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Worldwide, enhancement of oyster populations is undertaken to achieve a variety of goals including support of food production, local economies, water quality, coastal habitat, biodiversity, and cultural heritage. Although numerous strategies for improving oyster stocks exist, enhancement efforts can be thwarted by long-standing conflict among community groups about which strategies to implement, where efforts should be focused, and how much funding should be allocated to each strategy. The objective of this paper is to compare two engagement approaches that resulted in recommendations for multi-benefit enhancements to oyster populations and the oyster industry in Maryland, U.S.A., using the Consensus Solutions process with collaborative simulation modeling. These recommendations were put forward by the OysterFutures Workgroup in 2018 and the Maryland Oyster Advisory Commission (OAC) in 2021. Notable similarities between the efforts were the basic principles of the Consensus Solutions process: neutral facilitation, a 75% agreement threshold, the presence of management agency leadership at the meetings, a scientific support team that created a management scenario model in collaboration with community group representatives, numerous opportunities for representatives to listen to each other, and a structured consensus building process for idea generation, rating, and approval of management options. To ensure meaningful representation by the most affected user groups, the goal for membership composition was 60% from industry and 40% from advocacy, agency, and academic groups in both processes. Important differences between the processes included the impetus for the process (a research program versus a legislatively-mandated process), the size of the groups, the structure of the meetings, and the clear and pervasive impact of the COVID-19 pandemic on the ability of OAC members to interact. Despite differences and challenges, both groups were able to agree on a package of recommendations, indicating that consensus-based processes with collaborative modeling offer viable paths toward coordinated cross-sector natural resource decisions with scientific basis and community support. In addition, collaborative modeling resulted in ‘myth busting’ findings that allowed participants to reassess and realign their thinking about how the coupled human-oyster system would respond to management changes.

Chronic pain, once termed a hidden epidemic, is gaining increasing visibility around the world. It places a huge burden on patients, their families, and the wider community, with profound adverse effects on function, well-being, and quality of life. It is also a socioeconomic problem, straining health-care systems globally. This article provides an overview of the changing landscape of chronic noncancer pain. The epidemiology, classification, pain-related neuroscience, problems with overemphasis on biomedical focus, and the importance of adopting a more holistic sociopsychobiomedical framework are discussed. The article concludes with a brief discussion on health-care delivery systems in the context of chronic pain.

Introduction: Integrated team-based primary healthcare is well positioned to support opioid tapering for patients experiencing chronic pain. This paper describes the development, implementation and acceptability of a primary healthcare opioid tapering intervention ‘Assess Inform Manage Monitor’ (AIMM) at two sites. Methods: AIMM involved GP advice; nurse monitoring and potential engagement with: community pharmacist; psychologist; dietitian and exercise physiologist. Individuals receiving 90 days or more of prescription opioids were eligible. Patient and provider surveys and qualitative interviews were completed. Results: Of 140 eligible patients, 37 attended during the study period and were invited to participate. Patient post-intervention surveys (n = 8) and interviews (n = 6) indicated the intervention was acceptable, although the perceived value of some of the integrated team was low. GP and practice nurse support was valued. Providers (n = 4) valued team integration. Low weaning readiness was a barrier to engagement by patients and providers. Key lessons and conclusions: The intervention, whilst conceptually acceptable, was not feasible in its current form. Future efforts to transition patients towards integrated care should retain the practice nurse and place more focus on understanding and reinforcing patients’ readiness to wean. Greater inter-professional collaboration may also be needed. Such refinements may advance the cause of opioid reduction in primary care.

Abstract Background Despite their potential interest for clinical management, measurements of respiratory mechanics in patients with acute respiratory distress syndrome (ARDS) are seldom performed in routine practice. We introduced a systematic assessment of respiratory mechanics in our clinical practice. After the first year of clinical use, we retrospectively assessed whether these measurements had any influence on clinical management and physiological parameters associated with clinical outcomes by comparing their value before and after performing the test. Methods The respiratory mechanics assessment constituted a set of bedside measurements to determine passive lung and chest wall mechanics, response to positive end-expiratory pressure, and alveolar derecruitment. It was obtained early after ARDS diagnosis. The results were provided to the clinical team to be used at their own discretion. We compared ventilator settings and physiological variables before and after the test. The physiological endpoints were oxygenation index, dead space, and plateau and driving pressures. Results Sixty-one consecutive patients with ARDS were enrolled. Esophageal pressure was measured in 53 patients (86.9%). In 41 patients (67.2%), ventilator settings were changed after the measurements, often by reducing positive end-expiratory pressure or by switching pressure-targeted mode to volume-targeted mode. Following changes, the oxygenation index, airway plateau, and driving pressures were significantly improved, whereas the dead-space fraction remained unchanged. The oxygenation index continued to improve in the next 48 h. Conclusions Implementing a systematic respiratory mechanics test leads to frequent individual adaptations of ventilator settings and allows improvement in oxygenation indexes and reduction of the risk of overdistention at the same time. Trial registration The present study involves data from our ongoing registry for respiratory mechanics (ClinicalTrials.gov identifier: NCT02623192 . Registered 30 July 2015).

Abstract. Objective:. To describe implementation and report preliminary outcomes of a resource-efficient, standardized group pathway for chronic noncancer pain. Design:. Descriptive cross-sectional study of a group-based pain management pathway in comparison with an Australasian benchmarking data set. Setting:. An Australian tertiary multidisciplinary pain service. Subjects:. Patients with chronic noncancer pain actively participating in the group pathway in 2016. Methods:. Referred patients were prioritized to a short-duration group–based standardized pain management pathway linking education, assessment, and treatment groups. Measures of pain, mood, self-efficacy, and catastrophizing and reduction in daily opioid use were collated from the Australasian data set. Results:. In 2016, 928 patients were actively engaged with the pain service. More patients were prioritized to receive treatment in a group format in comparison with other Australasian services (68.4% vs 22%). A greater percentage of patients attended their first clinical contact within 3 months of referral (81.4%) compared with the Australasian average (68.6%). Comparable improvements in average pain intensity, pain interference, depression, anxiety, stress, pain catastrophizing, and self-efficacy were observed. There was significantly greater reduction in opioid use, including for those taking more than 40 mg of oral morphine equivalent daily dose. Conclusion:. Implementation of a sequence of short-duration groups as the default clinical pathway resulted in shorter waiting times and noninferior outcomes in key areas for patients completing the program, compared with Australasian averages. Given the resource efficiencies of the group process, this finding has implications for service design.

Background: GPs are central to opioid strategy in chronic non-cancer pain (CNCP). Lack of treatment alternatives and providers are common reasons cited for not deprescribing opioids. There are limited data about availability of multidisciplinary healthcare providers (MHCPs), such as psychologists, physiotherapists, or dietitians, who can provide broader treatments. Aim: To explore availability of MHCPs, and the association with GP opioid deprescribing and transition to therapeutic alternatives for CNCP. Design & setting: Cross-sectional survey of all practising GPs (N = 1480) in one mixed urban and regional Australian primary health network. Method: A self-report mailed questionnaire assessed the availability of MHCPs and management of their most recent patient on long-term opioids for CNCP. Results: Six hundred and eighty-one (46%) valid responses were received. Most GPs (71%) had access to a pain specialist and MHCPs within 50 km. GPs’ previous referral for specialist support was significantly associated with access to a greater number of MHCPs (P = 0.001). Employment of a nurse increased the rate ratio of available MHCPs by 12.5% (incidence rate ratio [IRR] 1.125, 95% confidence interval [CI] = 1.001 to 1.264). Only one-third (32%) of GPs reported willingness to deprescribe and shift to broader CNCP treatments. Availability of MHCPs was not significantly associated with deprescribing decisions. Conclusion: Lack of geographical access to known MHCPs does not appear to be a major barrier to opioid deprescribing and shifting toward non-pharmacological treatments for CNCP. Considerable opportunity remains to encourage GPs' decision to deprescribe, with employment of a practice nurse appearing to play a role.

OBJECTIVE: To report long term experience (1997-2009) of intrathecal (IT) therapy for chronic non-cancer pain in the context of our team's increasing emphasis on active management. DESIGN: Descriptive case series. SETTING: Australian tertiary multidisciplinary pain center, Hunter Integrated Pain Service (HIPS). INTERVENTION: This case series reports the changing use of IT implanted drug delivery systems (IDDSs) for chronic non-cancer pain over 13 years. Initially IT therapy was used selectively following multidisciplinary assessment and double blind IT trial. Typical therapy combined opioid with clonidine. Multidimensional management was offered. Treatment strategy changed in 2003 due to HIPS experience of limited therapeutic gains and equivocal support for IT therapy in the literature. Subsequently IT therapy was no longer initiated for non-cancer pain and those on established regimes were encouraged to shift to oral/transdermal opioids with greater emphasis on active management. Patient education and consultation were key elements. Where IT cessation was elective gradual dose reduction commenced as an outpatient. In elective and urgent cases ketamine infusion and oral clonidine were used during hospital admissions to cover the switch to oral/transdermal opioids. Over the study period transition occurred to a broader management framework in which IT therapy for chronic non-cancer pain was no longer supported by HIPS. RESULTS: 25 patients were managed using IDDSs; 8 implanted by HIPS and 17 by other teams. Dose escalation and adverse effects were common. 24 of 25 patients ceased IT therapy; 7 (29%) with urgent IDDS related complications, 16 (67%) electively and 1 due to an unrelated death. The remaining patient returned to her original team to continue IT therapy. One post-explantation patient transferred to another team to recommence IT therapy. The remainder were successfully maintained on oral/transdermal opioids combined with active management.

OBJECTIVE:: We aimed to determine internal medicine residents’ perceptions of the adequacy of their training to serve as in-hospital cardiac arrest team leaders, given the responsibility of managing acutely critically ill patients and with recent evidence suggesting that the quality of cardiopulmonary resuscitation provided in teaching hospitals is suboptimal. DESIGN:: Cross-sectional postal survey. SETTING:: Canadian internal medicine training programs. PARTICIPANTS:: Internal medicine residents attending Canadian English-speaking medical schools. INTERVENTIONS:: A survey was mailed to internal medicine residents asking questions relating to four domains: adequacy of training, perception of preparedness, adequacy of supervision and feedback, and effectiveness of additional training tools. MEASUREMENTS AND MAIN RESULTS:: Of the 654 residents who were sent the survey, 289 residents (44.2%) responded. Almost half of the respondents (49.3%) felt inadequately trained to lead cardiac arrest teams. Many (50.9%) felt that the advanced cardiac life support course did not provide the necessary training for team leadership. A substantial number of respondents (40%) reported receiving no additional cardiac arrest training beyond the advanced cardiac life support course. Only 52.1% of respondents felt prepared to lead a cardiac arrest team, with 55.3% worrying that they made errors. Few respondents reported receiving supervision during weekdays (14.2%) or evenings and weekends (1.4%). Very few respondents reported receiving postevent debriefing (5.9%) or any performance feedback (1.3%). Level of training and receiving performance feedback were associated with perception of adequacy of training (r = .085, p < .001). Respondents felt that additional training involving full-scale simulation, leadership skills training, and postevent debriefing would be most effective in increasing their skills and confidence. CONCLUSIONS:: The results suggest that residents perceive deficits in their training and supervision to care for critically ill patients as cardiac arrest team leaders. This raises sufficient concern to prompt teaching hospitals and medical schools to consider including more appropriate supervision, feedback, and further education for residents in their role as cardiac arrest team leaders. [ABSTRACT FROM AUTHOR]

At 4 a.m. on December 2, 2017, St. Joseph's Healthcare Hamilton - a multi-site, clinically diverse, tertiary academic and research hospital - deployed an electronic health record (EHR) system across the organization using a "big bang" approach. This effectively required all inpatient, emergency and many ambulatory services to put down their pens and document everything electronically at one moment in time without skipping a beat in providing excellent clinical care. The hospital leapt from the bottom to nearly the top of the internationally recognized measurement for EHR adoption - on time, in scope and within budget. This article presents the leadership's view on essential lessons learned with key recommendations for healthcare systems seeking successful implementation with this approach., (Copyright © 2019 Longwoods Publishing.)

Hypertension is known to increase the risk of atrial fibrillation. It has a role to play in atrial fibrosis and remodeling which tends to propagate further atrial fibrillation. Current anti arrhythmic therapy is unsatisfactory due to its toxicity. Management of hypertension offers an attractive target for improving therapy of atrial fibrillation. We examine the current evidence for anti hypertensive therapy in atrial fibrillation.