal strategies. Conclusions and Clinical Relevance—Euthanizing animals is a major stressor for many animal shelter workers. Information regarding the coping strategies identified in this study may be useful for training new euthanasia technicians

Scabies outbreaks in ten care homes for elderly people: a prospective study of clinical features, epidemiology, and treatment outcomes

Background Scabies outbreaks in residential and nursing care homes for elderly people are common, subject to diagnostic delay, and hard to control. We studied clinical features, epidemiology, and outcomes of outbreaks in the UK between 2014 and 2015. Methods We did a prospective observational study in residential care homes for elderly people in southeast England that reported scabies outbreaks to Public Health England health protection teams. An outbreak was defined as two or more cases of scabies (in either residents or staff) at a single care home. All patients who provided informed consent were included; patients with dementia were included if a personal or nominated consultee (ie, a family member or nominated staff member) endorsed participation. Dermatology-trained physicians examined residents at initial clinical visits, which were followed by two mass treatments with topical scabicide as per local health protection team guidance. Follow-up clinical visits were held 6 weeks after initial visits. Scabies was diagnosed through pre-defined case definitions as definite, probable, or possible with dermatoscopy and microscopy as appropriate. Findings 230 residents were examined in ten outbreaks between Jan 23, 2014, and April 13, 2015. Median age was 86·9 years (IQR 81·5–92·3), 174 (76%) were female, and 157 (68%) had dementia. 61 (27%) residents were diagnosed with definite, probable, or possible scabies, of whom three had crusted scabies. Physical signs differed substantially from classic presentations. 31 (51%) of the 61 people diagnosed with scabies were asymptomatic, and only 25 (41%) had burrows. Mites were visualised with dermatoscopy in seven (11%) patients, and further confirmed by microscopy in three (5%). 35 (57%) cases had signs of scabies only on areas of the body that would normally be covered. Dementia was the only risk factor for a scabies diagnosis that we identified (odds ratio 2·37 [95% CI 1·38–4·07]). At clinical follow-up, 50 people who were initially diagnosed with scabies were examined. No new cases of scabies were detected, but infestation persisted in ten people. Interpretation Clinical presentation of scabies in elderly residents of care homes differs from classic descriptions familiar to clinicians. This difference probably contributes to delayed recognition and suboptimal management in this vulnerable group. Dermatoscopy and microscopy were of little value. Health-care workers should be aware of the different presentation of scabies in elderly people, and should do thorough examinations, particularly in people with dementia. Funding Public Health England and British Skin Foundation