bluuebunny/crossref_metadata_2025 huggingface dataset:
Management of physical pain during induced second‐trimester medical abortions: a cross‐sectional study of methodological quality and recommendations in local clinical practice guidelines at Swedish hospitals
Authors: Carlsson Tommy
Published: August 2018

Aim

The aim was to assess the methodological quality and describe recommendations for pain management in local clinical practice guidelines about induced second‐trimester medical abortions at Swedish university and county hospitals.

Methods

In 2017, Swedish university and county hospitals that provided abortion care in the second trimester of pregnancy were contacted (n = 29), and guidelines from 25 were received (university: n = 6, county: n = 19). Guideline quality was assessed according to two systematic instruments. Recommendations were systematically assessed regarding frequency and tools for pain measurement, prophylactic pharmacologic treatment, as needed pharmacologic treatment and nonpharmacologic treatment.

Results

Overall methodological quality was poor across both instruments, as the majority of the guidelines did not fulfil the investigated quality criteria. For pain measurements, no guideline recommended measurement frequency and four recommended specific measurement tools. Prophylactic pharmacologic treatment, described in 23 (92%) guidelines, included paracetamol (n = 23, 92%), anti‐inflammatory drugs (n = 23, 92%) and opioids (n = 18, 72%). As needed pharmacologic treatment, described in 23 (92%) guidelines, included anaesthetics (n = 21, 84%), opioids (n = 21, 84%) and paracetamol (n = 1, 4%). Recommendations for as needed anaesthetics included paracervical block (n = 21, 84%), epidural analgesia (n = 16, 64%) and inhalation of nitrous oxide (n = 5, 20%). Nonpharmacologic treatments were recommended in nine (36%) guidelines.

Conclusions

The findings indicate that local clinical practice guidelines about induced second‐trimester medical abortions are of inadequate methodological quality and that a large majority lack recommendations concerning systematic pain measurements. Although most recommend prophylactic and as needed pharmacologic management, national inconsistencies exist in Sweden with regard to recommendations of epidural analgesia, nitrous oxide and nonpharmacologic methods. In Sweden, there is room for improvement in the development of these guidelines.
Trump Has Committed a Crime Against Humanity
Authors: Blau Judith
Published: August 2018

In this essay, I briefly trace the history of the scientific work that predicts rising temperatures, sea rise, and the effects of greenhouse gases on climate change. I then explain why Trump's withdrawal from the Paris Agreement warrants charging him with committing a crime against humanity.
Parallel domestication with a broad mutational spectrum of determinate stem growth habit in leguminous crops
Authors: Li Shuai , Ding Yanhua , Zhang Dajian , Wang Xutong , Tang Xuemin , Dai Deyan , Jin Hanqi , Lee Suk‐Ha , Cai Chunmei , Ma Jianxin
Published: August 2018

Stem growth habit is a key plant architecture trait determining yield potential in grain legumes, and the phenotypic change from the indeterminate stem growth habit of wild mungbeans (Vigna radiata) to the determinate stem growth habit of cultivated mungbeans is a critical domestication transition. Here we show that indeterminate stem growth in wild mungbean is modulated by a single gene,VrDet1, which encodes a signaling protein of shoot apical meristems. The transition from an indeterminate to a determinate stem growth habit was achieved by selection of two linked point mutations in two putativecis‐regulatory elements, resulting in a significant reduction in gene expression. Both the wild‐type nucleotides corresponding to the two point mutations were essential forVrDet1function. In addition, two highly diverse haplotypes ofVrdet1were found in cultivated mungbeans, suggesting dual domestication ofVrdet1.VrDet1was orthologous toDt1in wild soybean andPvTFL1yin wild common bean, where multiple loss‐of‐function mutations altering the coding sequences of individual genes were selected to produce determinate stems in cultivated accessions. Interspecific comparison of these orthologs in the wild and cultivated accessions reveals the most conservative interspecific and intraspecific parallel domestication events with the broadest mutational spectrum of a domestication trait in leguminous crops. We also found that interspecifically and functionally conserved promoters possesscis‐regulatory elements that are highly conserved in kind but greatly variable in number and order, demonstrating the evolutionary dynamics of regulatory sequences. This work provides insights into the origins of cultivated mungbean and exemplifies the conservativeness and plasticity of the domestication processes of related crops.
Laterality judgment performance between people with chronic pain and pain-free individuals: a systematic review protocol
Authors: Ravat Sadiya , Olivier Benita , Gillion Nadia , Lewis Francoise
Published: August 2018

Review question/objective:

The objective of this review is to establish the association between chronic pain and laterality judgment. Specifically, the review question: Is there a difference in laterality judgment in people with chronic pain and pain-free individuals?
Home oxygen therapy criteria, guidelines and protocols for hypoxia management in pediatric patients with acute bronchiolitis: a scoping review protocol
Authors: Watkins Terra , Keller Shelia
Published: August 2018

Review objective/question:

The objectives of this scoping review are: to explore existing literature related to discharge criteria, guidelines and protocols from hospitals or clinics that are being implemented for home oxygen therapy (HOT) in the management of hypoxia in pediatric patients with acute bronchiolitis, examine and conceptually map the evidence, and identify any gaps in the literature.

The question of this review is: what discharge criteria, guidelines, and protocols are used for HOT in the management of hypoxia in pediatric patients with acute bronchiolitis?
The association between prenatal exposure to environmental tobacco smoke and childhood obesity: a systematic review
Authors: Qureshi Rubab , Jadotte Yuri , Zha Peijia , Porter Sallie Ann , Holly Cheryl , Salmond Susan , Watkins Elizabeth Ann
Published: August 2018

Objective:

The objective of the review was to determine if prenatal exposure to environmental tobacco smoke (ETS) increases the risk of obesity and overweight in children.

Introduction:

Childhood obesity has reached epidemic proportions in many developed countries. This is of great concern as childhood obesity is associated with early onset of chronic diseases such as coronary artery disease, type II diabetes and hypertension in adulthood. Extensive research suggests a multifactorial etiology. These factors include genetic markers, individual lifestyle, social and environmental factors, particularly the interaction between these factors. Among environmental factors, prenatal exposure to ETS has been linked to increased rates of obesity and overweight in childhood.

Inclusion criteria:

This review considered studies on children of women who were non-smokers and who reported exposure to ETS during pregnancy. The exposure of interest was exposure to ETS or second hand smoke during pregnancy, determined by either: i) self-reported maternal exposure; and/or ii) serum cotinine levels. Observational studies such as cohort studies, case control studies, retrospective studies and analytical cross-sectional studies were included. Outcomes of interest were weight, height and body mass index of children from birth up to 18 years.

Methods:

A three-step search strategy was used to search for published and unpublished studies in the English language. No search range (years) was set. Two reviewers assessed the studies for inclusion and methodological quality using the Joanna Briggs Institute System for the Unified Management, Assessment and Review of Information (JBI SUMARI) standardized appraisal instruments. Data was extracted by two people independently and entered into the JBI extraction tool. Extracted data was pooled in a statistical meta-analysis based on a random effects model.

Results:

Nineteen studies were included in the review. Eight of the studies were included in the final meta-analysis. Findings suggest that there was an association between prenatal exposure to ETS and childhood obesity (odds ratio [OR]: 1.905, CI: 1.23–2.94), and no association between ETS exposure and overweight (OR: 1.51, CI: 0.49–4.59). The high rates of heterogeneity between studies in both of the meta-analyses determined by the I2statistic (97% and 99%, respectively) sanction caution in the interpretation and use of these findings.

Conclusions:

Based on the evidence, childhood obesity is associated with exposure to prenatal ETS, however overweight does not appear to be associated with this type of exposure.
Improving the accuracy of fluid intake charting through patient involvement in an adult surgical ward: a best practice implementation project
Authors: Liaw Yi Qi , Goh Mien Li
Published: August 2018

Objectives:

The main objective of this evidence-based utilization project was to improve the accuracy of fluid intake charting through patient involvement.

Introduction:

The accurate documentation and maintenance of fluid balance charts constitute an integral part of nursing care. However, inaccuracies in fluid balance charting by nurses often occur. Inaccurate charting can result in delayed interventions, affecting the safety of patients. It has been found that fluid intake charting in an acute surgical inpatient ward is highly inaccurate. Many expressions of dissatisfaction are evident among medical healthcare professionals and patients regarding the accurate updating of the charts. Therefore, evidence-based measures need to be implemented in order to improve the safety of patient care through accurate recording of patients’ fluid intake.

Methods:

The project took place in a 21-bed acute surgical ward which had 30 patients. The Joanna Briggs Institute Practical Application of Clinical Evidence System (JBI-PACES) and Getting Research into Practice (GRiP) tools were used to implement the evidence-based project. A pre- and post- audit methodology congruent with the framework was applied. The project was implemented in three phases from April to September 2016. The audit criteria obtained from JBI-PACES were used. The project's primary focus was to harness patient involvement in improving the accuracy of fluid intake charting.

Results:

Criteria 1 and 2 revealed low levels of compliance during the pre-implementation audit, 3% and 10%, respectively. There were significant improvements one month post-implementation for both Criteria 1 and 2, 100% and 87%, also respectively. Fisher's exact test was carried out and the statistical significance of the results was achieved (p < 0.001), compared to the pre-implementation audit. At six months post-implementation, the audit found that both criteria were adequately sustained as a practice in the ward (Criterion 1: 100%, Criterion 2: 83%).

Conclusions:

This project has demonstrated the effectiveness of improving the accuracy of fluid intake charting through patient involvement. The use of JBI-PACES and GRiP has allowed the effective utilization of evidence in practice. It has also provided evidence that effective engagement of the ground nurses and stakeholders coupled with the commitment of change champions and ground nurses can contribute to improving practice in a highly demanding acute care setting and lead to healthcare success.
Altered anabolic signalling and reduced stimulation of myofibrillar protein synthesis after feeding and resistance exercise in people with obesity
Authors: Beals Joseph W. , Skinner Sarah K. , McKenna Colleen F. , Poozhikunnel Elizabeth G. , Farooqi Samee A. , van Vliet Stephan , Martinez Isabel G. , Ulanov Alexander V. , Li Zhong , Paluska Scott A. , Burd Nicholas A.
Published: August 2018

Key points

Lifestyle modifications that include the regular performance of exercise are probably important for counteracting the negative consequences of obesity on postprandial myofibrillar protein synthetic responses to protein dense food ingestion.

We show that the interactive effect of resistance exercise and feeding on the stimulation of myofibrillar protein synthesis rates is diminished with obesity compared to normal weight adults.

The blunted myofibrillar protein synthetic response with resistance exercise in people with obesity may be underpinned by alterations in muscle anabolic signalling phosphorylation (p70S6K and 4E‐BP1).

The results obtained in the present study suggest that further exercise prescription manipulation may be necessary to optimize post‐exercise myofibrillar protein synthesis rates in adults with obesity.

We aimed to determine whether obesity alters muscle anabolic and inflammatory signalling phosphorylation and also muscle protein synthesis within the myofibrillar (MYO) and sarcoplasmic (SARC) protein fractions after resistance exercise. Nine normal weight (NW) (21 ± 1 years, body mass index 22 ± 1 kg m−2) and nine obese (OB) (22 ± 1 years, body mass index 36 ± 2 kg m−2) adults received l‐[ring‐13C6]phenylalanine infusions with blood and muscle sampling at basal and fed‐state of the exercise (EX) and non‐exercise (CON) legs. Participants performed unilateral leg extensions and consumed pork (36 g of protein) immediately after exercise. Basal muscle Toll‐like receptor 4 (TLR4) protein was similar between OB and NW groups (P > 0.05) but increased at 300 min after pork ingestion only in the OB group (P = 0.03). Resistance exercise reduced TLR4 protein in the OB group at 300 min (EX vs. CON leg in OB: P = 0.04). Pork ingestion increased p70S6K phosphorylation at 300 min in CON and EX of the OB and NW groups (P > 0.05), although the response was lower in the EX leg of OB vs. NW at 300 min (P = 0.05). Basal MYO was similar between the NW and OB groups (P > 0.05) and was stimulated by pork ingestion in the EX and CON legs in both groups (Δ from basal NW: CON 0.04 ± 0.01% h−1; EX 0.10 ± 0.02% h−1; OB: CON 0.06 ± 0.01% h−1; EX 0.06 ± 0.01% h−1; P < 0.05). MYO was more strongly stimulated in the EX vs. CON legs in NW (P = 0.02) but not OB (P = 0.26). SARC was feeding sensitive but not further potentiated by resistance exercise in both groups. Our results suggest that obesity may attenuate the effectiveness of resistance exercise to augment fed‐state MYO.
Checklist of the parasitic nasal mites of birds in Brazil
Authors: Mascarenhas Carolina Silveira , Bernardon Fabiana Fedatto , Gastal Silvia , Müller Gertrud
Published: August 2018

The diversity of avian nasal mites has been incompletely studied in South America and most reports have been made on the fauna of Brazil, especially from the 1940s to 1970s. Recently, the development of new research has contributed records of species not previously reported in the country. As a result, a compilation of records of nasal mites (Astigmata: Cytoditidae, Turbinoptidae; Prostigmata: Ereynetidae; Mesostigmata: Rhinonyssidae) of birds in Brazil is presented. One hundred and twenty-four species of nasal mites were recorded parasitizing 168 bird species. The Rhinonyssidae was the family with the highest number of mites reported (108 species). Most nasal mite hosts in Brazil are native birds, however, mites have also been reported parasitizing captive exotic birds, as well as introduced species and domesticated birds.
Rheology and microstructure of unsaturated wet granular materials: Experiments and simulations
Authors: Badetti M. , Fall A. , Hautemayou D. , Chevoir F. , Aimedieu P. , Rodts S. , Roux J.-N.
Published: August 2018

When dealing with unsaturated wet granular materials, a fundamental question is: What is the effect of capillary cohesion on the bulk flow and yield behavior? We investigate the dense-flow rheology of unsaturated granular materials through experiments and discrete element simulations of homogeneous, simple annular shear flows of frictional, cohesive, spherical particles. Dense shear flows of dry, cohesionless granular materials exhibit three regimes: Quasistatic, inertial, and intermediate [B. Andreotti et al., Contemp. Phys. 55, 151–152 (2013)]. Herewith, we show that the quasistatic and the intermediate regimes persist for unsaturated materials and that the rheology is essentially described by two dimensionless numbers: The reduced pressure P* comparing the cohesive to confining forces and the inertial number I, for a wide range of liquid content. This is consistent with recent numerical simulations [S. Khamseh et al., Phys. Rev. E 92, 022201 (2015)]. Finally, we measure the effective friction coefficient and the solid fraction variation throughout the wet bed. From this, we show that, in the quasistatic regime, the Mohr–Coulomb yield criterion is a good approximation for large enough P*. The experimental results agree quantitatively with the numerical simulation ones, provided the intergranular friction coefficient μ is set to its physical value identified from dry material rheology [M. Badetti et al., Eur. Phys. J. E 41, 68 (2018)]. To directly and quantitatively determine what happens inside the sheared granular bed, x-ray tomography measurements are carried out in a custom-made setup that enables imaging of a wet granular material after different shear histories. For the explored range of liquid content, samples remain homogeneous but exhibit some complex microscopic morphologies far from simple capillary bridges. From the x-ray microtomographic images, we can clearly distinguish liquid capillary bridges and liquid clusters by their morphologies. We see that the total number of capillary bridges decreases when one increases the liquid content and interestingly increases, at the expense of other morphologies, when we increase the shear strain. This explains the concordance between the experimental and numerical measurements since the numerical model is restricted to the pendular state, for which the liquid phase is completely discontinuous and no coalescence occurs between liquid bridges.
Evidence for Majorana bound states in an iron-based superconductor
Authors: Wang Dongfei , Kong Lingyuan , Fan Peng , Chen Hui , Zhu Shiyu , Liu Wenyao , Cao Lu , Sun Yujie , Du Shixuan , Schneeloch John , Zhong Ruidan , Gu Genda , Fu Liang , Ding Hong , Gao Hong-Jun
Published: August 2018

An iron home for Majoranas

The surface of the iron-based superconductor FeTe
0.55
Se
0.45
has been identified as a potential topological superconductor and is expected to host exotic quasiparticles called the Majorana bound states (MBSs). Wang
et al.
looked for signatures of MBSs in this material by using scanning tunneling spectroscopy on the vortex cores formed by the application of a magnetic field. In addition to conventional states, they observed the characteristic zero-bias peaks associated with MBSs and were able to distinguish between the two, owing to the favorable ratios of energy scales in the system.

Science
, this issue p.
333
MCM2 promotes symmetric inheritance of modified histones during DNA replication
Authors: Petryk Nataliya , Dalby Maria , Wenger Alice , Stromme Caroline B. , Strandsby Anne , Andersson Robin , Groth Anja
Published: August 2018

How cells ensure symmetric inheritance

Parental histones with modifications are recycled to newly replicated DNA strands during genome replication, but do the two sister chromatids inherit modified histones equally? Yu
et al.
and Petryk
et al.
found in mouse and yeast, respectively, that modified histones are segregated to both DNA daughter strands in a largely symmetric manner (see the Perspective by Ahmad and Henikoff). However, the mechanisms ensuring this symmetric inheritance in yeast and mouse were different. Yeasts use subunits of DNA polymerase to prevent the lagging-strand bias of parental histones, whereas in mouse cells, the replicative helicase MCM2 counters the leading-strand bias.

Science
, this issue p.
1386
, p.
1389
; see also p.
1311
Heterologous Expression of Full-Length Lanosterol 14α-Demethylases of Prominent Fungal Pathogens Candida albicans and Candida glabrata Provides Tools for Antifungal Discovery
Authors: Keniya Mikhail V. , Ruma Yasmeen N. , Tyndall Joel D. A. , Monk Brian C.
Published: August 2018

Targeting lanosterol 14α-demethylase (LDM) with azole drugs provides prophylaxis and treatments for superficial and disseminated fungal infections, but cure rates are modest for immunocompromised patients and individuals with comorbidities. The efficacy of azole drugs has also been reduced due to the emergence of drug-resistant fungal pathogens.
Crystal Structures of Full-Length Lanosterol 14α-Demethylases of Prominent Fungal Pathogens Candida albicans and Candida glabrata Provide Tools for Antifungal Discovery
Authors: Keniya Mikhail V. , Sabherwal Manya , Wilson Rajni K. , Woods Matthew A. , Sagatova Alia A. , Tyndall Joel D. A. , Monk Brian C.
Published: August 2018

Targeting lanosterol 14α-demethylase (LDM) with azole drugs provides prophylaxis and treatments for superficial and disseminated fungal infections, but cure rates are not optimal for immunocompromised patients and individuals with comorbidities. The efficacy of azole drugs has also been reduced due to the emergence of drug-resistant fungal pathogens.
DdvK, a Novel Major Facilitator Superfamily Transporter Essential for 5,5′-Dehydrodivanillate Uptake by Sphingobium sp. Strain SYK-6
Authors: Mori Kosuke , Niinuma Koh , Fujita Masaya , Kamimura Naofumi , Masai Eiji
Published: August 2018

The bioengineering of bacteria to selectively transport and metabolize natural substrates into specific metabolites is a valuable strategy for industrial-scale chemical production. The uptake of many substrates into cells requires specific transport systems, and so the identification and characterization of transporter genes are essential for industrial applications. A number of bacterial major facilitator superfamily transporters of aromatic acids have been identified and characterized, but many transporters of lignin-derived aromatic acids remain unidentified. The efficient conversion of lignin, an abundant but unutilized aromatic biomass resource, to value-added metabolites using microbial catabolism requires the characterization of transporters for lignin-derived aromatics. In this study, we identified the transporter gene responsible for the uptake of 5,5′-dehydrodivanillate, a lignin-derived biphenyl compound, in
Sphingobium
sp. strain SYK-6. In addition to characterizing its function, we applied this transporter gene to the production of a value-added metabolite from 5,5′-dehydrodivanillate.
Sequence Variation of Epstein-Barr Virus: Viral Types, Geography, Codon Usage, and Diseases
Authors: Correia Samantha , Bridges Ray , Wegner Fanny , Venturini Cristina , Palser Anne , Middeldorp Jaap M. , Cohen Jeffrey I. , Lorenzetti Mario A. , Bassano Irene , White Robert E. , Kellam Paul , Breuer Judith , Farrell Paul J.
Published: August 2018

Epstein-Barr virus causes most cases of infectious mononucleosis and posttransplant lymphoproliferative disease. It contributes to several types of cancer, including Hodgkin's lymphoma, Burkitt's lymphoma, diffuse large B cell lymphoma, nasopharyngeal carcinoma, and gastric carcinoma. EBV genome variation is important because some of the diseases associated with EBV have very different incidences in different populations and geographic regions, and differences in the EBV genome might contribute to these diseases. Some specific EBV genome alterations that appear to be significant in EBV-associated cancers are already known, and current efforts to make an EBV vaccine and antiviral drugs should also take account of sequence differences in the proteins used as targets.
Infection Dynamics of Hepatitis E Virus in Wild-Type and Immunoglobulin Heavy Chain Knockout J
H
−/−
Gnotobiotic Piglets
Authors: Yugo Danielle M. , Heffron C. Lynn , Ryu Junghyun , Uh Kyungjun , Subramaniam Sakthivel , Matzinger Shannon R. , Overend Christopher , Cao Dianjun , Kenney Scott P. , Sooryanarain Harini , Cecere Thomas , LeRoith Tanya , Yuan Lijuan , Jue Nathaniel , Clark-Deener Sherrie , Lee Kiho , Meng Xiang-Jin
Published: August 2018

According to the World Health Organization, approximately 20 million HEV infections occur annually, resulting in 3.3 million cases of hepatitis E and >44,000 deaths. The lack of an efficient animal model that can mimic the full-spectrum of infection outcomes hinders our ability to delineate the mechanism of HEV pathogenesis. Here, we successfully generated immunoglobulin heavy chain J
H
−/−
knockout gnotobiotic pigs using CRISPR/Cas9 technology, established a novel J
H
−/−
knockout and wild-type gnotobiotic pig model for HEV, and systematically determined the dynamic of acute HEV infection in gnotobiotic pigs. It was demonstrated that knockout of the Ig heavy chain in pigs decreased the level of HEV replication. Infected wild-type and J
H
−/−
knockout gnotobiotic piglets developed more pronounced HEV-specific lesions than other studies using conventional pigs, and the infected J
H
−/−
knockout pigs had significantly enlarged livers. The availability of this novel model will facilitate future studies of HEV pathogenicity.
Complete Genome Sequence of Lytic Oenococcus oeni Bacteriophage OE33PA
Authors: Jaomanjaka Fety , Claisse Olivier , Philippe Cécile , Le Marrec Claire
Published: August 2018

Oenococcus oeni
is the most common species of lactic acid bacteria associated with malolactic fermentation in wine. Here, we report the genome sequence of the lytic phage OE33PA (vB_OeS_OE33PA).
Genome Sequence of a Moderately Halophilic Bacillus cereus Strain, TS2, Isolated from Saltern Sediments
Authors: Shankar Manoharan , Mageswari Anbazhagan , Suganthi Chandrasekaran , Gunasekaran Paramasamy , Gothandam Kodiveri M. , Karthikeyan Sivashanmugam
Published: August 2018

We report the 5.3-Mbp genome sequence of
Bacillus cereus
strain TS2, which was isolated from the sediments of a solar saltern in southern India. Genome analysis of
B. cereus
TS2, a salt-resistant strain, will improve our understanding of how
B. cereus
, a food pathogen, responds to hyperosmotic stress.
Draft Genome Sequence of Deinococcus koreensis SJW1-2
T
, a Gamma Radiation-Resistant Bacterium Isolated from River Water
Authors: Baek Kiwoon , Chung Eu Jin , Choi Gang-Guk , Nam Young Ho , Choi Ahyoung
Published: August 2018

Deinococcus koreensis
SJW1-2
T
was isolated from river water and was observed to be highly resistant to gamma radiation. In this study, we report a draft genome sequence which revealed that SJW1-2
T
possesses genes involved in nucleotide excision repair.
Genome Sequence of a Plant Growth-Promoting Rhizobacterium, Pseudomonas sp. Strain 31-12
Authors: Hynes Russell K. , Dumonceaux Tim J. , Kangsopa Jakkrapong , Town Jennifer R.
Published: August 2018

We present here a draft genome sequence of
Pseudomonas
sp. strain 31-12, a plant growth-promoting rhizobacterium of several crop plants that was isolated from the rhizosphere of corn in southern Ontario, Canada.
Geospatial mapping of access to timely essential surgery in sub-Saharan Africa
Authors: Juran Sabrina , Broer P. Niclas , Klug Stefanie J. , Snow Rachel C. , Okiro Emelda A. , Ouma Paul O. , Snow Robert W. , Tatem Andrew J. , Meara John G. , Alegana Victor A.
Published: August 2018

Introduction

Despite an estimated one-third of the global burden of disease being surgical, only limited estimates of accessibility to surgical treatment in sub-Saharan Africa exist and these remain spatially undefined. Geographical metrics of access to major hospitals were estimated based on travel time. Estimates were then used to assess need for surgery at country level.

Methods

Major district and regional hospitals were assumed to have capability to perform bellwether procedures. Geographical locations of hospitals in relation to the population in the 47 sub-Saharan countries were combined with spatial ancillary data on roads, elevation, land use or land cover to estimate travel-time metrics of 30 min, 1 hour and 2 hours. Hospital catchment was defined as population residing in areas less than 2 hours of travel time to the next major hospital. Travel-time metrics were combined with fine-scale population maps to define burden of surgery at hospital catchment level.

Results

Overall, the majority of the population (92.5%) in sub-Saharan Africa reside in areas within 2 hours of a major hospital catchment defined based on spatially defined travel times. The burden of surgery in all-age population was 257.8 million to 294.7 million people and was highest in high-population density countries and lowest in sparsely populated or smaller countries. The estimated burden in children <15 years was 115.3 million to 131.8 million and had similar spatial distribution to the all-age pattern.

Conclusion

The study provides an assessment of accessibility and burden of surgical disease in sub-Saharan Africa. Yet given the optimistic assumption of adequare surgical capability of major hospitals, the true burden of surgical disease is expected to be much greater. In-depth health facility assessments are needed to define infrastructure, personnel and medicine supply for delivering timely and safe affordable surgery to further inform the analysis.
Next-generation audit and feedback for inpatient quality improvement using electronic health record data: a cluster randomised controlled trial
Authors: Patel Sajan , Rajkomar Alvin , Harrison James D , Prasad Priya A , Valencia Victoria , Ranji Sumant R , Mourad Michelle
Published: August 2018

Background

Audit and feedback improves clinical care by highlighting the gap between current and ideal practice. We combined best practices of audit and feedback with continuously generated electronic health record data to improve performance on quality metrics in an inpatient setting.

Methods

We conducted a cluster randomised control trial comparing intensive audit and feedback with usual audit and feedback from February 2016 to June 2016. The study subjects were internal medicine teams on the teaching service at an urban tertiary care hospital. Teams in the intensive feedback arm received access to a daily-updated team-based data dashboard as well as weekly inperson review of performance data (‘STAT rounds’). The usual feedback arm received ongoing twice-monthly emails with graphical depictions of team performance on selected quality metrics. The primary outcome was performance on a composite discharge metric (Discharge Mix Index, ‘DMI’). A washout period occurred at the end of the trial (from May through June 2016) during which STAT rounds were removed from the intensive feedback arm.

Results

A total of 40 medicine teams participated in the trial. During the intervention period, the primary outcome of completion of the DMI was achieved on 79.3% (426/537) of patients in the intervention group compared with 63.2% (326/516) in the control group (P<0.0001). During the washout period, there was no significant difference in performance between the intensive and usual feedback groups.

Conclusion

Intensive audit and feedback using timely data and STAT rounds significantly increased performance on a composite discharge metric compared with usual feedback. With the cessation of STAT rounds, performance between the intensive and usual feedback groups did not differ significantly, highlighting the importance of feedback delivery on effecting change.

Clinical Trial

The trial was registered with ClinicalTrials.gov (NCT02593253).
Interventions in hospitalised patients with cancer: the importance of impending death awareness
Authors: Geijteman Eric Cornelis Theodorus , Graaf Marcella van der , Witkamp Frederika E , Norden Sanne van , Stricker Bruno H , van der Rijt Carin C D , van der Heide Agnes , van Zuylen Lia
Published: August 2018

Objectives

Burdensome and futile interventions with the aim of prolonging life should be avoided in dying patients. However, current clinical practice has hardly been investigated.

We examined the number and type of diagnostic and therapeutic medical interventions in hospitalised patients with cancer in their last days of life. In addition, we investigated if physician awareness of impending death affected the use of these interventions.

Methods

Questionnaire study and medical record study. Attending physicians of patients who died in a university hospital between January 2010 and June 2012 were asked whether they had been aware of the patient’s impending death. The use of diagnostic and therapeutic interventions and medications was assessed by studying patients’ charts. We included 131 patients.

Results

In the last 72 and 24 hours of life, 59% and 24% of the patients received one or more diagnostic interventions, respectively. Therapeutic interventions were provided to 47% and 31%. In the last 24 hours of life, patients received on average 5.8 types of medication.

Awareness of a patient’s impending death was associated with a significant lower use of diagnostic interventions (48% vs 69% in the last 72 hours; 11% vs 37% in the last 24 hours) and several medications that potentially prolong life (eg, antibiotics and cardiovascular medication).

Conclusions

Many patients with cancer who die in hospital receive diagnostic and therapeutic interventions in the last days of life of which their advantages are questionable. To improve end-of-life care, medical care should be adapted.
10 Timely identification and support for carers of people at the end of life through the adult carer support plan: triangulating three data sources
Authors: Swan Susan , Meade Richard , Carduff Emma
Published: August 2018

Introduction

The Carers (Scotland) Act (2016) places a duty on local authorities to prepare an Adult Carer Support Plan (ACSP) and Young Carer Statement for any carer who requests one or is identified as such. From 2019 this will be assisted by a fast track process for carers of people in their last six months of life. Timely identification of unpaid carers assessment and support can; reduce the overwhelming pressure of caregiving increase competence confidence satisfaction and the quality of the care given.

Aim

To provide evidence on the supportive needs of carers to inform recommendations regarding the timescale for the creation of fast tracked ACSPs under the Carers (Scotland) Act (2016).

Methods

The study triangulated data from a literature review qualitative secondary analysis (n=19 interviews; 3 focus groups) and two primary focus groups with bereaved carers (n=11).

Results

Themes included; barriers to and triggers for identification and needs including physical support psychological support respite information communication co-ordination and competing demands. Additional themes were speed of decline and end of life care.

Conclusion

Health and social care professionals need to take a radical reactive move to presume that every patient has a carer and ensure they understand their entitlements. Carer identification is everyone’s responsibility and it should be the ambition of the Carer (Scotland) Act (2016) that this happens early in the illness trajectory. In so doing rapid assessment and support can be initiated to help carers navigate and cope with an uncertain often rapidly deteriorating illness trajectory.

Reference

. Scottish Government. (2016). 1 Carers (Scotland) Act. Scottish Government. Available at http://www.legislation.gov.uk/asp/2016/9/pdfs/asp_20160009_en.pdf (Accessed: 10 February 2018)
22 GP perceptions of the adequacy of community-based care for patients with advanced heart failure in a uk region (NI): a qualitative study
Authors: Graham-Wisener Lisa , Chen Jingwen Jessica , Gamble Kathryn , McGlade Kieran , Doherty Jennifer , Donnelly Patrick , Stone Carol A
Published: August 2018

Introduction

Although there is recognition of the multi-dimensional needs of patients with advanced heart failure (HF) conventional models of care have traditionally been medically focused. It is unknown whether community-based systems and services have improved and adapted to better meet the emotional social functional and medical needs of patients with HF and their families.

Aims

To assess the adequacy of community-based services available in Northern Ireland (NI) to meet the multidimensional needs of patients living with New York Heart Association Stage III and IV HF as experienced and perceived by general practitioners (GP).

Methods

Semi-structured interviews were conducted with GPs. Interviews were transcribed independently coded and analysed using a six-step thematic analysis approach.

Results

20 semi-structured interviews were conducted. GPs reported managing patients in a ‘reactive rather than proactive’ way responding only to acute medical needs with hospital admission the default due to lack of community-based services. Care provided by HF specialists was highly regarded but ‘access and coordination’ were lacking. Conversations regarding current and future care needs were considered important but challenging due to time constraints and prognostic uncertainty. GPs expressed that ‘specialist palliative care (SPC) is only a credible option in end stages’ related to limited understanding of the scope of SPC and concern that SPC services are cancer-focused.

Conclusions

Despite recent evidence for the effectiveness of integrated SPC in improving quality of life for patients with HF health and social care services within NI have not yet adapted to assess and meet these needs.
27 Understanding public attitudes: a crucial component for developing palliative care services
Authors: Islam Ishrat , Byrne Anthony , Nelson Annmarie
Published: August 2018

Introduction

A major challenge in developing new models of palliative care is to identify the current needs of the public patients and carer (Dixon 2015). There is a lack of evidence on people’s attitudes towards end of life care (EoLC) in Wales.

Aim

To increase understanding of people’s feelings views knowledge and preferences around EoLC.

Method

An online survey was conducted using an electronic survey tool. Descriptive statistics and thematic analysis were used to perform data analysis.

Results

2210 people (Age: Mean +SD; 55+14 years) participated in the survey 43% of those were members of the general public 29% were patients/carers and 23% were health professionals. 49% of respondents thought that available palliative care was inadequate and 92% believed that end of life care for dying people should have equal priority for the NHS. 95% of respondents thought that expressing preferences around EoLC in advance was important but only 13% had done this in practice and 60% did not know how to plan their EoLC. However the top three needs in EoLC were identified as having a trained carer (84%) access to other professionals (59%) and emergency care (44%). The top three preferences for EoLC were being surrounded by loved ones (62%) maintaining dignity (55%) and a feeling of peace (40%). Just 24% respondents would chose to be at home while receiving EoLC.

Conclusions

Understanding public attitudes is essential to understanding changing contexts of care. Developing a need-based palliative care model enhances an effective service delivery.

Reference

. Dixon J, et al. Equity in the provision of palliative care in the UK: Review of evidence2015;pg. 1–145. London: Personal Social Services Research Unit. Available at: https://www.mariecurie.org.uk/globalassets/media/documents/policy/campaigns/equity-palliative-care-uk-report-full-lse.pdf
28 Quality of life of patients attending marie curie day hospice over time: preliminary findings from a prospective cohort study
Authors: Cudmore Sarah , Finucane Anne , Holloway Gail , Grundy Pippa , Haraldsdottir Erna , Brazil Kevin , George Kernohan W
Published: August 2018

Introduction

Palliative care day services (PCDS) is a popular if variable palliative intervention provided on a routine basis in many hospices.

Aim and method

To understand PCDS within Marie Curie hospices we set out to identify the structure process and outcome associated with the service. We present preliminary data on quality of life from the Edinburgh service. A prospective cohort design was used to describe outcomes over an eight-week period. Attendance was recorded. Participants were invited to complete a set of questionnaires to assess quality of life at baseline four weeks and eight weeks post-baseline. Patient assessment involved completion of questionnaires covering physical and emotional health quality of life and wellbeing. The primary outcome measure was QoL as assessed by the McGill Quality of Life scale.

Results

Over a nine-week period at one day hospice nine patients and five carers consented to participate. Of the nine patients eight were assessed at four-weeks post baseline (one patient was in hospital); seven patients were assessed at eight weeks post-baseline (one patient had died; one was unwell). Over the eight-week follow up period the total mean score remained stable. The single item quality of life score increased a little (as has quality of health care and environment) whilst symptoms worsened as might be expected in this population.

Conclusion

Day services may sustain quality of life in spite of deteriorating health. Further data collection from two other sites is underway to enhance sample size.
38 From theory to clinical practice: lessons learned from the delivery of a breathlessness support service
Authors: Reilly Charles C , Maddocks Matthew , Jolley Caroline J , Moxham J , Higginson Irene J
Published: August 2018

Introduction

A single-blind randomised controlled trial demonstrated that an integrated palliative and respiratory care service for patients with advanced disease and chronic breathlessness known as the Breathlessness Support Service (BSS) resulted in improved patient’s mastery in the BSS group compared to standard care (mean difference 0·58 95% CI 0·01–1·15 p=0·048; effect size 0·44).1

Aim

To describe the clinical aspects of delivering the BSS with regards to; referral sources patient characteristics and interventions provided.

Method

Secondary data analysis of all patients that were referred to and completed that BSS intervention as part of the delayed intervention model RCT.1

Results

105 patients enrolled in the study 86 patients attended the first BSS clinic 75 completed the BSS intervention (two clinic appointments and a physiotherapy-based home visit). 80% of patients had non – malignant disease; respiratory medicine constituted most referrals. The majority (88%) of patients received solely non – pharmacological interventions. 35 (41%) patients reported that the have never accessed Pulmonary Rehabilitation (PR). At the point of discharge the BSS provided on ward referral and/or access to additional services (PR=53% social work=41% palliative care=11%).

Conclusions

Majority of referrals were from respiratory medicine and GP practices for patients with chronic breathlessness due to non – malignant disease which highlights the challenges of trying to palliate breathlessness in the generalist setting. The BSS provided patients with access to self-management non – pharmacological interventions delivered by integrated multi-disciplinary team with expertise in breathlessness management which resulted in improved breathlessness mastery.

Reference

. Higginson IJ, et al.An integrated palliative and respiratory care service for patients with advanced disease and refractory breathlessness: A randomised controlled trial.The Lancet Respiratory Medicine2014;2(12):979–987.
44 An evidenced-based heuristics model (or rule of thumb) to improve doctors’ intuition about when patients are imminently dying
Authors: White Nicola , Harries Priscilla , Harris Adam JL , Vickerstaff Victoria , Lodge Philip , McGowan Catherine , Minton Ollie , Tomlinson Christopher , Tookman Adrian , Reid Fiona , Stone Patrick
Published: August 2018

Introduction

Evidence suggests that the majority of doctors are not very good at identifying when a patient is dying1however there is little training available to improve this skill. Even experts are unable to articulate how they recognise when a patient is dying other than by saying that ‘I just knew’.2

Aim

To understand how expert palliative care doctors recognise a dying person.

Methods

Rather than relying on ‘years of experience’ as a surrogate measure of expertise we developed a test to identify which doctors really are the prognostic ‘experts’. The prognostic test consisted of 20 real patient case summaries. Participants (palliative care doctors) were asked to predict whether or not they expected the patient to die within the next 3 days. Those who were the most accurate at this task were deemed to be the ‘prognostic experts’ and were invited to complete an additional online judgement task. In this task it was possible to identify which factors were most influential in their prognostic decision-making.

Results

19/99 doctors who completed the prognostic test were deemed to be ‘experts’. Of those 14 also completed the additional judgement task. The following factors influenced the experts’ decisions: Cheyne Stokes breathing palliative performance score (PPS) a decline in condition in the previous 24 hours respiratory secretions cyanosis and level of agitation or sedation.

Conclusion

This novel study presents a simple evidenced-based heuristic (or rule of thumb) to help novices recognise when a patient is imminently dying.

References

. Neuberger J, Guthrie C, Aaronovitch D. More care less pathway: A review of the Liverpool Care Pathway.Department of Health2013.

. Taylor P, Dowding D, Johnson M. Clinical decision making in the recognition of dying: A qualitative interview study. BMC Palliative Care2017;16(1):11.
46 Patient safety in palliative care: a mixed methods study of reports to a national database of serious incidents
Authors: Yardley Iain , Yardley Sarah , Williams Huw , Carson-Stevens Andrew , Donaldson Liam J
Published: August 2018

Background

Patients receiving palliative care are vulnerable to patient safety incidents but little is known about the extent of harm caused or the origins of unsafe care in this population.

Aim

To quantify and qualitatively analyse serious incident reports in order to understand the causes and impact of unsafe care in a population receiving palliative care.

Setting and participants

Reports to a national database of ‘serious incidents requiring investigation’ involving patients receiving palliative care in the National Health Service (NHS) in England during the twelve year period April 2002 to March 2014.

Design

A mixed methods approach was used. Following quantification of type of incidents and their location a qualitative analysis using a modified framework method was used to interpret themes in reports to examine underlying causes and the nature of resultant harms.

Results

A total of 475 reports were identified: 266 related to pressure ulcers 91 to medication errors 46 to falls 21 to healthcare associated infections (HCAIs) 18 were other instances of disturbed dying 14 were allegations against health professions eight transfer incidents six suicides and five other concerns. The frequency of report types differed according to the care setting. Underlying causes included lack of palliative care experience under-resourcing and poor service coordination. Resultant harms included worsened symptoms disrupted dying serious injury and hastened death.

Conclusions

Unsafe care presents a risk of significant harm to patients receiving palliative care. Improvements in the coordination of care delivery alongside wider availability of specialist palliative care support may reduce this risk.