How do residents respond to uncertainty with peers and supervisors in multidisciplinary teams? Insights from simulations with epistemic fidelity

BACKGROUND

Residents struggle to express clinical uncertainty, often exhibiting negative cognitive, behavioral, and emotional responses to uncertainty when engaging with patients or supervisors. However, the Integrative Model of Uncertainty Tolerance posits that individuals may have positive or negative responses to perceived uncertainty. Situational characteristics, such as interactions with other health professionals, can impact whether the response is positive or negative. The team context in which residents interact with resident peers and supervisors could represent varying situational characteristics that enable a spectrum of responses to uncertainty. Understanding the situational characteristics of multidisciplinary teams that allow residents to display positive responses to perceived uncertainty could inform strategies to foster positive responses to uncertainty in other contexts. We explored resident responses to perceived uncertainty in a simulated multidisciplinary team context.

METHODS

A simulation-primed qualitative inquiry approach was used. Fourteen residents from Cardiology and Obstetrics and Gynecology participated in simulation scenarios involving pregnant patients with heart disease. We incorporated epistemic fidelity through the deliberate inclusion of ambiguity and complexity to prompt uncertainty. Audio recordings of debriefing sessions were analyzed using directed content analysis.

RESULTS

Residents recognized that uncertainty is unavoidable, and positive responses to uncertainty are crucial to team dynamics and patient safety. While residents had positive responses to expressing uncertainty to peers, they had predominantly negative responses to expressing uncertainty to supervisors. Predominant negative response to supervisors related to judgement from supervisors, and impacts on perceived trustworthiness or independence. Although residents recognized expressing uncertainty to a supervisor could identify opportunities for learning and resolve their uncertainty, the negative responses overshadowed the positive responses. Residents highly valued instances in which supervisors were forthcoming about their own uncertainty.

CONCLUSIONS

Through participation in simulations with epistemic fidelity, residents reflected on how they perceive and respond to uncertainty in multidisciplinary teams. Our findings emphasize the role of situational characteristics, particularly peers and supervisors, in moderating responses to perceived uncertainty. The productive discussions around responses to uncertainty in debriefing sessions suggest further studies of multidisciplinary simulations could enhance our understanding of how uncertainty is expressed, and potentially be used as an instructional intervention to promote positive responses to uncertainty.

Development of a tailored concussion education program for athletes: a pragmatic multimethods design and integrated knowledge translation approach from needs assessment to design

OBJECTIVES

To understand Canadian university athletic programme concussion management needs, and to describe development and content of a tailored online concussion education tool for Canadian university/college athletes.

DESIGN

An integrated knowledge translation multiphased, multimethods approach was used. Phases included a needs assessment survey with university representatives and athletes, content selection, mapping behavioural goals to evidenced-based behaviour change techniques, script/storyboard development, engagement interviews with university athletes and tool development using user-centred design techniques.

SETTING

Canadian U SPORTS universities (n=56).

PARTICIPANTS

Overall, 64 university representatives (eg, administrators, clinicians) and 27 varsity athletes (52% male, 48% female) completed the needs assessment survey. Five athletes participated in engagement interviews.

OUTCOME MEASURES

Surveys assessed previous athlete concussion education, recommendations for concussion topics and tool design, concussion management challenges and interest in implementing a new course.

RESULTS

Institutions used a median (Med) of two (range 1-5) approaches when educating athletes about concussion. Common approaches were classroom-style education (50%), online training (41%) and informational handouts (39%). University representatives rated most important topics as: (1) what is a concussion, (2) how to recognise a concussion and (3) how to report a concussion (Medall=4.8/5). Athletes felt symptom recognition (96%) and effects on the brain (85%) were most important. The majority of athletes preferred learning via computer (81%) and preferred to learn alone (48%) versus group learning (7%). The final resource was designed to influence four behaviours: (1) report symptoms, (2) seek care, (3) encourage teammates to report symptoms and (4) support teammates through concussion recovery. Examples of behaviour change techniques included: knowledge/skills, problem-solving scenarios, verbal persuasion and social comparison. Athletes are guided through different interactions (eg, videos, flip cards, scenarios, testimonials) to maximise engagement (material review takes ~30 min).

CONCLUSIONS

The Concussion Awareness Training Tool for athletes is the first Canadian education tool designed to address the needs of Canadian university/college athletes.

Fungal Planet description sheets: 1436-1477

Novel species of fungi described in this study include those from various countries as follows: Argentina, Colletotrichum araujiae on leaves, stems and fruits of Araujia hortorum. Australia, Agaricus pateritonsus on soil, Curvularia fraserae on dying leaf of Bothriochloa insculpta, Curvularia millisiae from yellowing leaf tips of Cyperus aromaticus, Marasmius brunneolorobustus on well-rotted wood, Nigrospora cooperae from necrotic leaf of Heteropogon contortus, Penicillium tealii from the body of a dead spider, Pseudocercospora robertsiorum from leaf spots of Senna tora, Talaromyces atkinsoniae from gills of Marasmius crinis-equi and Zasmidium pearceae from leaf spots of Smilaxglyciphylla. Brazil, Preussia bezerrensis from air. Chile, Paraconiothyrium kelleni from the rhizosphere of Fragaria chiloensis subsp. chiloensis f. chiloensis. Finland, Inocybe udicola on soil in mixed forest with Betula pendula, Populus tremula, Picea abies and Alnus incana. France, Myrmecridium normannianum on dead culm of unidentified Poaceae. Germany, Vexillomyces fraxinicola from symptomless stem wood of Fraxinus excelsior. India, Diaporthe limoniae on infected fruit of Limonia acidissima, Didymella naikii on leaves of Cajanus cajan, and Fulvifomes mangroviensis on basal trunk of Aegiceras corniculatum. Indonesia, Penicillium ezekielii from Zea mays kernels. Namibia, Neocamarosporium calicoremae and Neocladosporium calicoremae on stems of Calicorema capitata, and Pleiochaeta adenolobi on symptomatic leaves of Adenolobus pechuelii. Netherlands, Chalara pteridii on stems of Pteridium aquilinum, Neomackenziella juncicola (incl. Neomackenziella gen. nov.) and Sporidesmiella junci from dead culms of Juncus effusus. Pakistan, Inocybe longistipitata on soil in a Quercus forest. Poland, Phytophthora viadrina from rhizosphere soil of Quercus robur, and Septoria krystynae on leaf spots of Viscum album. Portugal (Azores), Acrogenospora stellata on dead wood or bark. South Africa, Phyllactinia greyiae on leaves of Greyia sutherlandii and Punctelia anae on bark of Vachellia karroo. Spain, Anteaglonium lusitanicum on decaying wood of Prunus lusitanica subsp. lusitanica, Hawksworthiomyces riparius from fluvial sediments, Lophiostoma carabassense endophytic in roots of Limbarda crithmoides, and Tuber mohedanoi from calcareus soils. Spain (Canary Islands), Mycena laurisilvae on stumps and woody debris. Sweden, Elaphomyces geminus from soil under Quercus robur. Thailand, Lactifluus chiangraiensis on soil under Pinus merkusii, Lactifluus nakhonphanomensis and Xerocomus sisongkhramensis on soil under Dipterocarpus trees. Ukraine, Valsonectria robiniae on dead twigs of Robinia hispida. USA, Spiralomyces americanus (incl. Spiralomyces gen. nov.) from office air. Morphological and culture characteristics are supported by DNA barcodes. Citation: Tan YP, Bishop-Hurley SL, Shivas RG, et al. 2022. Fungal Planet description sheets: 1436-1477. Persoonia 49: 261-350. https://doi.org/10.3767/persoonia.2022.49.08.

Cohort profile: the ESC EURObservational Research Programme Non-ST-segment elevation myocardial infraction (NSTEMI) Registry

AIMS

The European Society of Cardiology (ESC) EURObservational Research Programme (EORP) Non-ST-segment elevation myocardial infarction (NSTEMI) Registry aims to identify international patterns in NSTEMI management in clinical practice and outcomes against the 2015 ESC Guidelines for the management of acute coronary syndromes in patients presenting without ST-segment-elevation.

METHODS AND RESULTS

Consecutively hospitalised adult NSTEMI patients (n = 3620) were enrolled between 11 March 2019 and 6 March 2021, and individual patient data prospectively collected at 287 centres in 59 participating countries during a two-week enrolment period per centre. The registry collected data relating to baseline characteristics, major outcomes (in-hospital death, acute heart failure, cardiogenic shock, bleeding, stroke/transient ischaemic attack, and 30-day mortality) and guideline-recommended NSTEMI care interventions: electrocardiogram pre- or in-hospital, pre-hospitalization receipt of aspirin, echocardiography, coronary angiography, referral to cardiac rehabilitation, smoking cessation advice, dietary advice, and prescription on discharge of aspirin, P2Y12 inhibition, angiotensin converting enzyme inhibitor (ACEi)/angiotensin receptor blocker (ARB), beta-blocker, and statin.

CONCLUSION

The EORP NSTEMI Registry is an international, prospective registry of care and outcomes of patients treated for NSTEMI, which will provide unique insights into the contemporary management of hospitalised NSTEMI patients, compliance with ESC 2015 NSTEMI Guidelines, and identify potential barriers to optimal management of this common clinical presentation associated with significant morbidity and mortality.

Ecological interchangeability: supporting team adaptive expertise in moments of disruption

While undesirable, unexpected disruptions offer unique opportunities to enact adaptive expertise. For adaptive expertise to flourish, individuals and teams must embrace both efficiency and adaptation. While some industries do it readily, others continue to struggle with the tension between efficiency and adaptation, particularly when otherwise stable situations are unexpectedly disrupted. For instance, in healthcare settings, the efficiency mandate for strict compliance with scopes of practice can deter teams from using the adaptive strategy of making their members interchangeable. Yet, interchangeability has been hinted as a key capacity of today' teams that are required to navigate fluid team structures. Because interchangeability - as an adaptive strategy - can generate antagonistic reactions, it has not been well studied in fluid teams. Thus, in this exploratory qualitative study we sought to gain insights into how interchangeability manifests when fluid teams from five different contexts (healthcare, emergency services, orchestras, military, and business) deal with disruptive events. According to our participants, successful interchangeability was possible when people knew how to work within one's role while being aware of their teammates' roles. However, interchangeability included more than just role switching. Interchangeability took various forms and was most successful when teams capitalized on the procedural, emotional, and social dimensions of their work. To reflect this added complexity, we refer to interchangeability in fluid teams as Ecological Interchangeability. We suggest that ecological interchangeability may become a desired feature in the training of adaptive expertise in teams, if its underlying properties and enabling mechanisms are more fully understood.

Facing hierarchy: a qualitative study of residents’ experiences in an obstetrical simulation scenario

Background

Residents in surgical specialties face a steep hierarchy when managing medical crises. Hierarchy can negatively impact patient safety when team members are reluctant to speak up. Yet, simulation has scarcely been previously utilized to qualitatively explore the way residents in surgical specialities navigate this challenge. The study aimed to explore the experiences of residents in one surgical specialty, obstetrics and gynecology (Ob/Gyn), when challenging hierarchy, with the goal of informing future interventions to optimize resident learning and patient safety.

Methods

Eight 3rd- and 4th-year Ob/Gyn residents participated in a simulation scenario in which their supervising physician made an erroneous medical decision that jeopardized the wellbeing of the labouring mother and her foetus. Residents participated in 30–45 min semi-structured interviews that explored their approach to managing this scenario. Transcribed interviews were analysed using qualitative thematic inquiry by three research team members, finalizing the identified themes once consensus was reached.

Results

Study results show that the simulated scenario did create an experience of hierarchy that challenged residents. In response, residents adopted three distinct communication strategies while confronting hierarchy: (1) messaging — a mere reporting of existing clinical information; (2) interpretive — a deliberate construction of clinical facts aimed at swaying supervising physician’s clinical decision; and (3) advocative — a readiness to confront the staff physician’s clinical decision. Furthermore, residents utilized coping mechanisms to mitigate challenges related to confronting hierarchy, namely deflecting responsibility, diminishing urgency, and drafting allies. Both these communication strategies and coping mechanisms shaped their practice when challenging hierarchy to preserve patient safety.

Conclusions

Understanding the complex processes in which residents engage when confronting hierarchy can serve to inform the development and study of curricular innovations. Informed by these processes, we must move beyond solely teaching residents to speak up and consider a broader curriculum that targets not only residents but also faculty physicians and the learning environment within the organization.

Supplementary Information

The online version contains supplementary material available at 10.1186/s41077-022-00232-1.

“Maybe I’m not that approachable”: using simulation to elicit team leaders’ perceptions of their role in facilitating speaking up behaviors

Background

Simulation research that seeks to solve the problem of silence among interprofessional teams has focused almost exclusively on training subordinate team members to be more courageous and to speak up to team leaders using direct challenge scripts despite the great interpersonal cost. Consequently, the existing literature overemphasizes the responsibility of subordinate team members for speaking up and fails to consider the role and responsibilities of team leaders in sustaining silence. The purpose of this study is to identify and describe the subtle behaviors and actions of team leaders that both promote and discourage speaking up.

Methods

This study used a simulation-primed qualitative inquiry approach. Obstetricians (OB) at one academic center participated in an interprofessional simulation as an embedded participant. Five challenge moments (CM) were scripted for the OB involving deliberate clinical judgment errors or professionalism infractions. Other participants were unaware of the OB embedded participant role. Thirteen iterations were completed with 39 participants. Twelve faculty members completed a subsequent semi-structured interview. Scenarios were videotaped; debriefs and interviews were audio-recorded and transcribed verbatim. Data were analyzed using an inductive thematic approach.

Results

After participating in an interprofessional simulation, faculty participants reflected that being an approachable team leader requires more than simply avoiding disruptive behaviors. We found that approachability necessitates that team leaders actively create the conditions in which team members perceive that speaking up is welcomed, rather than an act of bravery. In practice, this conceptualization of approachability involves the tangible actions of signaling availability through presence, uncertainty through thinking aloud, and vulnerability through debriefing.

Conclusions

By using faculty as embedded participants with scripted errors, our simulation design provided an ideal learning opportunity to prompt discussion of the subtle behaviors and actions of team leaders that both promote and discourage speaking up. Faculty participants gained a new appreciation that their actions create the conditions for speaking up to occur before critical incidents through their verbal and non-verbal communication.

Supplementary Information

The online version contains supplementary material available at 10.1186/s41077-022-00227-y.

Effectiveness of an online module: climate-change and sustainability in clinical practice

BACKGROUND

Climate change has significant implications for health, yet healthcare provision itself contributes significant greenhouse gas emission. Medical students need to be prepared to address impacts of the changing environment and fulfil a key role in climate mitigation. Here we evaluate the effectiveness of an online module on climate-change and sustainability in clinical practice designed to achieve learning objectives adapted from previously established sustainable healthcare priority learning outcomes.

METHODS

A multi-media, online module was developed, and 3^rd and 4^th year medical students at Brighton and Sussex Medical School were invited to enrol. Students completed pre- and post-module questionnaires consisting of Likert scale and white space answer questions. Quantitative and qualitative analysis of responses was performed.

RESULTS

Forty students enrolled and 33 students completed the module (83% completion rate). There was a significant increase in reported understanding of key concepts related to climate change and sustainability in clinical practice (p < 0.001), with proportion of students indicating good or excellent understanding increasing from between 2 - 21% students to between 91 - 97% students. The majority (97%) of students completed the module within 90 min. All students reported the module was relevant to their training. Thematic analysis of white space responses found students commonly reported they wanted access to more resources related to health and healthcare sustainability, as well as further guidance on how to make practical steps towards reducing the environmental impact within a clinical setting.

CONCLUSION

This is the first study to evaluate learner outcomes of an online module in the field of sustainable health and healthcare. Our results suggest that completion of the module was associated with significant improvement in self-assessed knowledge of key concepts in climate health and sustainability. We hope this approach is followed elsewhere to prepare healthcare staff for impacts of climate change and to support improving the environmental sustainability of healthcare delivery.

TRIAL REGISTRATION

Study registered with Brighton and Sussex Medical School Research Governance and Ethics Committee (BSMS RGEC). Reference: ER/BSMS3576/8, Date: 4/3/2020.

Seasonal shifts in isoprenoid emission composition from three hyperdominant tree species in central Amazonia

Volatile isoprenoids regulate plant performance and atmospheric processes, and Amazon forests comprise the dominant source to the global atmosphere. Still, there is a poor understanding of how isoprenoid emission capacities vary in response to ecophysiological and environmental controls in Amazonian ecosystems. We measured isoprenoid emission capacities of three Amazonian hyperdominant tree species - Protium hebetatum, Eschweilera grandiflora, Eschweilera coriacea - across seasons and along a topographic and edaphic environmental gradient in the central Amazon. From wet to dry season, both photosynthesis and isoprene emission capacities strongly declined, while emissions increased among the heavier isoprenoids: monoterpenes and sesquiterpenes. Plasticity across habitats was most evident in P. hebetatum, which emitted sesquiterpenes only in the dry season, at rates that significantly increased along the hydro-topographic gradient from white sands (shallow root water access) to uplands (deep water table). We suggest that emission composition shifts are part of a plastic response to increasing abiotic stress (e.g. heat and drought) and reduced photosynthetic supply of substrates for isoprenoid synthesis. Our comprehensive measurements suggest that more emphasis should be placed on other isoprenoids, besides isoprene, in the context of abiotic stress responses. Shifting emission compositions have implications for atmospheric responses because of the strong variation in reactivity among isoprenoid compounds.

Adapting despite "walls coming down": Healthcare providers' experiences of COVID-19 as an implosive adaptation

INTRODUCTION

The COVID-19 pandemic has been a daunting exercise in adaptation for healthcare providers. While we are beginning to learn about the challenges faced by teams during the COVID-19 pandemic, what remains underexplored are the strategies team members used to adapt to these challenges. The goal of this study is therefore to explore how healthcare providers navigated and adapted to on-the-ground challenges imposed by COVID-19.

METHODS

We interviewed 20 healthcare workers at various hospitals in Ontario, who provided care as part of clinical teams during the COVID-19 pandemic. Data were collected and analyzed following Constructivist Grounded Theory principles including iteration, constant comparison and theoretical sampling.

RESULTS

Participants' accounts of their experiences revealed the process of 'implosive adaptation'. The 'reality check', the 'scramble' and the 'pivot' comprised this process. The reality check described the triggers, the scramble detailed the challenges they went through and the pivot prescribed the shifting of mindset as they responded to challenges. These stages were iterative, rather than linear, with blurred boundaries.

DISCUSSION

According to our participants, not all adaptations have to be successful during a crisis. The language of reality check, scramble and pivot provides a framework for teams to talk about and make sense of their approaches to crisis, even beyond the COVID-19 pandemic.

Patterns and trends among physicians-in-training named in civil legal cases: a retrospective analysis of Canadian Medical Protective Association data from 1993 to 2017

BACKGROUND

Medico-legal data show opportunities to improve safe medical care; little is published on the experience of physicians-in-training with medical malpractice. The purpose of this study was to examine closed civil legal cases involving physicians-in-training over time and provide novel insights on case and physicians characteristics.

METHODS

We conducted a retrospective descriptive study of closed civil legal cases at the Canadian Medical Protective Association (CMPA), a mutual medico-legal defence organization for more than 105 000 physicians, representing an estimated 95% of physicians in Canada. Eligible cases involved at least 1 physician-in-training and were closed between 1993 and 2017 (for time trends) or 2008 and 2017 (for descriptive analyses). We analyzed case rates over time using Poisson regression and the annualized change rate. Descriptive analyses addressed case duration, medico-legal outcome and patient harm. We explored physician specialties and practice characteristics in a subset of cases.

RESULTS

Over a 25-year period (1993-2017), 4921 physicians-in-training were named in 2951 closed civil legal cases, and case rates decreased significantly (β = -0.04, 95% confidence interval -0.05 to -0.03, where β was the 1-year difference in log case rates). The annualized change rate was -1.1% per year. Between 2008 and 2017, 1901 (4.1%) of 45 967 physicians-in-training were named in 1107 civil legal cases. Cases with physicians-in-training generally involved more severe patient harm than cases without physicians-in-training. In a subgroup with available information (n = 951), surgical specialties were named most often (n = 531, 55.8%).

INTERPRETATION

The rate of civil legal cases involving physicians-in-training has diminished over time, but more recent cases featured severe patient harm and death. Efforts to promote patient safety may enhance medical care and reduce the frequency and severity of malpractice issues for physicians-in-training.

Primary sclerosing cholangitis: A new case of cirrhosis in pregnancy

Cirrhosis is a multisystemic condition in which pregnancy is uncommon; however, the combination may lead to a higher incidence of spontaneous fetal loss and complications such as progressive jaundice, ascites and variceal bleeding. Here we present a 21-year-old woman who presented at 14 weeks' gestation with new jaundice and a two-month history of melena consistent with pre-existing cirrhosis of unclear aetiology. She delivered a healthy male infant at 34 weeks and five days of gestation vaginally with good haemostasis. In the literature, maternal mortality rates have been reported in up to 61% of these women, however, this risk is likely lower now with modern endoscopic therapies and improved access to blood products. There is limited information about labour and delivery in cirrhosis, although the best outcomes to date have been described in well-compensated women.

The fatigue paradox: Team perceptions of physician fatigue

OBJECTIVES

Ongoing calls to implement fatigue risk management in residency education assume a shared understanding of physician fatigue as a workplace hazard, yet we lack empirical evidence that all health care team members maintain this assumption. Thus, this study seeks to explore how health care team members understand the role of physician fatigue in an effort to inform the implementation of fatigue risk management in residency training and medical practice.

METHODS

This study uses constructivist grounded theory to explore perceptions of workplace fatigue and its impact on clinical practice. We conducted individual semi-structured interviews with physicians, nurses and senior residents across four hospitals in 8 different specialties for a total of 40 participants. Constant comparative analysis guided data analysis and led to the final grounded theory.

RESULTS

While participants outlined multiple problematic manifestations of physician fatigue on clinical performance, they were reluctant to acknowledge any negative impact of fatigue on patient care. We refer to these contradictions as the fatigue paradox. Four key themes sustain the fatigue paradox: the indefatigable physician, blind spots, faith in safety nets and the minimisation of fatigue-related events.

CONCLUSIONS

This study suggests that health care team members do not universally feel that physician fatigue is problematic for patient care, despite providing multiple examples to the contrary. This paradoxical understanding of fatigue likely exists because the system relies on fatigued physicians, particularly trainees, and provides few mechanisms to critically examine fatigue. Successful implementation of fatigue risk management in residency training may prove elusive if clinical supervisors are skeptical of the potentially negative impact of workplace fatigue.

Indoor PM2.5, VOCs and asthma outcomes: A systematic review in adults and their home environments

INTRODUCTION

As the amount of time people spend indoors increases globally, exposure to indoor air pollutants has become an important public health concern. Asthma is a complex disease caused and/or exacerbated by increased exposure to diverse chemical, physical and biological exposures from multiple indoor and outdoor sources. This review aims to investigate the relationship between increased indoor PM and VOC concentrations (i.e. objectively measured) and the risk of adult asthma in higher-income countries.

METHODS

Eleven databases were systematically searched on the February 1, 2019 and again on the February 2, 2020. Articles were limited to those published since 1990. Reference lists were independently screened by three reviewers and authors were contacted to identify relevant articles. Backwards and forward citation chasing was used to identify further studies. Data were extracted from included studies meeting our eligibility criteria by three reviewers and assessed for quality using the Newcastle-Ottawa scale designed for case-control and cohort studies.

RESULTS

Twelve studies were included in a narrative synthesis. We found insufficient evidence to determine the effect of PM2.5 on asthma in the indoor home environment. However, there was strong evidence to suggest that VOCs, especially aromatic compounds, and aliphatic compounds, were associated with increased asthma symptoms.

DISCUSSION & CONCLUSION

Although no single exposure appears to be responsible for the development of asthma or its associated symptoms, the use of everyday products may be associated with increased asthma symptoms. To prevent poor health outcomes among the general population, health professionals and industry must make a concerted effort to better inform the general population of the importance of appropriate use of and storage of chemicals within the home as well as better health messaging on product labelling.

Structural distress: experiences of moral distress related to structural stigma during the COVID-19 pandemic

INTRODUCTION

The COVID-19 pandemic has taken a significant toll on the health of structurally vulnerable patient populations as well as healthcare workers. The concepts of structural stigma and moral distress are important and interrelated, yet rarely explored or researched in medical education. Structural stigma refers to how discrimination towards certain groups is enacted through policy and practice. Moral distress describes the tension and conflict that health workers experience when they are unable to fulfil their duties due to circumstances outside of their control. In this study, the authors explored how resident physicians perceive moral distress in relation to structural stigma. An improved understanding of such experiences may provide insights into how to prepare future physicians to improve health equity.

METHODS

Utilizing constructivist grounded theory methodology, 22 participants from across Canada including 17 resident physicians from diverse specialties and 5 faculty members were recruited for semi-structured interviews from April-June 2020. Data were analyzed using constant comparative analysis.

RESULTS

Results describe a distinctive form of moral distress called structural distress, which centers upon the experience of powerlessness leading resident physicians to go above and beyond the call of duty, potentially worsening their psychological well-being. Faculty play a buffering role in mitigating the impact of structural distress by role modeling vulnerability and involving residents in policy decisions.

CONCLUSION

These findings provide unique insights into teaching and learning about the care of structurally vulnerable populations and faculty's role related to resident advocacy and decision-making. The concept of structural distress may provide the foundation for future research into the intersection between resident well-being and training related to health equity.

DATA ASSIMILATION APPLIED TO PRESSURISED WATER REACTORS

Best estimate plus uncertainty is the leading methodology to validate existing safety margins. It remains a challenge to develop and license these approaches, in part due to the high dimensionality of system codes. Uncertainty quantification is an active area of research to develop appropriate methods for propagating uncertainties, offering greater scientific reason, dimensionality reduction and minimising reliance on expert judgement. Inverse uncertainty quantification is required to infer a best estimate back on the input parameters and reduce the uncertainties, but it is challenging to capture the full covariance and sensitivity matrices. Bayesian inverse strategies remain attractive due to their predictive modelling and reduced uncertainty capabilities, leading to dramatic model improvements and validation of experiments. This paper uses state-of-the-art data assimilation techniques to obtain a best estimate of parameters critical to plant safety. Data assimilation can combine computational, benchmark and experimental measurements, propagate sparse covariance and sensitivity matrices, treat non-linear applications and accommodate discrepancies. The methodology is further demonstrated through application to hot zero power tests in a pressurised water reactor (PWR) performed using the BEAVRS benchmark with Latin hypercube sampling of reactor parameters to determine responses. WIMS 11 (dv23) and PANTHER (V.5:6:4) are used as the coupled neutronics and thermal-hydraulics codes; both are used extensively to model PWRs. Results demonstrate updated best estimate parameters and reduced uncertainties, with comparisons between posterior distributions generated using maximum entropy principle and cost functional minimisation techniques illustrated in recent conferences. Future work will improve the Bayesian inverse framework with the introduction of higher-order sensitivities.

COVID-19-Myocarditis and Return to Play: Reflections and Recommendations From a Canadian Working Group

The COVID-19–related pandemic has resulted in profound health, financial, and societal impacts. Organized sporting events, from recreational to the Olympic level, have been cancelled to both mitigate the spread of COVID-19 and protect athletes and highly active individuals from potential acute and long-term infection-associated harms. COVID-19 infection has been associated with increased cardiac morbidity and mortality. Myocarditis and late gadolinium enhancement as a result of COVID-19 infection have been confirmed. Correspondingly, myocarditis has been implicated in sudden cardiac death of athletes. A pragmatic approach is required to guide those who care for athletes and highly active persons with COVID-19 infection. Members of the Community and Athletic Cardiovascular Health Network (CATCHNet) and the writing group for the Canadian Cardiovascular Society/Canadian Heart Rhythm Society Joint Position Statement on the Cardiovascular Screening of Competitive Athletes recommend that highly active persons with suspected or confirmed COVID-19 infection refrain from exercise for 7 days after resolution of viral symptoms before gradual return to exercise. We do not recommend routine troponin testing, resting 12-lead electrocardiography, echocardiography, or cardiac magnetic resonance imaging before return to play. However, medical assessment including history and physical examination with consideration of resting electrocardiography and troponin can be considered in the athlete manifesting new active cardiac symptoms or a marked reduction in fitness. If concerning abnormalities are encountered at the initial medical assessment, then referral to a cardiologist who cares for athletes is recommended.

The Development of the DEMoBinc. Toolkit and the Results of Reliability Testing

Aims:

To develop a toolkit to assess the quality of institutionalised care, in both hospital and community settings, for individuals with long-term mental illness.

Methods:

The toolkit was developed by the UK research teams. Items were included to assess the six domains (Living Environment; Therapeutic Environment; Treatments and Interventions; Self-management and Autonomy; Social Policy, Citizenship and Advocacy; Clinical Governance) and three cross-cutting themes (Social Inclusion; Human Rights; Recovery-based Model) which emerged from the international literature review, Delphi exercises and cross-country care standards. Following translation and piloting in each country, the toolkit was refined and tested for reliability in 20 units in each country (a total of 200 units).

Results:

Test-retest reliability was assessed using intra-class correlations and Cohen's Kappa coefficients. Factors with low reliability or extreme response biases were dropped. Remaining items were subjected to an exploratory factor analysis to test the allocation of items to domains and cross-cutting themes and improve their internal consistency. Correlations between domains were explored to determine whether or not domains could be combined.

In the next phase of the study,the toolkit domain ratings will be analysed for associations with standardised assessments of service users' quality of life, autonomy and markers of recovery to investigate whether the toolkit can provide a proxy measurement of the institution's promotion of human rights and recovery.

Genetic structure and admixture in sheep from terminal breeds in the United States

Selection for performance in diverse production settings has resulted in variation across sheep breeds worldwide. Although sheep are an important species to the United States, the current genetic relationship among many terminal sire breeds is not well characterized. Suffolk, Hampshire, Shropshire and Oxford (terminal) and Rambouillet (dual purpose) sheep (n = 248) sampled from different flocks were genotyped using the Applied Biosystems Axiom Ovine Genotyping Array (50K), and additional Shropshire sheep (n = 26) using the Illumina Ovine SNP50 BeadChip. Relationships were investigated by calculating observed heterozygosity, inbreeding coefficients, eigenvalues, pairwise Wright’s F_ST estimates and an identity by state matrix. The mean observed heterozygosity for each breed ranged from 0.30 to 0.35 and was consistent with data reported in other US and Australian sheep. Suffolk from two different regions of the United States (Midwest and West) clustered separately in eigenvalue plots and the rectangular cladogram. Further, divergence was detected between Suffolk from different regions with Wright’s F_ST estimate. Shropshire animals showed the greatest divergence from other terminal breeds in this study. Admixture between breeds was examined using admixture, and based on cross‐validation estimates, the best fit number of populations (clusters) was K = 6. The greatest admixture was observed within Hampshire, Suffolk, and Shropshire breeds. When plotting eigenvalues, US terminal breeds clustered separately in comparison with sheep from other locations of the world. Understanding the genetic relationships between terminal sire breeds in sheep will inform us about the potential applicability of markers derived in one breed to other breeds based on relatedness.

Household energy efficiency and health: Area-level analysis of hospital admissions in England

INTRODUCTION

Fuel poverty affects up to 35% of European homes, which represents a significant burden on society and healthcare systems. Draught proofing homes to prevent heat loss, improved glazing, insulation and heating (energy efficiency measures) can make more homes more affordable to heat. This has prompted significant investment in energy efficiency upgrades for around 40% of UK households to reduce the impact of fuel poverty. Despite some inconsistent evidence, household energy efficiency interventions can improve cardiovascular and respiratory health outcomes. However, the health benefits of these interventions have not been fully explored; this is the focus of this study.

METHODS

In this cross sectional ecological study, we conducted two sets of analyses at different spatial resolution to explore population data on housing energy efficiency measures and hospital admissions at the area-level (counts grouped over a 3-year period). Housing data were obtained from three data sets covering housing across England (Household Energy Efficiency Database), Energy Performance Certificate (EPC) and, in the South West of England, the Devon Home Analytics Portal. These databases provided data aggregated to Lower Area Super Output Area and postcode level (Home Analytics Portal only). These datasets provided measures of both state (e.g. EPC ratings) and intervention (e.g. number of boiler replacements), aggregated spatially and temporally to enable cross-sectional analyses with health outcome data. Hospital admissions for adult (over 18 years) asthma, chronic obstructive pulmonary disease (COPD) and cardiovascular disease (CVD) were obtained from the Hospital Episode Statistics database for the national (1st April 2011 to 31st March 2014) and Devon, South West of England (1st April 2014 to 31st March 2017) analyses. Descriptive statistics and regression models were used to describe the associations between small area household energy efficiency measures and hospital admissions. Three main analyses were undertaken to investigate the relationships between; 1) household energy efficiency improvements (i.e. improved glazing, insulation and boiler upgrades); 2) higher levels of energy efficiency ratings (measured by Energy Performance Certificate ratings); 3) energy efficiency improvements and ratings (i.e. physical improvements and rating assessed by the Standard Assessment Procedure) and hospital admissions.

RESULTS

In the national analyses, household energy performance certificate ratings ranged from 37 to 83 (mean 61.98; Standard Deviation 5.24). There were a total of 312,837 emergency admissions for asthma, 587,770 for COPD and 839,416 for CVD. While analyses for individual energy efficiency metrics (i.e. boiler upgrades, draught proofing, glazing, loft and wall insulation) were mixed; a unit increase in mean energy performance rating was associated with increases of around 0.5% in asthma and CVD admissions, and 1% higher COPD admission rates. Admission rates were also influenced by the type of dwelling, tenure status (e.g. home owner versus renting), living in a rural area, and minimum winter temperature.

DISCUSSION

Despite a range of limitations and some mixed and contrasting findings across the national and local analyses, there was some evidence that areas with more energy efficiency improvements resulted in higher admission rates for respiratory and cardiovascular diseases. This builds on existing evidence highlighting the complex relationships between health and housing. While energy efficiency measures can improve health outcomes (especially when targeting those with chronic respiratory illness), reduced household ventilation rates can impact indoor air quality for example and increase the risk of diseases such as asthma. Alternatively, these findings could be due to the ecological study design, reverse causality, or the non-detection of more vulnerable subpopulations, as well as the targeting of areas with poor housing stock, low income households, and the lack of "whole house approaches" when retrofitting the existing housing stock.

CONCLUSION

To be sustainable, household energy efficiency policies and resulting interventions must account for whole house approaches (i.e. consideration of the whole house and occupant lifestyles). These must consider more alternative 'greener' and more sustainable measures, which are capable of accounting for variable lifestyles, as well as the need for adequate heating and ventilation. Larger natural experiments and more complex modelling are needed to further investigate the impact of ongoing dramatic changes in the housing stock and health.

STUDY IMPLICATIONS

This study supports the need for more holistic approaches to delivering healthier indoor environments, which must consider a dynamic and complex system with multiple interactions between a range of interrelated factors. These need to consider the drivers and pressures (e.g. quality of the built environment and resident behaviours) resulting in environmental exposures and adverse health outcomes.

Exploring traditional and complementary medicine use by Indigenous Australian women undergoing gynaecological cancer investigations

BACKGROUND

Indigenous Australian women experience worse gynaecological cancer outcomes than non-Indigenous women. While traditional and complementary medicine (T&CM) is increasingly used by cancer patients alongside conventional treatments, little is known about T&CM use by Indigenous women. This study aimed to explore the beliefs, attitudes and experiences related to T&CM use and disclosure among Indigenous women undergoing gynaecological cancer investigations.

METHODS

A mixed-methods design explored T&CM use among Indigenous women who presented for gynaecological cancer investigation at an urban Queensland hospital (September 2016 and January 2018).

RESULTS

Fourteen women participated. The reported use (86%) and perceived value of T&CM was high among the participants, however, women reported major challenges in communicating with healthcare providers about T&CM, commonly associated with trust and rapport.

CONCLUSIONS

These findings highlight the need for strategies to facilitate culturally-appropriate doctor-patient communication around T&CM to foster trust and transparency in gynaecological cancer care for Indigenous women.

Feasibility and Reliability of Nonexpert POCUS for Cardiovascular Preparticipation Screening of Varsity Athletes: The SHARP Protocol

BACKGROUND

Point of care ultrasound (POCUS) is a potential adjunctive cardiovascular preparticipation screening modality for young competitive athletes. A novel cardiac POCUS screening protocol, Screening the Heart of the Athlete Research Program (SHARP), was developed for nonexpert examiners to assess common structural etiologies associated with sudden cardiac arrest/death (SCA/D).

METHODS

Assessment of primary outcomes of feasibility, and reliability of obtained measurements, performed by comparison to formal transthoracic echocardiogram was undertaken. Inter-rater reliability was based on Intraclass correlation coefficients (ICC) defined as moderate for 0.40 to 0.59, good for 0.60 to 0.79, and excellent for 0.80 or greater. Electrocardiograms (ECGs) were also obtained. Identification of disease or other abnormalities was a secondary outcome.

RESULTS

Fifty varsity athletes at our institution underwent the SHARP protocol, with 19 undergoing formal transthoracic echocardiogram and ECG for comparison. POCUS image quality was good to excellent. Feasibility of assessing for hypertrophic cardiomyopathy, aortic root dilatation, and left-ventricular function was deemed highly possible but limited in 20% for right-ventricular assessment. Reliability was good for measurements of interventricular septal thickness (0.67), end diastolic left-ventricular diameter (0.61), aortic root diameter (0.63), and moderate for left-ventricular posterior wall thickness (0.42). No cardiovascular abnormalities were detected.

CONCLUSIONS

A novel, comprehensive SHARP POCUS protocol performed by nonexpert practitioners demonstrated feasibility and reliability to assess varsity level athletes for common structural etiologies associated with SCA/D. Further large athlete screening cohort studies are required to validate the SHARP protocol and the role of cardiac POCUS as a screening modality.

Distribution of the Recombinant Coagulation Factor 125I-rFVIIa in Rats

Recombinant human factor VIIa (rFVIIa; NovoSeven®) is a two-chain activated clotting factor that is used in the treatment of haemophilia. The distribution of radioactivity in male and pregnant and non-pregnant female rats has been examined by whole-body autoradiography (WBA) after single intravenous doses of 125I-radiolabelled rFVIIa at a dosage level of ca. 0.1 mg/kg.

Concentrations of radioactivity were highest in the blood and the highly perfused major thoracic and visceral organs and gonads. This distribution of radioactivity was generally similar in pregnant and non-pregnant females, and although radioactivity was concentrated in the foetal thyroid, it was present in other foetal tissues only at trace levels. Radioactivity in thyroid, urinary bladder and gastrointestinal tract of all rats was apparently associated with detached 125I-iodide. At early sacrifice times (up to 2 h), radioactivity was present in the bone marrow, but at later times (6-24 h) it was apparently associated with the mineralised bone structures.

The quantitative distribution of total and trichloroacetic acid precipitable radioactivity in the tissues of rats also was studied after single intravenous doses of 125I-rFVIIa and 125I-rFVII, the non-activated single chain precursor of FVIIa, which is normally present in the circulation. These studies confirmed the WBA findings and showed that the tissue distribution of 125I-rFVII and 125I-rFVIIa was similar, indicating that the distribution of rFVIIa during therapy would be similar to that produced from endogenous FVII as a physiological response to vascular injury.

Oxidative Stress and Cardiovascular Risk in Type 1 Diabetes Mellitus: Insights From the DCCT/EDIC Study

Background

Hyperglycemia leading to increased oxidative stress is implicated in the increased risk for the development of macrovascular and microvascular complications in patients with type 1 diabetes mellitus.

Methods and Results

A random subcohort of 349 participants was selected from the DCCT / EDIC (Diabetes Control and Complications Trial/Epidemiology of Diabetes Interventions and Complications) cohort. This included 320 controls and 29 cardiovascular disease cases that were augmented with 98 additional known cases to yield a case cohort of 447 participants (320 controls, 127 cases). Biosamples from DCCT baseline, year 1, and closeout of DCCT , and 1 to 2 years post‐ DCCT ( EDIC years 1 and 2) were measured for markers of oxidative stress, including plasma myeloperoxidase, paraoxonase activity, urinary F 2α isoprostanes, and its metabolite, 2,3 dinor‐8 iso prostaglandin F 2α . Following adjustment for glycated hemoblobin and weighting the observations inversely proportional to the sampling selection probabilities, higher paraoxonase activity, reflective of antioxidant activity, and 2,3 dinor‐8 iso prostaglandin F 2α , an oxidative marker, were significantly associated with lower risk of cardiovascular disease (−4.5% risk for 10% higher paraoxonase, P <0.003; −5.3% risk for 10% higher 2,3 dinor‐8 iso prostaglandin F 2α , P =0.0092). In contrast, the oxidative markers myeloperoxidase and F 2α isoprostanes were not significantly associated with cardiovascular disease after adjustment for glycated hemoblobin. There were no significant differences between DCCT intensive and conventional treatment groups in the change in all biomarkers across time segments.

Conclusions

Heightened antioxidant activity (rather than diminished oxidative stress markers) is associated with lower cardiovascular disease risk in type 1 diabetes mellitus, but these biomarkers did not change over time with intensification of glycemic control.

Clinical Trial Registration

URL : https://www.clinicaltrials.gov . Unique identifiers: NCT 00360815 and NCT 00360893.

Why Open-Ended Survey Questions Are Unlikely to Support Rigorous Qualitative Insights

Health professions education researchers are increasingly relying on a combination of quantitative and qualitative research methods to explore complex questions in the field. This important and necessary development, however, creates new methodological challenges that can affect both the rigor of the research process and the quality of the findings. One example is "qualitatively" analyzing free-text responses to survey or assessment instrument questions. In this Invited Commentary, the authors explain why analysis of such responses rarely meets the bar for rigorous qualitative research. While the authors do not discount the potential for free-text responses to enhance quantitative findings or to inspire new research questions, they caution that these responses rarely produce data rich enough to generate robust, stand-alone insights. The authors consider exemplars from health professions education research and propose strategies for treating free-text responses appropriately.

The Orbiting Carbon Observatory-2 early science investigations of regional carbon dioxide fluxes

NASA's Orbiting Carbon Observatory-2 (OCO-2) mission was motivated by the need to diagnose how the increasing concentration of atmospheric carbon dioxide (CO2) is altering the productivity of the biosphere and the uptake of CO2 by the oceans. Launched on 2 July 2014, OCO-2 provides retrievals of the column-averaged CO2 dry-air mole fraction ([Formula: see text]) as well as the fluorescence from chlorophyll in terrestrial plants. The seasonal pattern of uptake by the terrestrial biosphere is recorded in fluorescence and the drawdown of [Formula: see text] during summer. Launched just before one of the most intense El Niños of the past century, OCO-2 measurements of [Formula: see text] and fluorescence record the impact of the large change in ocean temperature and rainfall on uptake and release of CO2 by the oceans and biosphere.

Muscle thickness correlates to muscle cross-sectional area in the assessment of strength training-induced hypertrophy

Muscle thickness (MT) measured by ultrasound has been used to estimate cross-sectional area (measured by CT and MRI) at a single time point. We tested whether MT could be used as a valid marker of MRI determined muscle anatomical cross-sectional area (ACSA) and volume changes following resistance training (RT). Nine healthy, young, male volunteers (24 ± 2 y.o., BMI 24.1 ± 2.8 kg/m² ) had vastus lateralis (VL) muscle volume (VOL) and ACSA_mid (at 50% of femur length, FL) assessed by MRI, and VL MT measured by ultrasound at 50% FL. Measurements were taken at baseline and after 12 weeks of isokinetic RT. Differences between baseline and post-training were assessed by Student's paired t test. The relationships between MRI and ultrasound measurements were tested by Pearson's correlation. After RT, MT increased by 7.5 ± 6.1% (P < .001), ACSA_mid by 5.2 ± 5% (P < .001), and VOL by 5.0 ± 6.9% (P < .05) (values: means ± SD). Positive correlations were found, at baseline and 12 weeks, between MT and ACSA_mid (r = .82, P < .001 and r = .73, P < .001, respectively), and between MT and VOL (r = .76, P < .001 and r = .73, P < .001, respectively). The % change in MT with training was correlated with % change in ACSA_mid (r = .69, P < .01), but not % change in VOL (r = .33, P > .05). These data support evidence that MT is a reliable index of muscle ACSA_mid and VOL at a single time point. MT changes following RT are associated with parallel changes in muscle ACSA_mid but not with the changes in VOL, highlighting the impact of RT on regional hypertrophy.

Time to onset of bisphosphonate-related osteonecrosis of the jaws: a multicentre retrospective cohort study

OBJECTIVES

Osteonecrosis of the jaw (ONJ) is a potentially severe adverse effect of bisphosphonates (BP). Although the risk of ONJ increases with increasing duration of BP treatment, there are currently no reliable estimates of the ONJ time to onset (TTO). The objective of this study was to estimate the TTO and associated risk factors in BP-treated patients.

SUBJECTS AND METHODS

Retrospective analysis of data from 22 secondary care centres in seven countries relevant to 349 patients who developed BP-related ONJ between 2004 and 2012.

RESULTS

The median (95%CI) TTO was 6.0 years in patients treated with alendronate (n = 88) and 2.2 years in those treated with zoledronate (n = 218). Multivariable Cox regression showed that dentoalveolar surgery was inversely associated, and the use of antiangiogenics directly associated, with the TTO in patients with cancer treated with zoledronate.

CONCLUSIONS

The incidence of ONJ increases with the duration of BP therapy, with notable differences observed with respect to BP type and potency, route of administration and underlying disease. When data are stratified by BP type, a time of 6.0 and 2.2 years of oral alendronate and intravenous zoledronate therapy, respectively, is required for 50% of patients to develop ONJ. After stratification by disease, a time of 5.3 and 2.2 years of BP therapy is required for 50% of patients with osteoporosis and cancer, respectively, to develop ONJ. These findings have significant implications for the design of future clinical studies and the development of risk-reduction strategies aimed at either assessing or modulating the risk of ONJ associated with BP.

Four-week cold acclimation in adult humans shifts uncoupling thermogenesis from skeletal muscles to brown adipose tissue

KEY POINTS

Muscle-derived thermogenesis during acute cold exposure in humans consists of a combination of cold-induced increases in skeletal muscle proton leak and shivering. Daily cold exposure results in an increase in brown adipose tissue oxidative capacity coupled with a decrease in the cold-induced skeletal muscle proton leak and shivering intensity. Improved coupling between electromyography-determined muscle activity and whole-body heat production following cold acclimation suggests a maintenance of ATPase-dependent thermogenesis and decrease in skeletal muscle ATPase independent thermogenesis. Although daily cold exposure did not change the fibre composition of the vastus lateralis, the fibre composition was a strong predictor of the shivering pattern evoked during acute cold exposure.

ABSTRACT

We previously showed that 4 weeks of daily cold exposure in humans can increase brown adipose tissue (BAT) volume by 45% and oxidative metabolism by 182%. Surprisingly, we did not find a reciprocal reduction in shivering intensity when exposed to a mild cold (18°C). The present study aimed to determine whether changes in skeletal muscle oxidative metabolism or shivering activity could account for these unexpected findings. Nine men participated in a 4 week cold acclimation intervention (10°C water circulating in liquid-conditioned suit, 2 h day^-1 , 5 days week^-1 ). Shivering intensity and pattern were measured continuously during controlled cold exposure (150 min at 4 °C) before and after the acclimation. Muscle biopsies from the m. vastus lateralis were obtained to measure oxygen consumption rate and proton leak of permeabilized muscle fibres. Cold acclimation elicited a modest 21% (P < 0.05) decrease in whole-body and m. vastus lateralis shivering intensity. Furthermore, cold acclimation abolished the acute cold-induced increase in proton leak. Although daily cold exposure did not change the fibre composition of the m. vastus lateralis, fibre composition was a strong predictor of the shivering pattern evoked during acute cold. We conclude that muscle-derived thermogenesis during acute cold exposure in humans is not only limited to shivering, but also includes cold-induced increases in proton leak. The efficiency of muscle oxidative phosphorylation improves with cold acclimation, suggesting that reduced muscle thermogenesis occurs through decreased proton leak, in addition to decreased shivering intensity as BAT capacity and activity increase. These changes occur with no net difference in whole-body thermogenesis.