NeoTalk: Communication Skills Training for Neonatal Clinicians

BACKGROUND

Despite proven benefit, pediatric subspecialists often have not been offered formal serious illness communication skills training. We sought to: 1) develop and evaluate the impact of a communication skills course, based on the VitalTalk framework, on Neonatal Intensive Care Unit (NICU) clinicians; 2) evaluate provider comfort with key serious illness communication skills and frequency of use of those skills, before and after "NeoTalk" and; 3) explore differences and similarities between adult and pediatric serious illness communication skills courses.

METHODS

We developed a NICU specific communication skills course and surveyed course participants to evaluate comfort with key communication skills before and after course participation, and frequency of use of key skills before and 2 months after our course. Wilcoxon signed rank tests and Kruskal-Wallis tests were performed to compare participant responses across time points.

RESULTS

34 providers completed NeoTalk training. Complete pre- and post-course data was available for 29 participants. Participants reported increased comfort with skills including 'sharing difficult news' (P = .018), and 'responding to emotion' (P = .002). Participants did not report increased frequency in using target skills 2 months after training.

CONCLUSIONS

A multi-disciplinary cohort of NICU providers endorsed increased confidence in key communication skills but not increased skill application 2-months post-course completion. While a single course can successfully teach skills, additional exposure may be necessary to build new communication habits. Our experience developing NeoTalk helped elucidate some of the ways in which conversations about seriously ill infants may be different from conversations about seriously ill adults.

An Exploration of People Living with Parkinson's Experience of Cardio-Drumming; Parkinson's Beats: A Qualitative Phenomenological Study

Research has shown that physical activity has a range of benefits for people living with Parkinson's (PLwP), improving muscle strength, balance, flexibility, and walking, as well as non-motor symptoms such as mood. Parkinson's Beats is a form of cardio-drumming, specifically adapted for PLwP, and requires no previous experience nor skills. Nineteen PLwP (aged between 55 and 80) took part in the regular Parkinson's Beats sessions in-person or online. Focus group discussions took place after twelve weeks to understand the impacts of Parkinson's Beats. Through the framework analysis, six themes and fifteen subthemes were generated. Participants reported a range of benefits of cardio-drumming, including improved fitness and movement, positive mood, the flow experience, and enhanced social wellbeing. A few barriers to participation were also reported. Future research is justified, and best practice guidelines are needed to inform healthcare professionals, PLwP and their care givers.

A Minimally Invasive Endoscopic Transnasal and Transorbital Approach to Sinonasal Tumor Resection

A 35-year-old female with an extensive biphenotypic sinonasal sarcoma (BSNS) eroding through the left frontal sinus into the orbit required gross total resection of the tumor. We wanted to forgo an open approach and provide a less invasive alternative via combined endonasal and transorbital endoscopic techniques to allow for tumor removal through small, well-disguised incisions. We utilized three portals-nasal, transorbital, and anterior table window-to create interconnected orbit-sinonasal corridors, thus generating alternate pathways for visualization and manipulation of this extensive tumor. Laryngoscope, 134:1308-1312, 2024.

Assessment and management of diabetes-related foot infection according to the new International Working Group on the Diabetic Foot guidelines 2023-Multidisciplinary grand rounds

Diabetes-related foot disease is a serious and common complication for people with diabetes mellitus. The gold standard care for a person with diabetes-related foot disease is the involvement of a multidisciplinary foot team engaged in evidence-based care. To date, there are seven International Working Group on the Diabetic Foot (IWGDF) guidelines published to assist healthcare providers in managing diabetes-related foot disease around the world. This review discusses the acute management of diabetes-related foot infection with insights from experts of various specialities (internal medicine, infectious disease, vascular surgery, radiology) with a discussion on the implementation of IWGDF guidelines in real life practice and the challenges that healthcare providers may face.

Experiences of Interdisciplinary Working from the Perspective of the Society of Master Saddlers Qualified Saddle Fitters

Horse owners seek the advice and support of a number of equestrian professionals in carrying out their duty of care for their animal. In some instances, these professionals form a multi-disciplinary team (MDT). The aim of this study was to explore the experiences of the Society of Master Saddlers' qualified saddle fitters (SMSQSFs) working with other professionals and to understand the nature of inter-disciplinary working from an SMSQSF perspective. Semi-structured, one-to-one online interviews with fourteen SMSQSFs were completed. Areas explored included the nature of the participant's client base; the frequency and nature of their interactions with other professionals; their perceptions of horse owner expectations of an MDT approach; and any benefits, challenges, and barriers to an MDT approach within an equestrian setting. Interviews were video and audio recorded (MS Teams), transcribed verbatim (Otter ai), and imported into qualitative data analysis software (NVivo, version 12). Data were analysed using thematic analysis. Six themes were identified: (1) effective communication; (2) multidisciplinary expectations; (3) horse welfare; (4) professionalism; (5) relationships; (6) working together. Communication was recognised as a crucial component of an effective MDT. Most participants valued and desired an MDT approach. They felt they had a key role to play within the equestrian MDT, not only in the prevention of deterioration in horse welfare but also in improving the functionality and performance of the horse-rider partnership. Effective MDT working was also seen as having benefits to SMSQSFs and other professional stakeholders alike, although time and financial constraints were identified as barriers to MTD working. The role of the horse owner within the MDT was unclear and potentially complex, and this and other factors such as the professional identity of the SMSQSF, personal relationships, and input from others outside of the MDT team were identified as challenges to effective MDT working. This present study found that SMSQSFs experience similar benefits and challenges to an MDT approach as seen in human healthcare settings. The role of the horse owner, communication, and professional recognition are indicated as pivotal to MDT effectiveness in achieving optimal saddle fit.

Rethinking leadership approaches for community-wide opioid crisis intervention: harnessing positive inquiry to unearth front-line insight

BACKGROUND/AIM

The opioid crisis presents a complex and widespread health challenge for communities, necessitating a deeper exploration beyond simple solutions. To address this crisis, it is crucial to identify and disseminate best practices. In this study, we focused on positive deviance narratives from Columbus, Ohio, a community deeply affected by the opioid crisis.

METHODS

Employing an appreciative inquiry framework, we conducted purposive sampling to interview 47 frontline professionals and individuals grappling with opioid use disorder (OUD).

RESULTS

Our research revealed several key insights, highlighting successful themes through positive narratives. First, perceiving OUD as a chronic disease emerged as a critical perspective, acknowledging the long-term nature of the condition and the need for sustained care. Second, re-humanising and de-stigmatising opioid users played a vital role in facilitating their recovery and reintegration into society. Embracing inclusive care delivery was another important aspect, ensuring that individuals from diverse backgrounds receive equitable access to effective treatment. Moreover, re-energising professionals to combat burnout proved essential, emphasising the importance of supporting and motivating healthcare providers in their efforts. Finally, fostering cross-institutional relationship building and collaboration emerged as a significant factor, as it encouraged a coordinated approach to addressing the crisis. Designing adaptive organisational structures also played a crucial role, enabling healthcare institutions to respond effectively to evolving challenges.

CONCLUSIONS

Using a positive deviance approach to a challenging public health crisis like OUD can help us discover new and innovative care management approaches for community wide interventions.

Mission possible: open innovation in nursing and patient care services at Massachusetts General Hospital

OBJECTIVES

Although front-line nurses and staff are uniquely positioned to identify the inefficiencies and gaps in care delivery, formal processes are not always in place to hear from those very employees.

DESIGN

We established a scalable process that embodies open innovation principles, to broaden and distribute the innovation locus.

SETTING

Massachusetts General Hospital, Boston, MA.

PARTICPITANTS

We invited 8800+ nurses and other direct caregivers to participate in organisational problem solving.

INTERVENTIONS

We solicited employees to (1) identify pain points and develop solutions and (2) crowd vote to indicate which ideas they want to see implemented.

RESULTS

177 employees submitted 225 ideas, and 928 cast a vote. The 40 participants who submitted top-voted ideas were invited to develop a detailed implementation plan; of those, 27 submitted one. Four ideas emerged as winners.

CONCLUSIONS

Formulating a clear call for ideas, securing leadership buy-in and generating excitement about the process were essential to our efforts. Challenges associated with opening the innovation process involved managing a large volume of participants and submissions, and providing on-the-go training to nurses and staff who were not used to being asked to participate in organisational problem solving.

Highlights and Perioperative Implications from the 2022 American College of Cardiology and American Heart Association Guidelines for Diagnosis and Management of Aortic Disease

As the understanding of aortic diseases and their complications grow, increasing importance of uniformity in diagnosis and management is crucial for optimal care of this patient population. The 2022 American College of Cardiology and American Heart Association Guidelines for Diagnosis and Management of Aortic Disease discusses these considerations in detail. The purpose of this review is to highlight essential recommendations that are of relevance to the perioperative physician who manages these patients. A few notable points include, shared decision-making with patients, creation of multidisciplinary aortic teams, lower diameter thresholds for surgery in certain situations, and increased testing for patients with heritable aortic diseases. In addition to briefly reviewing basics of aortic diseases, the authors discuss changes to guidelines that are especially relevant to perioperative care.

Seven leadership and followership lessons from kidney transplantation during lockdown

BACKGROUND

The renal transplant team in Northern Ireland performed 70 transplants in 61 days during the first wave of COVID-19, an 8-fold increase in their typical activity. Mobilising diverse professional skills to achieve this number, especially under COVID-19 conditions, required extraordinary effort on the part of everyone involved along the transplant patient pathway, management and staff from other patient groups.

METHODS

Fifteen transplant team members were interviewed to explore their experiences during this time.

RESULTS

Seven key leadership and followership lessons, contextualised within The Healthcare Leadership model, were learnt from these experiences.

CONCLUSIONS

While circumstances were untypical, the achievement and motivation of staff were no less commendable. We contend that this was not only because of the unusual circumstances but as a result of extraordinary leadership and followership, teamworking and individual agility.Recommendations for those leading services which require a quick response and collaborative effort are made.

Understanding leadership development in DPT and MOT graduates at AdventHealth University via focus groups

PURPOSE

While leadership knowledge, skills and behaviours develop during graduate education, faculty members engaged in curriculum design for doctor of physical therapy (DPT) and masters of occupational therapy (MOT) professionals want to understand how this occurs. The objective of this study was to understand what influenced the development of leadership in graduates.

PATIENTS AND METHODS

A detailed narrative was created for virtual focus groups. Purposive sampling was used and eligible participants were emailed. Those who agreed to participate reviewed an institutional review board approved consent form and were sent a link through an online, recorded Microsoft Teams session. Forty-three DPT and MOT Class of 2022 Graduates were eligible for participation. Recordings were exported, deidentified and validated for transcript accuracy and then deleted. Transcripts were analysed for emerging themes via NVivo.

RESULTS

Ten graduates consented to participate. Saturation was reached during thematic analysis and three weighted themes emerged: leadership characteristics, on-campus curriculum and off-campus curriculum. Further data analysis revealed progression in leadership skill attainment over time and graduates attributed leadership development to the programme and aligned with current frameworks of multiprofessional/interprofessional education.

CONCLUSION

These findings should be used to guide curriculum design for effective leadership development. These experiences align with the goal of advanced clinical practice of future healthcare leaders.

Utility of a Pediatric Adaptive Sports Clinic: A Case Series Review

BACKGROUND

Limited funding is available for athletes with disabilities in the United Kingdom. This compounds the barriers to participation and development that already exist.

METHOD

To combat this growing problem, a Multi-Disciplinary Pediatric Adaptive Sports Clinic was formed.

RESULT

Fifteen athletes with disabilities attended the Clinic from November 2017 to November 2019. In our cohort, there were 10 males and 5 females (age range: 13-18 years). Most athletes participated at a grassroots level (n = 9). The range of diagnoses included cerebral palsy, Ehlers Danlos syndrome and congenital hand differences. Forty-four appointments were made after the initial meeting with a 95% attendance rate. Improvements beyond the minimal clinically important differences (MCID) for the Patient Specific Functional Scale, Numerical Pain Rating Scale, and Medical Research Council Manual Muscle Testing Scale were noted in over half of cases.

CONCLUSION

With a focus on injury prevention and strength and conditioning techniques, this clinic supported athletes to successfully compete from a recreational to an elite level across all types of sports and adolescent ages by providing patient-specific regimens. Our case series provides preliminary evidence to suggest the formation of similar clinics that can support athletes with disabilities across a range of sports.

A Multi-Disciplinary Approach to Diagnosis and Treatment of Radionecrosis in Malignant Gliomas and Cerebral Metastases

Radiation necrosis represents a potentially devastating complication after radiation therapy in brain tumors. The establishment of the diagnosis and especially the differentiation from progression and pseudoprogression with its therapeutic implications requires interdisciplinary consent and monitoring. Herein, we want to provide an overview of the diagnostic modalities, therapeutic possibilities and an outlook on future developments to tackle this challenging topic. The aim of this report is to provide an overview of the current morphological, functional, metabolic and evolving imaging tools described in the literature in order to (I) identify the best criteria to distinguish radionecrosis from tumor recurrence after the radio-oncological treatment of malignant gliomas and cerebral metastases, (II) analyze the therapeutic possibilities and (III) give an outlook on future developments to tackle this challenging topic. Additionally, we provide the experience of a tertiary tumor center with this important issue in neuro-oncology and provide an institutional pathway dealing with this problem.

The role of the multidisciplinary team in the management of psoriatic arthritis

Psoriatic arthritis (PsA) has a heterogenous clinical phenotype with manifestations in a number of different organs and systems. Whilst PsA is typified by enthesitis, synovitis and psoriasis (skin and nail); innate and adaptive immune system dysfunction often results in concomitant conditions. These include inflammatory bowel disease, uveitis, metabolic syndrome, metabolic bone disease and mental health issues. All of which have the potential to impact on quality of life, daily function, employment, family life and social activities. Through a collection of clinical vignettes, we describe the importance of multi-disciplinary and multi-speciality involvement in the care of people with PsA.

Hospital mortality among COVID-19 patients - Experience of a multi-disciplinary tertiary care teaching hospital of Chhattisgarh in Central India

Introduction

The mortality from coronavirus disease 2019 (COVID-19) infection and the severity of it vary among populations. There is a dearth of research on epidemiology and clinical outcomes in central Indian populations with COVID-19. Our aim was to provide an analysis of all hospitalized mortality among patients with COVID-19 infection in a tertiary care hospital of Chhattisgarh in central India. This analysis helped us to know the severity predictors for mortality and in future will help the authorities to formulate a plan to decrease the mortality in the epidemic or uncertain ongoing pandemic.

Methodology

This was a retrospective observational study using the hospital-based record of multi-disciplinary teaching hospital in Chhattisgarh, India. All COVID-19 reverse-transcriptase polymerase chain reaction-positive patients who were declared dead or died during the course of treatment from April 1, 2020 to March 31, 2021 were included in the study. In-hospital mortality was the primary outcome of interest. In secondary analysis, age and gender distribution, co-morbidity, length of stay, and the cause of death were also investigated.

Results

A total of 7495 patients with a confirmed diagnosis of COVID-19 were enrolled in the study, of whom 762 (10.16%) died in the hospital with COVID-19 as the primary cause of death. The majority of the patients were more than 60 years of age (45.7%). A total of 416 (54.4%) of the deceased patients were having co-morbidity with diabetes (13.4%), hypertension (16.4%), or both (24.4%). The majority of the patients who succumbed had a hospital stay of less than a week (≤7) (68.5%). More than half of the patients (58.3%) who expired had referred and reported to the hospital in the second or third week of illness. The respiratory system involvement was the dominant contributor of death with pneumonia (78.8%) being the most common cause, followed by acute respiratory distress syndrome (62.2%). 13.6% of expired patients had multiple system involvement, and 11.2% had sepsis as well.

Conclusion

Mortality in COVID-19 patients was associated with advanced age, co-morbidities such as diabetes and hypertension, and delay in hospitalization. These are high-risk groups and should be vaccinated against COVID-19 on priority.

Light pollution: a landscape-scale issue requiring cross-realm consideration

Terrestrial, marine and freshwater realms are inherently linked through ecological, biogeochemical and/or physical processes. An understanding of these connections is critical to optimise management strategies and ensure the ongoing resilience of ecosystems. Artificial light at night (ALAN) is a global stressor that can profoundly affect a wide range of organisms and habitats and impact multiple realms. Despite this, current management practices for light pollution rarely consider connectivity between realms. Here we discuss the ways in which ALAN can have cross-realm impacts and provide case studies for each example discussed. We identified three main ways in which ALAN can affect two or more realms: 1) impacts on species that have life cycles and/or stages in two or more realms, such as diadromous fish that cross realms during ontogenetic migrations and many terrestrial insects that have juvenile phases of the life cycle in aquatic realms; 2) impacts on species interactions that occur across realm boundaries, and 3) impacts on transition zones or ecosystems such as mangroves and estuaries. We then propose a framework for cross-realm management of light pollution and discuss current challenges and potential solutions to increase the uptake of a cross-realm approach for ALAN management. We argue that the strengthening and formalisation of professional networks that involve academics, lighting practitioners, environmental managers and regulators that work in multiple realms is essential to provide an integrated approach to light pollution. Networks that have a strong multi-realm and multi-disciplinary focus are important as they enable a holistic understanding of issues related to ALAN.

Malaysian Society of Gastroenterology and Hepatology consensus statement on metabolic dysfunction-associated fatty liver disease

The Malaysian Society of Gastroenterology and Hepatology saw the need for a consensus statement on metabolic dysfunction-associated fatty liver disease (MAFLD). The consensus panel consisted of experts in the field of gastroenterology/hepatology, endocrinology, bariatric surgery, family medicine, and public health. A modified Delphi process was used to prepare the consensus statements. The panel recognized the high and increasing prevalence of the disease and the consequent anticipated increase in liver-related complications and mortality. Cardiovascular disease is the leading cause of mortality in MAFLD patients; therefore, cardiovascular disease risk assessment and management is important. A simple and clear liver assessment and referral pathway was agreed upon, so that patients with more severe MAFLD can be linked to gastroenterology/hepatology care, while patients with less severe MAFLD can remain in primary care or endocrinology, where they are best managed. Lifestyle intervention is the cornerstone in the management of MAFLD. The panel provided a consensus on the use of statin, angiotensin-converting enzyme inhibitor or angiotensin receptor blocker, sodium-glucose cotransporter-2 inhibitor, glucagon-like peptide-1 agonist, pioglitazone, vitamin E, and metformin, as well as recommendations on bariatric surgery, screening for gastroesophageal varices and hepatocellular carcinoma, and liver transplantation in MAFLD patients. Increasing the awareness and knowledge of the various stakeholders on MAFLD and incorporating MAFLD into existing noncommunicable disease-related programs and activities are important steps to tackle the disease. These consensus statements will serve as a guide on MAFLD for clinicians and other stakeholders.

A comparison of praevia and non-praevia outcomes in placenta accrete spectrum cases: A single centre analysis

BACKGROUND

Placenta accreta spectrum (PAS) causes severe maternal morbidity and mortality. Antenatal diagnosis can optimise maternal outcomes and reduce the risk of complications. PAS cases where the placenta is not low lying are suggested to be more difficult to diagnose antenatally and are potentially associated with different outcomes.

AIM

The aim was to compare factors associated with births in PAS pregnancies with and without placenta praevia at a single tertiary centre over 15 years.

MATERIALS AND METHODS

A retrospective review of all births complicated by PAS was conducted from a site-specific database. Cases with and without a placenta praevia were analysed to compare differences in maternal risk factors, outcomes and histological diagnosis.

RESULTS

Between June 2006 and July 2020 there were 134 cases of PAS, 106 with placenta praevia. Cases without praevia were less likely to have a history of previous caesarean section and to be admitted for delivery planning or with antepartum haemorrhage. A higher proportion of cases without praevia were delivered at term, with no overall difference in emergency or elective deliveries. There was a significantly lower rate of hysterectomy in the non-praevia group. The overall estimated blood loss was significantly lower in those without praevia.

CONCLUSION

Suspected PAS without placenta praevia is at lower risk of hysterectomy and massive blood loss. The management approach can be tailored accordingly, with good operative outcomes with transverse abdominal and uterine incisions. Antenatal diagnosis can be difficult to accurately predict the degree of invasion, and a higher level of suspicion is required.

Safety risks among frail older people living at home in the Netherlands - A cross-sectional study in a routine primary care sample

Frail older people face a range of problems and risks that could undermine their ability to live safely at home. A comprehensive overview of these risks, from a multidimensional perspective, is currently lacking. This study aims to examine the prevalence of risks in multiple domains of life among frail older people living at home. We used cross-sectional data from 824 people aged 65 years and older, who received a comprehensive geriatric assessment (the interRAI Home Care [interRAI-HC]) between 2014 and 2018, as part of routine care from 25 general practices in the region of West-Friesland, the Netherlands. The interRAI-HC identifies amenable risks related to people's clinical conditions, functioning, lifestyle and behaviour, and social and physical environment. Descriptive statistics were used to examine population characteristics (age, gender, marital status, living arrangements and presence of chronic conditions) and prevalence of risks. Most common risks were related to people's clinical conditions (i.e cardio-respiratory health, urinary incontinence, pain), functioning (i.e. limitations in instrumental activities of daily living and mood) and social environment (i.e. limitations in informal care and social functioning). More than 80% of frail older people faced multiple risks, and often on multiple domains of life simultaneously. People experiencing multiple risks per person, and on multiple domains simultaneously, were more often widowed and living alone. The multidimensional character of risks among frail older people living at home implies that an integrated approach to care, comprising both health and social care, is necessary. Insight in the prevalence of these risks can give direction to care allocation decisions.

Evaluation of the Structure and Health Impacts of Exercise-Based Cardiac and Pulmonary Rehabilitation and Prehabilitation for Individuals With Cancer: A Systematic Review and Meta-Analysis

Exercise-based, multimodal rehabilitation programming similar to that used in the existing models of cardiac or pulmonary rehabilitation or prehabilitation is a holistic potential solution to address the range of physical, psychological, and existential (e.g., as their diagnosis relates to potential death) stressors associated with a cancer diagnosis and subsequent treatment. The purpose of this study was to systematically evaluate the structure and format of any type of exercise-based, multimodal rehabilitation programs used in individuals with cancer and the evidence base for their real-world effectiveness on metrics of physical (e.g., cardiorespiratory fitness, blood pressure) and psychological (e.g., health-related quality of life) health. Very few of the 33 included exercise-based, multimodal rehabilitation programs employed intervention components, education topics, and program support staff that were multi-disciplinary or cancer-specific. In particular, a greater emphasis on nutrition care, and the evaluation and management of psychosocial distress and CVD risk factors, with cancer-specific adaptations, would broaden and maximize the holistic health benefits of exercise-based rehabilitation. Despite these opportunities for improvement, exercise-based, multimodal rehabilitation programs utilized under real-world settings in individuals with cancer produced clinically meaningful and large effect sizes for cardiorespiratory fitness (VO2peak, ±2.9 mL/kg/min, 95% CI = 2.6 to 3.3) and 6-minute walk distance (+47 meters, 95% CI = 23 to 71), and medium effect sizes for various measures of cancer-specific, health-related quality of life. However, there were no changes to blood pressure, body mass index, or lung function. Overall, these findings suggest that exercise-based, multimodal rehabilitation is a real-world therapy that improves physical and psychological health among individuals with cancer, but the holistic health benefits of this intervention would likely be enhanced by addressing nutrition, psychosocial concerns, and risk factor management through education and counselling with consideration of the needs of an individual with cancer.

In pursuit of a better world: crop improvement and the CGIAR

The CGIAR crop improvement (CI) programs, unlike commercial CI programs, which are mainly geared to profit though meeting farmers' needs, are charged with meeting multiple objectives with target populations that include both farmers and the community at large. We compiled the opinions from >30 experts in the private and public sector on key strategies, methodologies, and activities that could the help CGIAR meet the challenges of providing farmers with improved varieties while simultaneously meeting the goals of: (i) nutrition, health, and food security; (ii) poverty reduction, livelihoods, and jobs; (iii) gender equality, youth, and inclusion; (iv) climate adaptation and mitigation; and (v) environmental health and biodiversity. We review the crop improvement processes starting with crop choice, moving through to breeding objectives, production of potential new varieties, selection, and finally adoption by farmers. The importance of multidisciplinary teams working towards common objectives is stressed as a key factor to success. The role of the distinct disciplines, actors, and their interactions throughout the process from crop choice through to adoption by farmers is discussed and illustrated.

In pursuit of a better world: crop improvement and the CGIAR

The CGIAR crop improvement (CI) programs, unlike commercial CI programs, which are mainly geared to profit though meeting farmers' needs, are charged with meeting multiple objectives with target populations that include both farmers and the community at large. We compiled the opinions from >30 experts in the private and public sector on key strategies, methodologies, and activities that could the help CGIAR meet the challenges of providing farmers with improved varieties while simultaneously meeting the goals of: (i) nutrition, health, and food security; (ii) poverty reduction, livelihoods, and jobs; (iii) gender equality, youth, and inclusion; (iv) climate adaptation and mitigation; and (v) environmental health and biodiversity. We review the crop improvement processes starting with crop choice, moving through to breeding objectives, production of potential new varieties, selection, and finally adoption by farmers. The importance of multidisciplinary teams working towards common objectives is stressed as a key factor to success. The role of the distinct disciplines, actors, and their interactions throughout the process from crop choice through to adoption by farmers is discussed and illustrated.

Assessing the Delivery of Coordinated Care to Patients with Advanced Chronic Kidney Disease in Ontario, Canada: A Survey of Patients and Healthcare Professionals

Introduction:

Patients with advanced Chronic Kidney Disease (CKD) have complex health needs, and thus require care that is coordinated across professionals and organizations. This study aimed to describe the extent of coordinated care delivery for patients with advanced CKD from the perspectives of both patients and healthcare professionals.

Methods:

The Coordination Scale of the Patient Assessment of Chronic Illness Care (PACIC-26) survey was administered to a random sample of 14,257 patients on maintenance dialysis or receiving care in end-stage kidney disease preparation clinics in Ontario, Canada. A five-item survey was administered to 596 multidisciplinary nephrology professionals.

Results:

Among the 1,925 patient respondents, 67% reported they had been referred to an allied health professional; 19% had been encouraged to attend programs in the community; and 34% had been told how their visits with other types of doctors helped their treatment (% reporting “always” or “most of the time”). Patient responses were significantly different by treatment modality/setting, but not by gender or geographic location of treatment facility. Among the 276 professional respondents, 37% reported their patients’ care was well-coordinated across settings; 56% reported participating in interdisciplinary care planning discussions; and 53% reported they are aware of appropriate home and community services to support their patients (% reporting “always” or “most of the time”).

Conclusion:

The results suggest that care for patients with advanced CKD in Ontario is not consistently coordinated. Healthcare professionals may enhance patient perceptions of coordinated care through explicit communication with patients about how the professionals they see and treatments or services they receive influence their overall health and well-being. At a systems level, there is a need to improve professional awareness of and linkages to home- and community-based services.

Conservation biological control research is strongly uneven across trophic levels and economic measures

Conservation biological control suppresses pests by promoting established rather than inoculative or mass released natural enemies. Research in this approach has expanded rapidly this century but uptake remains limited. Why? Most of the 150 peer reviewed papers reporting field experiments include results on natural enemies and/or pests. Only a minority report effects on crop damage levels or yield, and very few consider economic consequences. This is despite evidence for potential benefits across this full spectrum of response variables. We argue that the limited scope of work to date constrains the development of a compelling evidence base to demonstrate the field effectiveness of conservation biological control, hampering its uptake so encourage researchers to include the assessment of economic impact in future studies of conservation biological control. © 2020 Society of Chemical Industry.

The utility of a local multidisciplinary working group to oversee the establishment of rapidly evolving standards of care and to support trial recruitment during the COVID-19 pandemic

Coronavirus disease 2019 (COVID-19) was first identified in December 2019 in Wuhan, China. The first analyses of cases described high numbers of critically ill patients requiring intensive care admission with significant late inflammatory features. By the time the first cases of SARS-CoV-2 infection were diagnosed in the UK, a wide range of drugs were under consideration and it became clear that the input of clinicians covering all organ systems (in particular, infectious diseases, haematology, rheumatology, renal medicine and intensive care) and of expert specialist pharmacists was necessary at the local level. Thus, an expert multidisciplinary (MDT) group within our organisation was convened to offer a standardised approach and robust clinical governance for the treatment of COVID-19 patients admitted to our hospitals and rapidly develop standards of care as evidence evolved. This commentary explores the methods and mechanisms for creating an MDT COVID-19 treatment working group which are applicable to any hospital likely to admit and care for high numbers of COVID-19 patients and demonstrates how the structure and governance of the group allowed for rapid adoption of both dexamethasone and tocilizumab into standard of care as data became available.

Day case angioplasty in a secondary care setting - initial experience

Background: Peripheral artery disease presents an increasing healthcare burden worldwide. Day-case angioplasty in a secondary care setting can be a safe and effective means of meeting the growing demand for lower limb revascularisation. We evaluated the safety and efficacy of a day-case-based angioplasty service in a UK district general hospital. Patients and methods: Consecutive patients undergoing endovascular revascularisation between August 2018-February 2020 were analysed retrospectively. All patients were discussed at a multi-disciplinary (diabetic foot) team meeting following a day case algorithm. Patient and procedural characteristics, technical success, peri-procedural complications, and 30-day outcome of day-case angioplasties were compared with those requiring overnight stay or were hospitalized. Results: Fifty-seven percent of 138 patients were diabetic, mean age 75 ± 12 years, 95% had critical limb ischaemia (Fontaine III 12%, IV 83%), and baseline ankle brachial pressure index [ABPI] 0.40 ± 0.30. Sixty-three patients (45%) were treated as planned day cases, 21 (15%) required overnight admission for social indications. Fifteen (11%) were planned admissions with the need for sequential debridement procedures, and 39 (28%) were already hospitalised at the time of referral to the vascular service. The overall technical success was 92% and not successful procedures mainly occurred in patients > 80 years. The ABPI increased at the initial follow-up to 0.84 ± 0.18. Fifty-three percent required treatment of > 1 level, 80% included recanalisations of chronic total occlusions, and average total lesion length was 133 ± 90 mm. Closure devices were employed in all cases. There were no major peri-procedural complications. A single minor access-site related bleeding episode (0.8%) occurred, requiring 24 h observation in hospital. While significantly more wounds had closed in out-patients, the mortality, major amputation and target lesion revascularization did not differ between groups. Conclusions: Safe and effective day-case-based angioplasty can be provided in a secondary care setting for patients with critical limb ischaemia needing complex multi-level procedures.

A family systems approach to genetic counseling: Development of narrative interventions

To what extent are family systems approaches relevant in the genomics era? What difference does it make to remember the wider social context within which ‘problems’ associated with a genetic diagnosis reside? How does this influence the conversations we have with our patients? These questions will be considered in relation to systemic approaches to genetic counseling practice. Narrative therapy with an emphasis on people's strengths, wishes, and ways of resisting the effects of a problem may be a particularly useful framework for genetic counselors. Narrative practice views people as multi‐storied and is concerned with the question of how we encourage people to tell their stories in ways that make them feel stronger. Increased uptake of genomic testing and the number of people seeking genetic counseling present opportunities to consider new ways of working, particularly around support following a new genetic diagnosis. One option is to realize the potential of group interventions. Family therapy and narrative practices have the potential to encourage communication and for families to learn from each other.

A Collaborative Approach to the Development of Multi-Disciplinary Teams and Services for Child and Adolescent Mental Health in Uganda

Background: Children and adolescents are especially vulnerable to mental, neurological and substance use disorders during various stages of their growth and development. They often require specialized personnel whose training is time consuming and costly. Consequently many children and adolescents remain untreated in developing countries. This paper describes steps Uganda is taking to develop local capacity for child and adolescent mental health services through training of multi-disciplinary teams. Methods: A 2 year training programme was introduced in accordance with the Ugandan Ministry of Health Child and Adolescent Mental Health Strategy. This had been jointly developed in 2008 by Mbarara University of Science and Technology, Makerere University, the Uganda Ministry of Health and East London Foundation NHS Trust, United Kingdom (UK). The initial funding for the programme focused on monitoring and evaluation of the training, quality of clinical practice and clinical activity data. Results: Fifty health workers have been trained and are now working at regional referral hospitals and non-governmental organizations. Monitoring and evaluation demonstrated major increases in the range of disorders and client numbers (2,184-31,034) over 6 years. There was increased confidence, knowledge and skills in assessment. Learning in a multidisciplinary environment was interesting and helpful. Assessments were more thorough and child centred and more psychological treatments were being used. Programme graduates are now contributing as trainers. Conclusion: The clinically focused multidisciplinary training has yielded rewarding outcomes across Uganda. Ongoing support and collaborative work can expand service capacity in child and adolescent mental health for Uganda and other developing countries.

Tackling the Challenges of 21st-Century Open Science and Beyond: A Data Science Lab Approach

In recent years, there has been a drive toward more open, cross-disciplinary science taking center stage. This has presented a number of challenges, including providing research platforms for collaborating scientists to explore big data, develop methods, and disseminate their results to stakeholders and decision makers. We present our vision of a "data science lab" as a collaborative space where scientists (from different disciplines), stakeholders, and policy makers can create data-driven solutions to environmental science's grand challenges. We set out a clear and defined research roadmap to serve as a focal point for an international research community progressing toward a more data-driven and transparent approach to environmental data science, centered on data science labs. This includes ongoing case studies of good practice, with the infrastructural and methodological developments required to enable data science labs to support significant increase in our cross- and trans-disciplinary science capabilities.

Communicating traumatic pathology to ensure shared understanding: is there a recipe for the perfect preliminary image evaluation?

Medical imaging and emergency departments work collaboratively to interpret trauma radiographs. In addition to accurate radiographic interpretation, clear communication is crucial to ensure appropriate and timely management of musculoskeletal injuries. This two-step 'how to guide' provides the reviewer with a recipe for effectively evaluating trauma radiographs for traumatic pathology and succinctly documenting the findings. Step 1 is a systematic search of the radiograph: soft tissues, bones, alignment of joints and satisfaction of search (SBASS). Utilising SBASS increases reviewer confidence in identifying traumatic pathology of the appendicular and axial skeleton. Step 2 is a streamlined communication model for the documentation of pathological findings. The WWW acronym (What is it? Where is it? What is it doing?) can be adapted to describe simple or complex traumatic pathology.

A multi-disciplinary care pathway improves symptoms, QoL and medication use in refractory angina

Refractory angina (RA) is a growing clinical problem. Long-term mortality is better than expected and focus has shifted to improving symptoms, quality of life and psychological morbidity. We established a dedicated multi-disciplinary care pathway for patients with RA and assessed its effect on psychological outcomes, quality of life and polypharmacy. We reviewed electronic health records to capture demographics, changes in medication use, and patient-related outcome measures (Seattle Angina Questionnaire [SAQ] and Hospital Anxiety and Depression Scale) before and after enrolment. One hundred and ninety patients were referred to our service. Pre- and post-questionnaire data were available in 83 patients. Anxiety and depression scores significantly improved (p<0.05) as well as quality of life and all subcategories of the SAQ (p<0.0001). Patients were most commonly on three or four anti-anginal drugs. In patients with no demonstrable reversible ischaemia, there was a significant reduction in anti-anginal usage (mean reduction of two drugs) after completion of our pathway (p<0.025). In conclusion, a dedicated multi-disciplinary pathway for RA is associated with improvements in quality of life, mental health and polypharmacy. An ischaemia-driven method to rationalise medication may reduce polypharmacy in patients with RA, particularly in patients with no demonstrable ischaemia.

Cost of Diabetic Foot Ulcer Management in China: A 7-Year Single-Center Retrospective Review

BACKGROUND

The cost of care for diabetic foot ulcers has became a global economic burden. The study aimed to analyze diabetic foot ulcer cost changes over time and to identify factors associated with these variables, so as to strengthen and improve the management of diabetic foot ulcers.

METHODS

We retrospectively analyzed the data in the electronic medical record system of our wound treatment center. The homepage of the system was queried using the national clinical version 2.0 disease diagnosis code (ICD-10), the data of patient's basic information were exported. Through the statistics and analysis of these data, the socioeconomic changes and possible risk factors of diabetic foot ulcers management in recent years were obtained.

RESULTS

There were 3654 patients included in the study, an average of 522 per year. The total cost per patient increased from ¥15,535.58 in 2014 to ¥42,040.60 in 2020, with an average of ¥21,826.91. The average length of stay between 14.29 days and 31.4 days from 2014 to 2020, with an average of 18.10 days. Besides, the average incidence of peripheral arterial disease in diabetic foot ulcers patients admitted was as high as 81.9%, and the average amputation rate was 9.9%. The study reflected the total cost and length of stay of diabetic foot patients increased significantly from 2014 to 2020, which were related to age (>85 years), gender (male), peripheral arterial disease, amputation (P < 0.05).

CONCLUSION

A heavy cost from diabetic foot ulcers and its complications was significantly increased yearly, which was related to older age, co-morbidity, amputation and duration of hospitalization. The prevention and treatment of diabetic foot ulcers have a long way to go, early comprehensive prevention and multi-disciplinary cooperation may still be an effective way.

Raising to the Challenge: Building a Federated Biobank to Accelerate Translational Research-The University Biobank Limburg

Irreproducibility of research results is one of the major contributing factors to the failure of translating basic research results into tangible bedside progress. To address this, the University Biobank Limburg (UBiLim) was founded by a collaboration between Hasselt University, the Hospital East-Limburg, and the Jessa Hospital. This paper describes the evolution of this process and the barriers encountered on the way. UBiLim evolved from an archival collection over a single-site biobank into a federated structure, supporting translational research at the founding institutions. Currently, UBiLim is a federated biobank, with an established organizational structure and processing, and storage facilities at each of the three sites. All activities are integrated in an ISO15189-accredited Quality Management System and based on (inter)national biobank guidelines. Common methods for processing and storage of a plethora of sample types, suitable for state-of-the-art applications, were validated and implemented. Because the biobank is embedded in two hospitals, the request of researchers to include certain sample types or enroll specific patient groups can quickly be met. Funding has been a major challenge in each step of its evolution and remains the biggest issue for long-term biobank sustainability. To a lesser extent, the Belgian legislation and the operational cost of information management system are also concerns for smooth biobank operations. Nonetheless, UBiLim serves as a facilitator and accelerator for translational research in the Limburg area of Belgium that, given the fields of research, may have an impact on international patient care.

Outcomes of Multi-disciplinary Management of Metastatic Renal Cell Carcinoma

Metastatic renal cell carcinoma (mRCC) is associated with a poor prognosis. It is traditionally a treatment-resistant disease necessitating multi-modal treatment and close follow-up. We herein report a case of mRCC in a patient who was managed closely by a multi-disciplinary team and still retained a very good performance status and treatment response three years after diagnosis. We highlight the importance of close monitoring, switching systemic therapies at progression, early palliative radiotherapy, and patient education in controlling disease burden and maintaining quality of life in patients with mRCC.

What is needed by staff to implement PROMs into routine oncology care? A qualitative study with the multi-disciplinary team

INTRODUCTION

The aim of this study was to identify strategies to implement patient-reported outcome measures (PROMs) into routine oncology outpatients' clinical care.

METHODS

Qualitative focus groups were conducted with staff from multiple disciplines using a semistructured interview guide, with supporting data collected in field notes. Data were analysed using a Directed Content Analysis guided by an implementation science framework. The synthesis of the extracted data aimed to identify key requirements which correspond to intrinsic enablers and barriers for implementation.

RESULTS

52 staff members from the multi-disciplinary team participated. Data extracted showed five key themes and three key requirements regarding implementation of PROMs. Staff would consider using PROMs if there was strong research evidence that demonstrates benefits for patient outcomes, if PROM data was relevant to current clinical practice, and if applied appropriately in the specific setting. These findings add pragmatic detail and new knowledge to the current evidence on pathways to PROM implementation. This data can be used to inform implementation of PROMs into health services.

CONCLUSION

Staff have valuable tacit knowledge of what works in practice that offers a unique opportunity to increase successful implementation of a PROM intervention for patient symptom reporting.

Developing Residents as Medical Educators via the McMaster Multidisciplinary Academic Day Planning Committee

Background

Residents are being asked to perform educator roles such as curriculum design and learner assessment with minimal professional development in leadership or medical education. The Multidisciplinary Academic Day (MAD) planning committee is a resident-led initiative responsible for delivering combined educational half-day sessions and workshops for all residents at McMaster University.

Objective

We sought to determine the impact participation in MAD planning committee had on residents' professional development and career goals. 

Methods

We conducted a program evaluation survey of 19 of 30 (63.3%) current and former committee members to determine how the MAD planning committee’s alumni perceived its usefulness, and how participation affected their professional development. 

Results

Residents cited a desire to gain medical education experience, learn about event planning and management, and improve resident education as reasons for joining the committee; 89.5% of respondents felt they had met these goals. Experience on the committee included skills related to curriculum design, developing needs assessments and programmatic evaluation. Many residents felt it helped them acquire leadership skills such as decision-making, idea generation, delegation, and public speaking. Several noted that it had sparked an interest in medical education as part of an academic career, and one former member subsequently pursued a Master’s of Education. The majority of the respondents (78.9%) felt it was helpful for their careers and 94.7% would recommend this experience to others interested in leadership and medical education. 

Conclusion

Involvement in the MAD planning committee is a highly useful way for residents to acquire leadership skills, develop an interest in medical education and work in a multidisciplinary team. 

Multi-disciplinary training hubs in North West England: the training hub lead perspective

Introduction: Increasing the capacity of Primary Care to meet the challenge of providing future complex and multi-disciplinary care in England has led to the increasing establishment of 'Training Hubs' [TH]. Other terms are used interchangeably to refer to TH activity: Advanced Training Practices, Enhanced Training Practices and Community Education Providers. The aim of this study was to gather the perceptions of TH Leads in North West England on how they established their TH and lessons learned. Methods: Five semi-structured telephone interviews were undertaken with TH Leads. Thematic analysis of the transcripts was undertaken. Findings: Four themes were identified: Motivation and Expectations of Establishing THs; Benefits to Learners and Practice Staff; Implementation Challenges and Barriers to Scale-Up; Sustainability and Wider Implementation. Discussion: TH Leads highlighted that the establishment of THs enhanced the multi-disciplinary learning experience. However, several barriers for sustaining the quality of the TH learning environments were identified. Difficulties recruiting 'Spoke Practices' were greater than expected. Findings identified the following factors for consideration for wider implementation: the maintenance of TH Lead support networks; appropriateness of funding to encourage practices who may be reluctant to take on this additional responsibility; the importance of communication channels between THs and HEIs; careful management of students numbers.

Burnout Syndrome in UK Intensive Care Unit staff: Data from all three Burnout Syndrome domains and across professional groups, genders and ages

Introduction

This is the first comprehensive evaluation of Burnout Syndrome across the UK Intensive Care Unit workforce and in all three Burnout Syndrome domains: Emotional Exhaustion, Depersonalisation and lack of Personal Accomplishment.

Methods

A questionnaire was emailed to UK Intensive Care Society members, incorporating the 22-item Maslach Burnout Inventory Human Services Survey for medical personnel. Burnout Syndrome domain scores were stratified by 'risk'. Associations with gender, profession and age-group were explored.

Results

In total, 996 multi-disciplinary responses were analysed. For Emotional Exhaustion, females scored higher and nurses scored higher than doctors. For Depersonalisation, males and younger respondents scored higher.

Conclusion

Approximately one-third of Intensive Care Unit team-members are at 'high-risk' for Burnout Syndrome, though there are important differences according to domain, gender, age-group and profession. This data may encourage a more nuanced understanding of Burnout Syndrome and more personalised strategies for our heterogeneous workforce.

Towards an integrated approach to understand Mexican cavefish evolution

The Mexican tetra, Astyanax mexicanus, comes in two forms: a classical river-dwelling fish and a blind and depigmented cave-dwelling fish. The two morphotypes are used as models for evolutionary biology, to decipher mechanisms of morphological and behavioural evolution in response to environmental change. Over the past 40 years, insights have been obtained from genetics, developmental biology, physiology and metabolism, neuroscience, genomics, population biology and ecology. Here, we promote the idea that A. mexicanus, as a model, has reached a stage where an integrated approach or a multi-disciplinary method of analysis, whereby a phenomenon is examined from several angles, is a powerful tool that can be applied to understand general evolutionary processes. Mexican cavefish have undergone considerable selective pressure and extreme morphological evolution, an obvious advantage to contribute to our understanding of evolution through comparative analyses and to pinpoint the specific traits that may have helped their ancestors to colonize caves.

Teaching handover in undergraduate education: an evidence-based multi-disciplinary approach

This article was migrated. The article was marked as recommended. Poor standards of handover threaten patient safety and continuity of care, contributing significantly to morbidity and mortality. Handover practices has risen to the forefront of the patient safety agenda, with a call to develop and implement undergraduate handover modules into undergraduate healthcare education. Recent systematic reviews demonstrate a common failure of educational interventions to demonstrate a theoretical and pedagogical framework underpinning the delivery of education and method of assessment. The authors developed and piloted a multi-disciplinary evidence-based undergraduate handover training program to health care students studying at a UK university. The intervention was designed based on underpinning educational theories. It has been developed in a manner that supports dissemination and replication, with a model that is cost effective. The intervention was designed to assess learner reaction, attitudes and confidence, and knowledge and skills. This was achieved through a pre- and post-intervention attitude questionnaire, and an externally validated pre- and post-intervention knowledge assessment. 46 undergraduate students participated, with a statistically significant increase in self-reported attitudes (p < 0.001) and knowledge (p < 0.001) following the handover intervention. Students participated from the disciplines of medicine, adult nursing, pharmacy, mental health nursing, paramedic practice and operating department practioners. This intervention serves as a significant resource for those looking to develop local interventions and stands as a truly multi-disciplinary approach to handover education, mirroring the clinical reality. The introduction of this handover intervention immediately improves the attitudes, knowledge and skills of undergraduate healthcare students. Future work should sample beyond the selected 6 professions, investigating the transference of outcomes to the workplace, as well as the impact on patient safety.

In-situ Interprofessional Perinatal Drills: The Impact of a Structured Debrief on Maximizing Training While Sensing Patient Safety Threats

Introduction

In-situ interprofessional emergency team training improves participants’ with confidence and knowledge and identifies latent safety threats. This study examined the impact of a structured debrief on an interprofessional perinatal team’s ability to identify latent safety threats and assess competency in managing perinatal emergencies. It was hypothesized that latent safety threats would be reduced and checklist compliance would increase during subsequent in-situ perinatal team training.

Methods

Two in-situ training sessions were held six months apart. The perinatal emergency response team provided care for a standardized patient with preterm twin gestation. Each session included off-ward delivery and resuscitation of the first infant, transportation to appropriate inpatient units, cesarean delivery, and resuscitation of the second twin. Postpartum hemorrhage ensued, requiring massive transfusion protocol activation. Medical experts assessed team performance with critical action checklists. A structured debrief identified latent safety threats, developed action plans, and reviewed checklist compliance. Checklist compliance rates were analyzed using a z-ratio test.

Results

The first training session: seven teams (75 staff) completed 75% (292/391) critical action checklist items and identified 34 latent safety threats. Second training session: four teams (45 staff) completed 89% (94/106) critical action checklist items. Ten latent safety threats were mitigated during the second session. Utilizing a z-ratio, a significant difference was detected between the overall checklist compliance rates of the two sessions, z = -3.069, p = .002. Post-hoc power calculation was <10%.

Conclusions

In-situ interprofessional perinatal emergency team training is feasible, identifies latent patient safety threats, and may improve team competency.

Is Research Experience Detrimental to a Clinical Pharmacist's Career?

A recent article in the Canadian Journal of Hospital Pharmacy discussed pharmacists’ perception of clinical research. The article illustrated that pharmacists lack the time, resources, and skills to conduct research. In the current paper, two ex-pharmacists, who now work as physicians, commented on the prejudice towards pharmacy researchers. Pharmacy researchers face obstacles such as being mislabeled as “non-clinical” and lacking opportunities to be involved in high-impact publications. The current paper discussed ways to improve pharmacy research, including collaboration with well-established researchers, putting less emphasis on the “clinical” pharmacist title, and changing the pharmacy culture.

The History and Horizons of Microscale Neural Interfaces

Microscale neural technologies interface with the nervous system to record and stimulate brain tissue with high spatial and temporal resolution. These devices are being developed to understand the mechanisms that govern brain function, plasticity and cognitive learning, treat neurological diseases, or monitor and restore functions over the lifetime of the patient. Despite decades of use in basic research over days to months, and the growing prevalence of neuromodulation therapies, in many cases the lack of knowledge regarding the fundamental mechanisms driving activation has dramatically limited our ability to interpret data or fine-tune design parameters to improve long-term performance. While advances in materials, microfabrication techniques, packaging, and understanding of the nervous system has enabled tremendous innovation in the field of neural engineering, many challenges and opportunities remain at the frontiers of the neural interface in terms of both neurobiology and engineering. In this short-communication, we explore critical needs in the neural engineering field to overcome these challenges. Disentangling the complexities involved in the chronic neural interface problem requires simultaneous proficiency in multiple scientific and engineering disciplines. The critical component of advancing neural interface knowledge is to prepare the next wave of investigators who have simultaneous multi-disciplinary proficiencies with a diverse set of perspectives necessary to solve the chronic neural interface challenge.

Evaluating the impact of integrated development: are we asking the right questions? A systematic review

Background: Emerging global transformations - including a new Sustainable Development Agenda - are revealing increasingly interrelated goals and challenges, poised to be addressed by similarly integrated, multi-faceted solutions. Research to date has focused on determining the effectiveness of these approaches, yet a key question remains: are synergistic effects produced by integrating two or more sectors?  We systematically reviewed impact evaluations on integrated development interventions to assess whether synergistic, amplified impacts are being measured and evaluated.

Methods: The International Initiative for Impact Evaluation’s (3ie) Impact Evaluation Repository comprised our sampling frame (n = 4,339). Following PRISMA guidelines, we employed a three-stage screening and review process.

Results: We identified 601 journal articles that evaluated integrated interventions. Seventy percent used a randomized design to assess impact with regard to whether the intervention achieved its desired outcomes. Only 26 of these evaluations, however, used a full factorial design to statistically detect any synergistic effects produced by integrating sectors. Of those, seven showed synergistic effects.

Conclusions: To date, evaluations of integrated development approaches have demonstrated positive impacts in numerous contexts, but gaps remain with regard to documenting whether integrated programming produces synergistic, amplified outcomes. Research on these program models needs to extend beyond impact only, and more explicitly examine and measure the synergies and efficiencies associated with linking two or more sectors. Doing so will be critical for identifying effective integrated development strategies that will help achieve the multi-sector SDG agenda.

Limitations on the Ability to Negotiate Justice: Attorney Perspectives on Guilt, Innocence, and Legal Advice in the Current Plea System

In the American criminal justice system the vast majority of criminal convictions occur as the result of guilty pleas, often made as a result of plea bargains, rather than jury trials. The incentives offered in exchange for guilty pleas mean that both innocent and guilty defendants plead guilty. We investigate the role of attorneys in this context, through interviews with criminal defense attorneys. We examine defense attorney perspectives on the extent to which innocent defendants are (and should be) pleading guilty in the current legal framework and their views of their own role in this complex system. We also use a hypothetical case to probe the ways in which defense attorneys consider guilt or innocence when providing advice on pleas. Results indicate that attorney advice is influenced by guilt or innocence, but also that attorneys are limited in the extent to which they can negotiate justice for their clients in a system in which uncertainty and large discrepancies between outcomes of guilty pleas and conviction at trial can make it a sensible option to plead guilty even when innocent. Results also suggest conflicting opinions over the role of the attorney in the plea-bargaining process.

The Current Trend of the Translational Research Paradigm

The translational research paradigm is a process of discovering basic science concepts and applying the knowledge in clinical practice, aiming to improve patient care. The stages involved in the paradigm form a complex network of shared knowledge amongst research collaborators, including patients. This nature of the paradigm allows those involved to work together effectively. However, the translational research paradigm is often overlooked by many scientists, educators, and research institutions. Hence, a large amount of comprehensive and hugely invested research projects fail to make a scientific impact. We aim to outline and describe this paradigm in order to aid in the successful translation of effective research.

Shared decision-making at the end of life: A focus group study exploring the perceptions and experiences of multi-disciplinary healthcare professionals working in the home setting

BACKGROUND

Globally recommended in healthcare policy, Shared Decision-Making is also central to international policy promoting community palliative care. Yet realities of implementation by multi-disciplinary healthcare professionals who provide end-of-life care in the home are unclear.

AIM

To explore multi-disciplinary healthcare professionals' perceptions and experiences of Shared Decision-Making at end of life in the home.

DESIGN

Qualitative design using focus groups, transcribed verbatim and analysed thematically.

SETTING/PARTICIPANTS

A total of 43 participants, from multi-disciplinary community-based services in one region of the United Kingdom, were recruited.

RESULTS

While the rhetoric of Shared Decision-Making was recognised, its implementation was impacted by several interconnecting factors, including (1) conceptual confusion regarding Shared Decision-Making, (2) uncertainty in the process and (3) organisational factors which impeded Shared Decision-Making.

CONCLUSION

Multiple interacting factors influence implementation of Shared Decision-Making by professionals working in complex community settings at the end of life. Moving from rhetoric to reality requires future work exploring the realities of Shared Decision-Making practice at individual, process and systems levels.

Evaluation of cognitive load and emotional states during multidisciplinary critical care simulation sessions

Background

The simulation in critical care setting involves a heterogeneous group of participants with varied background and experience. Measuring the impacts of simulation on emotional state and cognitive load in this setting is not often performed. The feasibility of such measurement in the critical care setting needs further exploration.

Methods

Medical and nursing staff with varying levels of experience from a tertiary intensive care unit participated in a standardised clinical simulation scenario. The emotional state of each participant was assessed before and after completion of the scenario using a validated eight-item scale containing bipolar oppositional descriptors of emotion. The cognitive load of each participant was assessed after the completion of the scenario using a validated subjective rating tool.

Results

A total of 103 medical and nursing staff participated in the study. The participants felt more relaxed (-0.28±1.15 vs 0.14±1, P<0.005; d=0.39), excited (0.25±0.89 vs 0.55±0.92, P<0.005, d=0.35) and alert (0.85±0.87 vs 1.28±0.73, P<0.00001, d=0.54) following simulation. There was no difference in the mean scores for the remaining five items. The mean cognitive load for all participants was 6.67±1.41. There was no significant difference in the cognitive loads among medical staff versus nursing staff (6.61±2.3 vs 6.62±1.7; P>0.05).

Conclusion

A well-designed complex high fidelity critical care simulation scenario can be evaluated to identify the relative cognitive load of the participants' experience and their emotional state. The movement of learners emotionally from a more negative state to a positive state suggests that simulation can be an effective tool for improved knowledge transfer and offers more opportunity for dynamic thinking.

Supportive & palliative interventions in motor neurone disease: what we know from current literature?

Although there is no cure for motor neurone disease (MND), the advent of supportive interventions including multidisciplinary care (MDC) has improved treatment interventions and enhanced quality of life (QOL) for MND patients and their carers. Our integrative review showed evidence-based MDC, respiratory management and disease-modifying therapy that have improved the outcomes of patients diagnosed with MND. Supportive approaches to nutritional maintenance and optimization of symptomatic treatments, including management of communication and neuropsychiatric issues, improve the QOL for MND patients. Notwithstanding improvement to care and QOL, survival benefit has become evident with the advent of a MDC framework, early treatment with non-invasive ventilation (NIV). In addition, weight maintenance remains critical, as weight loss is associated with more rapid disease progression. The endof- life phase is poorly defined in MND patients and treatment remains challenging, yet effective symptom control through palliative care (PC) is achievable and essential.