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Decision speed and quality are both vital for organizational survival and prosperity. However, they are assumed to be in tension, and there has been limited theory development concerning whether, and if so how, both are attainable. To address this gap, we turn to behavioral integration which captures the intensity of intra-team interactions. While behavioral integration is considered an antecedent of decision quality, it is presumed to slow decision-making, and overall, there remains a “black box” surrounding the mechanisms, behaviors, and processes which transmit behavioral integration to decision outcomes. Our theoretical account challenges the notion of behavioral integration being an impediment to decision speed, and we present new theory and evidence—comprising a mixed-method field study—explaining how behavioral integration acts as a key driver of both decision speed and quality, while theorizing decision uncertainty as a new and important boundary condition.

Optimal training of the future workforce is essential if we are to deliver effective healthcare in all situations and circumstances. Doctors will need to have the appropriate knowledge and skills to work in their chosen environment. However, additionally they will need to have contentment, by having made the right career choices, and resilience if they are to avoid burnout, which represents a clear threat to service provision.1,2 Undertaking training in a remote and rural environment provides direct relevance for those planning a career in remote and rural medicine. Having spent time working in a remote and rural environment, we have become persuaded of its value as part of all junior doctors' clinical development. Increasingly, junior doctors are seeking to take a break in their training progression, and a remote and rural placement may represent a valuable option with the potential to recruit those doctors to remote and rural practice.3 This paper was developed using an iterative conversation with a convenience sample – the junior and senior staff of the Balfour Hospital, NHS Orkney. The hospital serves a population of 25,000 people and visitors of the Orkney Islands, an archipelago off the north coast of Scotland, with no land connection to the mainland. Non-consultant grade staff include early-year junior doctors, hospital practitioners and general practitioner (GP) trainees, but no registrars. Email was used to invite contributions and create a provisional list. This was supplemented with one-to-one conversations with junior and senior staff. The ‘10 reasons’ were identified and then iteratively revised through further communications and conversations. ### You are exposed to the complete spectrum of medicine Large and particularly urban hospitals no longer offer a true general medical take. For very good reasons, acute myocardial infarction and stroke are hived off to subspecialty services.4 In a wider context, major trauma, oncology, paediatrics and obstetrics are often not co-located …

Background Early cancer recurrence after oesophagectomy is a common problem, with an incidence of 20–30 per cent despite the widespread use of neoadjuvant treatment. Quantification of this risk is difficult and existing models perform poorly. This study aimed to develop a predictive model for early recurrence after surgery for oesophageal adenocarcinoma using a large multinational cohort and machine learning approaches. Methods Consecutive patients who underwent oesophagectomy for adenocarcinoma and had neoadjuvant treatment in one Dutch and six UK oesophagogastric units were analysed. Using clinical characteristics and postoperative histopathology, models were generated using elastic net regression (ELR) and the machine learning methods random forest (RF) and extreme gradient boosting (XGB). Finally, a combined (ensemble) model of these was generated. The relative importance of factors to outcome was calculated as a percentage contribution to the model. Results A total of 812 patients were included. The recurrence rate at less than 1 year was 29·1 per cent. All of the models demonstrated good discrimination. Internally validated areas under the receiver operating characteristic (ROC) curve (AUCs) were similar, with the ensemble model performing best (AUC 0·791 for ELR, 0·801 for RF, 0·804 for XGB, 0·805 for ensemble). Performance was similar when internal–external validation was used (validation across sites, AUC 0·804 for ensemble). In the final model, the most important variables were number of positive lymph nodes (25·7 per cent) and lymphovascular invasion (16·9 per cent). Conclusion The model derived using machine learning approaches and an international data set provided excellent performance in quantifying the risk of early recurrence after surgery, and will be useful in prognostication for clinicians and patients., Early recurrence after surgery for adenocarcinoma of the oesophagus is common. A risk prediction model was derived using modern machine learning methods that accurately predicts risk of early recurrence using postoperative pathology. Machine learning may help

Background & Aims: Most patients with esophageal adenocarcinoma (EAC) present with de novo tumors. Although this could be due to inadequate screening strategies, the precise reason for this observation is not clear. We compared survival of patients with prevalent EAC with and without synchronous Barrett esophagus (BE) with intestinal metaplasia (IM) at the time of EAC diagnosis. Methods: Clinical data were studied using Cox proportional hazards regression to evaluate the effect of synchronous BE-IM on EAC survival independent of age, sex, TNM stage, and tumor location. We analyzed data from a cohort of patients with EAC from the Mayo Clinic (n=411; 203 with BE and IM) and a multicenter cohort from the United Kingdom (n=1417; 638 with BE and IM). Results: In the Mayo cohort, BE with IM had a reduced risk of death compared to patients without BE and IM (hazard ratio [HR] 0.44; 95% CI, 0.34–0.57; PConclusion: Two types of EAC can be characterized based on the presence or absence of BE. These findings could increase our understanding the etiology of EAC, and be used in management and prognosis of patients.

Rapid tranquillisation (RT) aims to quickly calm the severely agitated patient, in order to reduce the risk of imminent and serious violence to self or others. While it is widely used within mental health care settings, there is little published information on patterns of practice. Retrospective data collection identified a total of 2267 incidents of RT within the Central and North West London NHS Foundation Trust over a 19 month period equating to a mean frequency of approximately four incidents per day. These incidents mainly occurred in acute inpatient services and two and a half times more frequently in PICUs than on open wards. Of all the PICUS, the female PICU used most RT. Intramuscular RT was reported more often in most services. Restraint was used in 57% (n=1300) of RT incidents and minor injury resulted in only 11% of these incidents overall. There were no reports of major injury or death in the data set. Variations in RT use were seen across the Trust’s geography and ward types.

Objective: Barrett's oesophagus shows appearances described as ‘intestinal metaplasia’, in structures called ‘crypts’ but do not typically display crypt architecture. Here, we investigate their relationship to gastric glands.\ud \ud Methods: Cell proliferation and migration within Barrett's glands was assessed by Ki67 and iododeoxyuridine (IdU) labelling. Expression of mucin core proteins (MUC), trefoil family factor (TFF) peptides and LGR5 mRNA was determined by immunohistochemistry or by in situ hybridisation, and clonality was elucidated using mitochondrial DNA (mtDNA) mutations combined with mucin histochemistry.\ud \ud Results: Proliferation predominantly occurs in the middle of Barrett's glands, diminishing towards the surface and the base: IdU dynamics demonstrate bidirectional migration, similar to gastric glands. Distribution of MUC5AC, TFF1, MUC6 and TFF2 in Barrett's mirrors pyloric glands and is preserved in Barrett's dysplasia. MUC2-positive goblet cells are localised above the neck in Barrett's glands, and TFF3 is concentrated in the same region. LGR5 mRNA is detected in the middle of Barrett's glands suggesting a stem cell niche in this locale, similar to that in the gastric pylorus, and distinct from gastric intestinal metaplasia. Gastric and intestinal cell lineages within Barrett's glands are clonal, indicating derivation from a single stem cell.\ud \ud Conclusions: Barrett's shows the proliferative and stem cell architecture, and pattern of gene expression of pyloric gastric glands, maintained by stem cells showing gastric and intestinal differentiation: neutral drift may suggest that intestinal differentiation advances with time, a concept critical for the understanding of the origin and development of Barrett's oesophagus.

Methods are described whereby a series of novel bi- and difunctional (telechelic) high 1,4-microstructure polybutadienes are prepared by use of an anionic functional initiator. This initiator, 3-dimethylaminopropyllithium, has been extensively investigated and methods for its preparation and use in non-polar solvents are described. When utilised in such non-polar solvents the polybutadienes produced are uniquely functionalised, possessing a high 1,4-structure and a low glass transition temperature. Evidence is presented to demonstrate that these reactions are true ‘living’ polymerisations and that quantitative functional termination reactions may be used to yield a wide range of multi-, bi- or difunctional polymers.

The management of kangaroos is one of the most controversial issues in Australian wildlife management today - kangaroos are 'in plague proportions' or 'on the verge of extinction' depending on whom you spoke to last. This book examines the ecology and management of kangaroos and shows how they interact with their own environment and with that shaped by sheep grazing and the wool industry. It presents the results of intensive and detailed studies of feeding behaviour, movement and habitat utilisation, body condition and population dynamics, weather and plant growth. These are then synthesised to produce a clear picture of how kangaroos cope so successfully with the climatic extremes of the arid zone, how they and the sheep jointly affect each other's fortunes, and what the options are for the future management of kangaroos both within the national parks and on the sheep rangelands.