How do hospitals respond to feedback about blood transfusion practice? A multiple case study investigation

National clinical audits play key roles in improving care and driving system-wide change. However, effects of audit and feedback depend upon both reach (e.g. relevant staff receiving the feedback) and response (e.g. staff regulating their behaviour accordingly). This study aimed to investigate which hospital staff initially receive feedback and formulate a response, how feedback is disseminated within hospitals, and how responses are enacted (including barriers and enablers to enactment). Using a multiple case study approach, we purposively sampled four UK hospitals for variation in infrastructure and resources. We conducted semi-structured interviews with staff from transfusion-related roles and observed Hospital Transfusion Committee meetings. Interviews and analysis were based on the Theoretical Domains Framework of behaviour change. We coded interview transcripts into theoretical domains, then inductively identified themes within each domain to identify barriers and enablers. We also analysed data to identify which staff currently receive feedback and how dissemination is managed within the hospital. Members of the hospital’s transfusion team initially received feedback in all cases, and were primarily responsible for disseminating and responding, facilitated through the Hospital Transfusion Committee. At each hospital, key individuals involved in prescribing transfusions reported never having received feedback from a national audit. Whether audits were discussed and actions explicitly agreed in Committee meetings varied between hospitals. Key enablers of action across all cases included clear lines of responsibility and strategies to remind staff about recommendations. Barriers included difficulties disseminating to relevant staff and needing to amend feedback to make it appropriate for local use. Appropriate responses by hospital staff to feedback about blood transfusion practice depend upon supportive infrastructures and role clarity. Hospitals could benefit from support to disseminate feedback systematically, particularly to frontline staff involved in the behaviours being audited, and practical tools to support strategic decision-making (e.g. action-planning around local response to feedback)

The acute management of trauma hemorrhage: a systematic review of randomized controlled trials.

PublishedResearch Support, Non-U.S. Gov'tReviewINTRODUCTION: Worldwide, trauma is a leading cause of death and disability. Haemorrhage is responsible for up to 40% of trauma deaths. Recent strategies to improve mortality rates have focused on optimal methods of early hemorrhage control and correction of coagulopathy. We undertook a systematic review of randomized controlled trials (RCT) which evaluated trauma patients with hemorrhagic shock within the first 24 hours of injury and appraised how the interventions affected three outcomes: bleeding and/or transfusion requirements; correction of trauma induced coagulopathy and mortality. METHODS: Comprehensive searches were performed of MEDLINE, EMBASE, CENTRAL (The Cochrane Library Issue 7, 2010), Current Controlled Trials, ClinicalTrials.gov, the World Health Organization International Clinical Trials Registry Platform (ICTRP) and the National Health Service Blood and Transplant Systematic Review Initiative (NHSBT SRI) RCT Handsearch Database. RESULTS: A total of 35 RCTs were identified which evaluated a wide range of clinical interventions in trauma hemorrhage. Many of the included studies were of low methodological quality and participant numbers were small. Bleeding outcomes were reported in 32 studies; 7 reported significantly reduced transfusion use following a variety of clinical interventions, but this was not accompanied by improved survival. Minimal information was found on traumatic coagulopathy across the identified RCTs. Overall survival was improved in only three RCTs: two small studies and a large study evaluating the use of tranexamic acid. CONCLUSIONS: Despite 35 RCTs there has been little improvement in outcomes over the last few decades. No clear correlation has been demonstrated between transfusion requirements and mortality. The global trauma community should consider a coordinated and strategic approach to conduct well designed studies with pragmatic endpoints.This research project was funded by the National Institute for Health Research Programme Grant for Applied Research (RP-PG-0407-10036)

Distribution and abundance of sei whales off the west coast of the Falkland Islands

The survey was funded by Falklands Conservation, the Royal Society for the Protection of Birds, and the Falkland Islands Government Environmental Studies Budget.Little information exists on the current status of Southern Hemisphere sei whales (Balaenoptera borealis). We assessed their distribution and abundance along the west coast of the Falkland Islands (southwest Atlantic) during February and March 2018, using line transect and nonsystematic surveys. Abundance estimates were generated for a single survey stratum using design- and model-based approaches. Sightings of sei whales and unidentified baleen whales (most, if not all, likely to be sei whales) occurred from the coast to the 100 m depth isobath that marked the offshore boundary of the stratum. The modeled distribution predicted highest whale densities in King George Bay and in the waters between Weddell Island and the Passage Islands. Sei whale abundance was estimated as 716 animals (CV = 0.22; 95% CI [448, 1,144]; density = 0.20 whales/km2) using the design-based approach, and 707 animals (CV = 0.11; 95% CI [566, 877]; density = 0.20 whales/km2) using the model-based approach. For sei whales and unidentified baleen whales combined, the equivalent estimates were 916 animals (CV = 0.19; 95% CI [606, 1,384]; density = 0.26 whales/km2) and 895 animals (CV = 0.074; 95% CI [777, 1,032]; density = 0.25 whales/km2). The data indicate that the Falkland Islands inner shelf region may support globally important seasonal feeding aggregations of sei whales, and potentially qualify as a Key Biodiversity Area.PostprintPeer reviewe

Four Butterflies: End of Life Stories of Transition and Transformation

In this article, the author discusses her experiences as an Artist In Residence in the Department of Palliative Care and Rehabilitation Medicine at the University of Texas M. D. Anderson Cancer Center. Emphasis is placed on the ways in which end of life images and narratives often unfold in the fragile yet powerful space where conceptions of aesthetics and spirituality intersect with critical issues in the medical humanities. Drawing on four vivid case studies, the author examines the ways in which end of life narratives shed valuable light on conceptions of the subtlety of human embodiment; issues of violation, sorrow, and forgiveness; the mystical dimensions of traditional cultural beliefs; and the capacity for perceiving the natural world as a living symbol of grace. In so doing, she explores how the themes of transition and transformation become invested with meaningful existential and symbolic dimensions in artworks that give voice and presence to some of the most vulnerable, and often invisible, members of our societyﾗpeople at the end of life

Relativistic suppression of Auger recombination in Weyl semimetals

Auger recombination (AR) being electron-hole annihilation with energy-momentum transfer to another carrier is believed to speed up in materials with small band gap. We theoretically show that this rule is violated in gapless three-dimensional materials with ultra-relativistic electron-hole dispersion, Weyl semimetals (WSM). Namely, AR is prohibited by energy-momentum conservation laws in prototypical WSM with a single Weyl node, even in the presence of anisotropy and tilt. In real multi-node WSM, the geometric dissimilarity of nodal dispersions enables weak inter-node AR, which is further suppressed by strong screening due to large number of nodes. While partial AR rates between the nodes of the same node group are mutually equal, the inter-group processes are non-reciprocal, so that one of groups is geometrically protected from AR. Our calculations show that geometrical protection can help prolonging AR lifetime by the two orders of magnitude, up to the level of nanoseconds.Comment: 6 pages + 10 pages of supporting informatio

Learning To Be Affected: Social suffering and total pain at life’s borders.

The practice of Live Sociology in situations of pain and suffering is the author’s focus. An outline of the challenges of understanding pain is followed by a discussion of Bourdieu’s ‘social suffering’ (1999) and the palliative care philosophy of ‘total pain’. Using examples from qualitative research on disadvantaged dying migrants in the UK, attention is given to the methods that are improvised by dying people and care practitioners in attempts to bridge intersubjective divides, where the causes and routes of pain can be ontologically and temporally indeterminate and/or withdrawn. The paper contends that these latter phenomena are the incitement for the inventive bridging and performative work of care and Live Sociological methods, both of which are concerned with opposing suffering. Drawing from the ontology of total pain, I highlight the importance of (i) an engagement with a range of materials out of which attempts at intersubjective bridging can be produced, and which exceed the social, the material, and the temporally linear; and (ii) an empirical sensibility that is hospitable to the inaccessible and non-relational