Using the MRC Framework for Complex Interventions to Develop Clinical Decision Support: A Case Study.

The Medical Research Council (MRC) framework for complex interventions provides useful guidance to assist with the development and evaluation of health technology interventions such as decision support. In this paper we briefly summarise a project that focused on designing a decision support intervention to assist with the recognition, assessment and management of pain in patients with dementia in an acute hospital setting. We reflect on our experience of using the MRC framework to guide our study design, and highlight the importance of considering decision support interventions as complex interventions

The effects of river flooding on dioxin and PCBs in beef

In 2008-2010, samples of meat from 40 beef cattle, along with grass, soil and commercial feed, taken from ten matched pairs of flood-prone and control farms, were analysed for PCDD/Fs and PCBs. Concentrations were higher in soil and grass from flood-prone farms. The beef samples from flood-prone farms had total TEQ levels about 20% higher than on control farms. A majority of flood-prone farms (7/10) had higher median levels in beef than on the corresponding control farm. This first controlled investigation into PCDD/F and PCB contamination in beef produced on flood-prone land, presents robust evidence that flooding is a contaminant transfer mechanism to cattle raised on river catchments with a history of urbanisation and industrialisation. PCDD/F and PCB sources in these river systems are likely to be a result of the legacy of contamination from previous industrialisation, as well as more recent combustion activity or pollution events. Crow

Ablation debris control by means of closed thick film filtered water immersion

The performance of laser ablation generated debris control by means of open immersion techniques have been shown to be limited by flow surface ripple effects on the beam and the action of ablation plume pressure loss by splashing of the immersion fluid. To eradicate these issues a closed technique has been developed which ensured a controlled geometry for both the optical interfaces of the flowing liquid film. This had the action of preventing splashing, ensuring repeatable machining conditions and allowed for control of liquid flow velocity. To investigate the performance benefits of this closed immersion technique bisphenol A polycarbonate samples have been machined using filtered water at a number of flow velocities. The results demonstrate the efficacy of the closed immersion technique: a 93% decrease in debris is produced when machining under closed filtered water immersion; the average debris particle size becomes larger, with an equal proportion of small and medium sized debris being produced when laser machining under closed flowing filtered water immersion; large debris is shown to be displaced further by a given flow velocity than smaller debris, showing that the action of flow turbulence in the duct has more impact on smaller debris. Low flow velocities were found to be less effective at controlling the positional trend of deposition of laser ablation generated debris than high flow velocities; but, use of excessive flow velocities resulted in turbulence motivated deposition. This work is of interest to the laser micromachining community and may aide in the manufacture of 2.5D laser etched patterns covering large area wafers and could be applied to a range of wavelengths and laser types

Underperforming policy networks : the biopesticides network in the United Kingdom

Loosely integrated and incomplete policy networks have been neglected in the literature. They are important to consider in terms of understanding network underperformance. The effective delivery and formulation of policy requires networks that are not incomplete or underperforming. The biopesticides policy network in the United Kingdom is considered and its components identified with an emphasis on the lack of integration of retailers and environmental groups. The nature of the network constrains the actions of its agents and frustrates the achievement of policy goals. A study of this relatively immature policy network also allows for a focus on network formation. The state, via an external central government department, has been a key factor in the development of the network. Therefore, it is important to incorporate such factors more systematically into understandings of network formation. Feedback efforts from policy have increased interactions between productionist actors but the sphere of consumption remains insufficiently articulated

The relative meaning of absolute numbers: the case of pain intensity scores as decision support systems for pain management of patients with dementia.

Assessment and management of pain in patients with dementia is known to be challenging, due to patients' cognitive and/or communication difficulties. In the UK, pain in hospital is managed through regular assessments, with the use of pain intensity scores as triggers for action. The aim of this study was to understand current pain assessment practices, in order to later inform the development of a decision support tool designed to improve the management of pain for people with dementia in hospital. An exploratory study was conducted in four hospitals in the UK (11 wards), with observations of patients with dementia (n = 31), interviews of staff (n = 52) and patients' family members (n = 4) and documentary analysis. A thematic analysis was carried out, structured along dimensions of decision making. This paper focuses on the emergent themes related to the use of assessment tools and pain intensity scores. A variety of tools were used to record pain intensity, usually with numerical scales. None of the tools in actual use had been specifically designed for patients with cognitive impairment. With patients with more severe dementia, the patient's body language and other cues were studied to infer pain intensity and then a score entered on behalf of the patient. Information regarding the temporality of pain and changes in pain experience (rather than a score at a single point in time) seemed to be most useful to the assessment of pain. Given the inherent uncertainty of the meaning of pain scores for patients with dementia, numerical scales were used with caution. Numerical scores triggered action but their meaning was relative - to the patient, to the clinician, to the time of recording and to the purpose of documenting. There are implications for use of data and computerized decision support systems design. Decision support interventions should include personalized alerting cut-off scores for individual patients, display pain scores over time and integrate professional narratives, mitigating uncertainties around single pain scores for patients with dementia

Improvement in immune parameters and human immunodeficiency virus-1 viral response in individuals treated with 16α-bromoepiandrosterone (HE2000)

ABSTRACTA randomised, double-blind, placebo-controlled study examined the safety, tolerance, immunological effect and anti-human immunodeficiency virus (HIV) activity of sub-cutaneously administered HE2000 (16α-bromoepiandrosterone) as monotherapy in treatment-naïve patients with HIV-1. Twenty-four patients received five sequential daily doses of 50 or 100 mg of HE2000 or placebo every 6 weeks for up to three courses, and were followed thereafter for 3 months. HE2000 was safe, with transient injection site reactions being the main side-effect. Peripheral blood samples, collected serially, were analysed for changes in immune cell phenotypes. Significant increases were observed in the numbers of circulating dendritic cells, early activated (CD69+CD25–) CD8 T-cells and T-NK cells after administration of 50-mg doses of HE2000 (p <0.05). Gene expression in peripheral blood mononuclear cells was analysed by real-time RT-PCR. Before treatment, HIV-1-infected patients had significantly elevated transcripts for a number of inflammatory mediators (p <0.012). After 50 mg or 100 mg HE2000, but not after placebo, there were significant sustained decreases in IL-1β, TNF-α, IL-6 and Cox-2 transcripts (p <0.05). There were no significant differences in CD4 cell numbers, although patients receiving 50-mg doses demonstrated a significant decrease in viral load (– 0.6 log; p <0.01). Anti-HIV-1 T-cell responses were analysed serially using GAG-peptides to stimulate cytoplasmic IFN-γ responses. After three courses, the 50-mg dose group demonstrated a significant increase in CD8 T-cell response against two distinct GAG peptide pools (p <0.03). These findings suggest that immune-based therapies may be able to impact viral load by decreasing inflammation and/or stimulating CD8 T-cells

The use and impact of digital COVID-19 tracking in adult social care: a prospective cohort study of care homes in Greater Manchester

Background: To support proactive care during the coronavirus pandemic, a digital COVID-19 symptom tracker was deployed in Greater Manchester (UK) care homes. This study aimed to understand what factors were associated with the post-uptake use of the tracker and whether the tracker had any effects in controlling the spread of COVID-19. Methods: Daily data on COVID-19, tracker uptake and use, and other key indicators such as staffing levels, the number of staff self-isolating, availability of personal protective equipment, bed occupancy levels, and any problems in accepting new residents were analysed for 547 care homes across Greater Manchester for the period April 2020 to April 2021. Differences in tracker use across local authorities, types of care homes, and over time were assessed using correlated effects logistic regressions. Differences in numbers of COVID-19 cases in homes adopting versus not adopting the tracker were compared via event design difference-in-difference estimations. Results: Homes adopting the tracker used it on 44% of days post-adoption. Use decreased by 88% after one year of uptake (odds ratio 0.12; 95% confidence interval 0.06-0.28). Use was highest in the locality initiating the project (odds ratio 31.73; 95% CI 3.76-268.05). Care homes owned by a chain had lower use (odds ratio 0.30; 95% CI 0.14-0.63 versus single ownership care homes), and use was not associated with COVID-19 or staffing levels. Tracker uptake had no impact on controlling COVID-19 spread. Staff self-isolating and local area COVID-19 cases were positively associated with lagged COVID-19 spread in care homes (relative risks 1.29; 1.2-1.4 and 1.05; 1.0-1.1, respectively). Conclusions: The use of the COVID-19 symptom tracker in care homes was not maintained except in Locality 1 and did not appear to reduce the COVID-19 spread. COVID-19 cases in care homes were mainly driven by care home local-area COVID-19 cases and infections among the staff members. Digital deterioration trackers should be co-produced with care home staff, and local authorities should provide long-term support in their adoption and use

Embedding robotic surgery into routine practice and impacts on communication and decision making: A review of the experience of surgical teams

While an increasing number of healthcare providers are purchasing surgical robots because of anticipated improvements in patient outcomes, their implementation into practice is highly variable. In robotic surgery, the surgeon is physically separated from the patient and the rest of the team with the potential to impact communication and decision making in the operating theatre and subsequently patient safety. Drawing on the approach of realist evaluation, in this article we review reports of the experience of surgical teams that have introduced robotic surgery to identify how and in what contexts robotic surgery is successfully integrated into practice and how and in what contexts it affects communication and decision making. Our analysis indicates that, while robotic surgery might bring about a number of benefits, it also creates new challenges. Robotic surgery is associated with increased operation duration, which has implications for patient safety, but strategies to reduce it can be effective with appropriate support from hospital administration and nursing management. The separation of the surgeon from the team can compromise communication but may be overcome through use of standardised communication. While surgeon situation awareness may be affected by the separation, the ergonomic benefits of robotic surgery may reduce stress and tiredness and enhance surgeon decision making. Our review adds to the existing literature by revealing strategies to support the introduction of robotic surgery and contextual factors that need to be in place for these to be effective

Atmospheric Flow Validation for Contaminant Transport

Presentation on atmospheric flow validation for contaminant transport.https://digitalcommons.usmalibrary.org/presentations/1015/thumbnail.jp

Analyzing the properties promoting shear bands and damage initiation in 3-point bending of ultra-high strength steel

Ultra-high strength steels (UHSS) have been developed to reduce the weight and increase strength capability of high value products such as crane structures. The bendability of UHSS steels has limited its application in production as their yield strength has increased, the bendability has been found to reduce with the reduction of tensile ductility. In this paper, the material properties affecting bendability in UHSS have been investigated and factors have been identified by analysing specimens pre and post bend testing [1-3] using a combined approach of in- and ex-situ small mechanical testing, Digital Image Correlation (DIC), modelling and characterisation. The propagation of shear bands in bending has been identified as the mechanism promoting damage in the tensile face to occur in the bending of steels. Identifying these factors combined to promote failure is of great importance while also developing a practical approach to identifying procedures to improve bendability. A small-scale bend test with new tooling and specimen geometry has been conducted inside the chamber of a Camscan SEM to observe the propagation of shear bands and damage initiation at the scale of the microstructure. Micrographs produced during the test were processed using DIC to study shear band formation in relation to strain distributions. Using these techniques shear bands and damage are observed at the tensile surface of the bend test. The strain localises in shear bands in a bifurcating pattern from the tensile surface in bending. Damage initiates at the surface where these shear bands intersect promoting a high strain at the surface. This damage promotes the shear bands to move through the sub-surface promoting further deformation then promoting more damage when the plasticity is exhausted. In this test a large 5µm inclusion is observed to interact with shear bands and seen to affect the damage propagation of the specimen and localise high strains at a region local to it. This region is where the failure originates from. Further analysis of the interaction between subsurface properties and the localisation of strain and shear bands will be studied