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Abstract This study develops a 73-year dataset of water balance components from 1950 to 2022 for the Laurentian Great Lakes Basins. This is carried out using the Large Lakes Statistical Water Balance Model (L2SWBM), which provides a Bayesian statistical framework that assimilates binational input datasets sourced from the United States and Canada. The L2SWBM infers feasible water balance component estimates through this Bayesian framework by constraining the output with a standard water balance equation. The result is value-added time series, including expressions of uncertainty, that ultimately close the water balance across the interconnected Great Lakes system. Therefore, the L2SWBM facilitates the understanding of discrepancies in datasets and hydroclimate parameters. This enhanced reliability stemming from coordinated data, with an understanding and quantification of uncertainty, could significantly boost confidence in decision support tools for water resources practitioners and policymakers. This joint effort advances scientific understanding and strengthens strategies and policies designed to bolster resilience in Great Lakes communities and its ecosystem in the face of a shifting climate.

Objectives: Trivalent inactivated influenza vaccine effectiveness was low in a prospective cohort of healthcare personnel (HCP) in Israel from 2016 to 2019. We conducted a randomised immunogenicity trial of quadrivalent recombinant influenza vaccine (RIV4) and standard-dose inactivated influenza vaccine (IIV4) among frequently and infrequently vaccinated previous cohort participants. Methods: From October 2019 to January 2020, we enrolled and randomly allocated HCP from two Israeli hospitals to receive IIV4 or RIV4. Hemagglutination inhibition (HAI) antibody titres against 2019-2020 vaccine reference influenza viruses were compared between vaccine groups using geometric mean titre (GMT) ratios from sera collected one-month post-vaccination and by frequency of vaccination in the past 5 years (>2 vs ≤2). Results: Among 415 HCP, the GMT ratio comparing RIV4 to IIV4 was 2.0 (95% confidence interval [CI] 1.7-2.7) for A(H1N1)pdm09, 1.6 (95% CI: 1.3-1.9) for A(H3N2), 1.8 (95% CI: 1.4-2.2) for B(Yamagata), and 1.1 (95% CI: 0.9-1.4) for B(Victoria). Similarly, RIV4 elicited higher HAI titres than IIV4 against all 2019-2020 vaccine reference viruses except B(Victoria) among infrequently and frequently vaccinated HCP (lower bound of GMT ratio 95% CIs ≥1.0). Conclusion: RIV4 had improved immunogenicity for influenza vaccine strains among both infrequent and frequent vaccinees compared to standard-dose IIV4. Clinical trials registration: NCT04523324

The EML4–ALK oncogene drives tumour progression in approximately 5% of cases of non-small-cell lung cancers. At least 15 EML4–ALK variants have been identified, which elicit differential responses to conventional ALK inhibitors. Unfortunately, most, if not all, patients eventually acquire resistance to these inhibitors and succumb to the disease, which warrants the need for alternative targets to be identified. The most aggressive variant, EML4–ALK variant 3 (V3), assembles into a complex on interphase microtubules together with the NEK9 and NEK7 kinases, which leads to the downstream phosphorylation of NEK7 substrates. Overall, this promotes an elongated cell morphology and an enhanced migratory phenotype, which likely contributes to the increased metastasis often seen in V3 patients. Here, using two separate approaches to displace V3 from microtubules and a variety of in vitro assays, we show that microtubule association of EML4–ALK V3 is required for both V3 phenotypes, as removal of the oncogenic fusion protein from microtubules led to the dissociation of the V3–NEK9–NEK7 complex and the reversal of both phenotypic changes. Overall, we propose that targeting the interaction between EML4–ALK V3 and microtubules might offer a novel therapeutic option, independent of ALK activity, for V3+ NSCLC patients with acquired resistance to ALK inhibitors.

Abstract Background Theileria haneyi is one of the three known causative agents of equine piroplasmosis. While imidocarb is generally effective in the clearance of the highly pathogenic Theileria equi, it is ineffective in the treatment of T. haneyi. Moreover, co-infection with T. haneyi has been shown to impede the successful treatment of T. equi. Furthermore, tulathromycin and diclazuril have demonstrated inefficacy in eradicating T. haneyi. The absence of an effective therapeutic agent against this parasite represents a significant obstacle in managing equine piroplasmosis. Methods To address this issue, we evaluated the efficacy of buparvaquone in the treatment of T. haneyi in chronically infected horses. Results Our findings showed that treatment of horses with the recommended dose of 2.5 mg/kg of buparvaquone led to a rapid abatement of T. haneyi levels, to a level where the parasites were not detectable by nested PCR. Following treatment, the horses remained PCR negative for a minimum of seven weeks until recrudescence occurred. Subsequent re-administration of buparvaquone at an increased dosage of 6 mg/kg upon recrudescence failed to exert a theilericidal effect on T. haneyi. Throughout the treatment regimen, the hematological parameters of the horses and most components of the chemistry panel remained within the normal range, except for blood urea nitrogen levels, which fell below the normal range in certain instances. conclusions BPQ at 2.5 mg/kg and 6 mg/kg had a robust theilericidal effect but was ineffective in the clearance of the T. haneyi infection in persistently infected animals. Graphical Abstract

Abstract The global energy budget is pivotal to understanding planetary evolution and climate behaviors. Assessing the energy budget of giant planets, particularly those with large seasonal cycles, however, remains a challenge without long-term observations. Evolution models of Saturn cannot explain its estimated Bond albedo and internal heat flux, mainly because previous estimates were based on limited observations. Here, we analyze the long-term observations recorded by the Cassini spacecraft and find notably higher Bond albedo (0.41 ± 0.02) and internal heat flux (2.84 ± 0.20 Wm−2) values than previous estimates. Furthermore, Saturn’s global energy budget is not in a steady state and exhibits significant dynamical imbalances. The global radiant energy deficit at the top of the atmosphere, indicative of the planetary cooling of Saturn, reveals remarkable seasonal fluctuations with a magnitude of 16.0 ± 4.2%. Further analysis of the energy budget of the upper atmosphere including the internal heat suggests seasonal energy imbalances at both global and hemispheric scales, contributing to the development of giant convective storms on Saturn. Similar seasonal variabilities of planetary cooling and energy imbalance exist in other giant planets within and beyond the Solar System, a prospect currently overlooked in existing evolutional and atmospheric models.

IntroductionTheileria orientalis, an economically significant tick-borne hemoparasite, infects cattle globally. The T. orientalis Ikeda genotype, transmitted by Haemaphysalis longicornis ticks, is associated with clinical manifestations characterized by anemia, abortions, and mortality, although subclinical infections prevail. Despite the common occurrence of subclinical infections, therapeutic interventions targeting T. orientalis Ikeda in such cases are currently lacking, impeding effective parasite control measures. To address this critical knowledge gap, we assessed the efficacy of buparvaquone (BPQ) in eliminating the T. orientalis Ikeda, US isolate, in sub-clinically infected cattle.MethodsTwelve sub-clinically infected calves, identified by the presence of T. orientalis in peripheral blood alongside the absence of fever and anemia, were enrolled in the study. Six calves received two treatments of the BPQ label dose (2.5 mg/kg) at a 48-h interval, while additional three calves received the drug at a dosage of 6 mg/kg following the same regimen. Three untreated calves served as controls.Results and discussionEndpoint and quantitative PCR analyses revealed that BPQ exerted a transient effect on T. orientalis parasitemia. Parasites remained undetectable in peripheral blood until weeks 4 and 11 post-treatment in animals administered 2.5 mg/kg and 6 mg/kg of BPQ, respectively. Intriguingly, following recrudescence, administering 6 mg/kg to animals previously treated with 2.5 mg/kg did not result in a reduction in parasite load. Pharmacokinetic analysis data suggested that escalating the dosage led to a less than proportional increase in serum concentrations of BPQ. Moreover, a significant yet reversible decrease (p

Abstract Repeat vaccination with egg-based influenza vaccines could preferentially boost antibodies targeting the egg-adapted epitopes and reduce immunogenicity to circulating viruses. In this randomized trial (Clinicaltrials.gov: NCT03722589), sera pre- and post-vaccination with quadrivalent inactivated egg-based (IIV4), cell culture-based (ccIIV4), and recombinant (RIV4) influenza vaccines were collected from healthcare personnel (18-64 years) in 2018−19 (N = 723) and 2019−20 (N = 684) influenza seasons. We performed an exploratory analysis. Vaccine egg-adapted changes had the most impact on A(H3N2) immunogenicity. In year 1, RIV4 induced higher neutralizing and total HA head binding antibodies to cell- A(H3N2) virus than ccIIV4 and IIV4. In year 2, among the 7 repeat vaccination arms (IIV4-IIV4, IIV4-ccIIV4, IIV4-RIV4, RIV4-ccIIV4, RIV4-RIV4, ccIIV4-ccIIV4 and ccIIV4-RIV4), repeat vaccination with either RIV4 or ccIIV4 further improved antibody responses to circulating viruses with decreased neutralizing antibody egg/cell ratio. RIV4 also had higher post-vaccination A(H1N1)pdm09 and A(H3N2) HA stalk antibodies in year 1, but there was no significant difference in HA stalk antibody fold rise among vaccine groups in either year 1 or year 2. Multiple seasons of non-egg-based vaccination may be needed to redirect antibody responses from immune memory to egg-adapted epitopes and re-focus the immune responses towards epitopes on the circulating viruses to improve vaccine effectiveness.

Theileria equi (T. equi) is an apicomplexan parasite that causes severe hemolytic anemia in equids. Presently, there is inadequate knowledge of the immune responses induced by T. equi in equid hosts impeding understanding of the host parasite relationship and development of potent vaccines for control of T. equi infections. The objective of this study was to evaluate the host-parasite dynamics between T. equi merozoites and infected horses by assessing cytokine expression during primary and secondary parasite exposure, and to determine whether the pattern of expression correlated with clinical indicators of disease. Our findings showed that the expression of pro-inflammatory cytokines was very low and inconsistent during both primary and secondary infection. There was also no correlation between the symptoms observed during primary infection and expression of the cytokines. This suggests that the symptoms might have occurred primarily due to hemolysis and likely not the undesirable effects of pro-inflammatory responses. However, IL-10 and TGF-β1 were highly expressed in both phases of infection, and their expression was linked to antibody production but not moderation of pro-inflammatory cytokine responses.

We reviewed the tools that have been developed to characterize and communicate seasonal influenza activity in the United States. Here we focus on systematic surveillance and applied analytics, including seasonal burden and disease severity estimation, short-term forecasting, and longer-term modeling efforts. For each set of activities, we describe the challenges and opportunities that have arisen because of the COVID-19 pandemic. In conclusion, we highlight how collaboration and communication have been and will continue to be key components of reliable and actionable influenza monitoring, forecasting, and modeling activities.

The subfornical organ (SFO) is a sensory circumventricular organ of the central nervous system and plays a key role in regulation of a number of homeostatic processes because of its ability to detect and respond to circulating signals and communication to homeostatic control centres. A previous study reported a change in expression of 687 transcripts in rat SFO following a 48h fast; of particular interest was the observed downregulation of the transcript encoding the Nav1.3 voltage-gated Na + channel. Therefore, we carried out a study to examine the effects of a 48h fast on electrical properties of SFO neurons. First, we carried out an immunohistochemical analysis of rat SFO to confirm expression of Nav1.3 protein. Next, we carried out qPCR analysis of mRNA from SFO of sated rats and 48h fasted rats and confirm that a 48hr fast caused a downregulation of Nav1.3. Using patch clamp analysis of SFO neurons acutely isolated from rats following a 48h fast, a statistically significant decrease in peak Na +  current density, as well as shifts in voltage dependence of activation and inactivation, and a slowing to time dependent recovery from inactivation were observed. These changes were accompanied by a depolarization of the threshold to fire action potentials and a decrease in frequency of spontaneous action potentials. Together, these data show that the electrical properties of SFO neurons are altered by a 48hr fast, indicating SFO is a dynamic sensor of circulating signals., Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2024 The Authors. Published by Elsevier Inc. All rights reserved.)

Background: Rural Australia has large geographic distances between emergency departments with variability of services and medical support. Emergency nurses must be appropriately skilled to assess and manage unpredictable and diverse presentations. HIRAID® is an evidence-based framework to support emergency nurses in assessment and care delivery. To inform implementation, the study aimed to identify the enablers and barriers to introducing HIRAID® in practice., Methods: This embedded mixed methods study was conducted in 11 rural, regional emergency departments in Southern New South Wales, Australia. Respondents completed a 22-item survey, indicating their level of agreement on statements related to practice change, free text responses were optional. Quantitative data were analysed using descriptive statistics and qualitative data using content analysis. Results were identified as barriers or enablers, then integrated and mapped to the Theoretical Domains Framework., Results: The survey was completed by 102 (54 %) nurses. Two enablers and four barriers to implementation were identified and mapped to 10 Theoretical Domains Framework domains. Key barriers were workplace limitations, such as time and resources, and knowledge of the HIRAID® intervention., Conclusion: Barriers varied between facilities related to adequate support to implement and the impact on patient care. The results will inform a strategy to implement HIRAID®., (Copyright © 2024 The Authors. Published by Elsevier Ltd.. All rights reserved.)

Objectives: Evidence-based tools are needed to support aged care nurses in recognising and responding to changes in residents' conditions and clinical deterioration. Systematised emergency nursing frameworks such as HIRAID® (History including Infection risk, Red flags, Assessment, Interventions, Diagnostics, reassessment and communication) assist nurses in accurately assessing and documenting a patient's condition and identifying and prioritising care needs. This study aimed to adapt the HIRAID® emergency nursing framework for use in the residential aged care setting., Methods: A real-time Delphi method was employed to contextually adapt the HIRAID® framework. Twelve expert health-care clinical leaders with understanding of patient assessment and residential aged care management were recruited through purposive sampling. Panel consensus was established a priori at 80%. A secondary measure of panel stability was used to understand panel consensus., Results: Consensus was reached after two survey rounds. In Round 1, 105 (88%) of 119 items were accepted after reaching consensus. In Round 2, all remaining 29 items reached consensus, whereby 20 were accepted and nine rejected. Key modifications were identified for 'History', which needed to consider more comprehensive and adaptive techniques, and 'Interventions' and 'Diagnostics', where differences arose in the scope of practice of aged care nurses compared to their acute care counterparts., Conclusion: The study demonstrated how a small expert multidisciplinary health-care panel can be stable and reach consensus to adapt and contextualise an emergency care framework to the aged care setting. These findings will form the content to scaffold educational resources to support learning and practice change., (© 2024 AJA Inc?.)

Background: Increased demand, wait times and length of stay have seen many emergency departments implement nurse-initiated protocols In New South Wales, Australia, 74 nurse-initiated protocols have been developed for implementation. The aim of this paper is to identify the barriers and enablers to nurses' use of these protocols to inform and maximise future implementation., Methods: Data were collected via surveys informed by the theoretical domains' framework and the Practice Environment Scale of the Nursing Work Index (PES-NWI). Descriptive statistics summarised quantitative data and content analysis was performed on qualitative data. Results were integrated and classified as barriers or enablers to nurses' use of protocols., Results: The nurses' response rate was 82 % (n = 76) and doctors 72 % (n = 34) Six categories were generated; one barrier (lack of resources), three enablers (patient and organisational benefits, nurses' motivation, nurses' desire to develop their practice) and two were both a barrier and enabler ( nurse confidence and the work environment)., Conclusion: Emergency nurses are highly motivated to use nurse-initiated protocols to positively impact patient outcomes. However, a lack of resources, time, access to education and confidence are barriers to use that need to be addressed when designing implementation., Competing Interests: Declaration of Competing Interest We declare author Prof Kate Curtis is an Associate Editor and Prof Margaret Fry is a Senior Editor for the Australasian Emergency Care., (Copyright © 2024 The Authors. Published by Elsevier Ltd.. All rights reserved.)

Background: The health issues experienced by older people can often be severe and complex, and an increasing number are using residential aged care services to meet their care needs. High-quality nursing care is fundamental to the health and safety of aged care residents and is contingent on nurses' accurate assessment, informed decision-making, and delivery of timely interventions. However, the role of the aged care nurse is often challenging, impeded by factors such as understaffing, high workloads, and a lack of access to clinical infrastructure and resources. When these challenges mount, residents are put at greater risk of adverse outcomes, such as avoidable clinical deterioration and hospital transfers. This study describes the adaptation and implementation of the emergency nursing framework, HIRAID® (History including Infection risk, Red Flags, Assessment, Interventions, Diagnostics, reassessment, communication and plan)-a tool to assist nurses' assessment, decision-making and care in residential aged care., Methods: The HIRAID® framework will be adapted for residential aged care using a real-time Delphi and panel of aged care and nursing experts. The co-designed HIRAID® Aged Care framework will be trialled in 23 residential aged care homes in Sydney, Australia, in a modified stepped-wedge cluster randomised controlled trial design. All homes will be randomised into one of four clusters. Outcomes of interest include the rate of clinical deterioration events resulting from nurses' actions, the rate of hospital transfers determined to be inappropriate, performance against the national mandatory aged care quality indicators, resident satisfaction with care, nurse and medical staff satisfaction with communication, and the quality of nursing documentation. These outcomes will be evaluated using a combination of qualitative and quantitative analysis of routinely collected resident data, expert assessments of facility documentation events against validated criteria, and pre- and post-intervention surveys of residents, family carers, nurses, and medical staff., Discussion: This protocol describes a pragmatic trial that aims to translate an evidence-based framework from the emergency care context into residential aged care. The adapted HIRAID® Aged Care framework will be the first of its kind to standardise and guide holistic nursing assessment, decision-making, and documentation in residential aged care in Australia., Ethics and Dissemination: This research has been approved by the Western Sydney Local Health District Human Research Ethics Committee: 2023/ETH00523. A waiver of consent has been approved to access resident health data and nursing documentation at each participating site., Trial Registration: Australian and New Zealand Clinical Trial Registry, ACTRN12623000481673. Registered 12 May 2023., Protocol Version: Version 1.0 6 February 2024., (© 2024. The Author(s).)

Objective: Selective serotonin reuptake inhibitor (SSRI) prescribing is increasingly being integrated into primary care, but few data are available about prescribing patterns by pediatric primary care clinicians (PCCs) following implementation of integrated behavioral health (BH) care., Methods: Using administrative claims data, we performed a cross-sectional analysis of SSRI prescribing within a statewide pediatric primary care network over 10 years after the initiation of an integrated BH program, calculating the rate of PCC and specialist SSRI prescribing. Using electronic health record data, we analyzed a proposed set of quality metrics for SSRI initiation., Results: Over 10 years, SSRI prescribing by PCCs increased from 56 fills/1000 patient-years to 446; over the same time period, prescribing by specialists for the network's patients rose from 233 fills/1000 patient-years to 380. In 2013, PCCs prescribed 19% of all SSRIs, while by 2022, they prescribed 54% of the total (P < 0.001 for change for PCCs compared to specialists). Among 16,272 initial SSRI prescribing events by PCCs, 99.6% prescribed a recommended SSRI; 97.5% used an appropriate starting dose; 55.2% documented a validated symptom rating scale at initiation; 53.4% had a contact within 14 days; 67.8% had a follow-up visit within 60 days; and 37.4% documented a symptom rating scale within 60 days., Conclusions: In the first 10 years of a pediatric integrated BH program, SSRI prescribing by PCCs increased over 7-fold and surpassed specialist prescribing for the patient population. PCCs chose medications and starting doses appropriately but could improve their use of validated symptom rating scales and consistent follow-up., Competing Interests: Declaration of Competing Interest The authors have no conflicts of interest to report., (Copyright © 2024 Academic Pediatric Association. Published by Elsevier Inc. All rights reserved.)

Purpose: Therapeutic proteins are often delivered by subcutaneous (SC) autoinjector to enable self-administration. Autoinjectors typically deliver up to 1 mL injected volumes per dose. Delivery of larger volumes may be limited by injection site discomfort, including pain, swelling, and redness. Delivery at a slower rate may mitigate this discomfort. This single-center, randomized, crossover study evaluated the acceptability and tolerability of varying volumes and delivery rates of SC saline in healthy volunteers., Patients and Methods: Eligible participants were adults (18-65 years) with a body mass index of 18.5-32.0 kg/m 2 . Participants (N = 24) were randomized to multiple sequences of infusions over five visits, with infusions ranging from 1 to 5 mL at rates of 1.50-6.00 mL/minute (min) and including a 1 mL SC infusion in 10 seconds (s) at a rate of 6.00 mL/min. The primary objective was to identify acceptable volume and delivery rates of SC saline, as assessed by visual analogue scale (VAS) pain scores, a tolerability and acceptability questionnaire, and infusion leakage., Results: Infusions that met the acceptability criteria were 1 mL in 10s, 4 mL in 58s, and 3 mL in 2 mins. Higher delivery volumes and rates were associated with higher VAS pain scores but remained within the VAS acceptability criteria., Conclusion: These findings may support the development of larger-volume injectors for self-administration of future medicines., Competing Interests: Chika Akinseye was an employee of, and shareholder in, GSK at the time of the study. Andrew Fiorini was an employee of GSK at the time of the study, and a shareholder in GSK. Emily Jarvis is an employee of, and shareholder in, GSK. Michelle Fry is an employee of, and shareholder in, GSK. Abid Raza was a complementary worker for GSK at the time of the study. Sara Soleman was an employee of, and shareholder in, GSK at the time of the study. Stephanie Igwe is an employee of, and shareholder in, GSK. Mark Palmer is an employee of, and shareholder in, GSK. The authors report no other conflicts of interest in this work., (© 2024 Akinseye et al.)

Background: Nurses play a key role in the recognition and response to clinical deterioration., Aim: The aim of this scoping review was to explore, map and synthesise existing research related to the ward nurses' role in recognising and responding to clinical deterioration., Methods: A scoping review was undertaken to identify English only studies focused on the ward nurse's role in recognition and response to clinical deterioration of the hospitalised adult. Search terms included 'clinical deterioration', 'nurses', 'wards', 'general', 'hospital, units' and 'hospitals'. The Cumulative Index to Nursing and Allied Health Literature, EMBASE, Ovid MEDLINE, PubMed, ProQuest and Science Direct databases were searched for eligible studies., Results: Forty-six studies met the inclusion criteria and three major themes were synthesised: (i) recognition of deterioration; (ii) nursing assessment; and, (iii) challenges responding to patient deterioration., Conclusion: The review highlighted significant variability in the ward nurses' role, activities, and skills in assessing, monitoring, managing and escalating care for clinical deterioration.

Background: Internationally, the nursing workforce is ageing. Chronic conditions are becoming more prevalent amongst the ageing nursing workforce. With an increase in chronic conditions and an ageing nursing workforce, understanding environmental influences on nurses' health and work capacity is vital to supporting this workforce., Aim: A scoping review was conducted to explore the influence of a critical care environment on nurses' health and work capacity., Design: A scoping review was conducted according to PRISMA-ScR guidelines., Methods: Database extraction occurred in June 2023 and included MEDLINE Complete, PubMed, Scopus, CINAHL, and Embase., Results: Eight studies met the inclusion criteria. Studies were conducted internationally with sample sizes from 20 to 500 critical care nurses (CCNs)., Conclusions: Findings identified the critical care environment had an impact on nurses' health and working capacity. Many CCNs self-reported having a chronic condition that influenced their nursing practice. Further research is needed to explore how to mitigate the influence of a chronic condition to support this valuable workforce.

Aim: To develop an evidence-driven, behaviour change focused strategy to maximise implementation and uptake of HIRAID (History including Infection risk, Red flags, Assessment, Interventions, Diagnostics, communication and reassessment) in 30 Australian rural, regional and metropolitan emergency departments., Design: An embedded, mixed-methods study., Methods: This study is the first phase of a step-wedge cluster randomised control trial of HIRAID involving over 1300 emergency nurses. Concurrent quantitative and qualitative data were collected via an electronic survey sent to all nurses to identify preliminary barriers and enablers to HIRAID implementation. The survey was informed by the Theoretical Domains Framework, which is a synthesis of behavioural change theories that applies the science of intervention implementation in health care to effect change. Quantitative data were analysed using descriptive statistics and qualitative data with inductive content analysis. Data were then integrated to generate barriers and enablers to HIRAID implementation which were mapped to the Theoretical Domains Framework. Corresponding intervention functions and Behaviour Change techniques were selected and an overarching implementation strategy was developed through stakeholder consultation and application of the APEASE criteria (Affordability, Practicability, Effectiveness and cost-effectiveness, Acceptability, Side-effects/safety and Equity)., Results: Six barriers to HIRAID implementation were identified by 670 respondents (response rate ~58%) representing all 30 sites: (i) lack of knowledge about HIRAID; (ii) high workload, (iii) lack of belief anything would change; (iv) not suitable for workplace; (v), uncertainty about what to do and (vi) lack of support or time for education. The three enablers were as follows: (i) willingness to learn and adopt something new; (ii) recognition of the need for something new and (iii) wanting to do what is best for patient care. The 10 corresponding domains were mapped to seven intervention functions, 21 behaviour change techniques and 45 mechanisms. The major components of the implementation strategy were a scaffolded education programme, clinical support and environmental modifications., Conclusions: A systematic process guided by the behaviour change wheel resulted in the generation of a multifaceted implementation strategy to implement HIRAID across rural, regional and metropolitan emergency departments. Implementation fidelity, reach and impact now require evaluation., Impact: HIRAID emergency nursing assessment framework reduced clinical deterioration relating to emergency care and improved self-confidence and documentation in emergency departments in pilot studies. Successful implementation of any intervention in the emergency department is notoriously difficult due to workload unpredictability, the undifferentiated nature of patients and high staff turnover. Key barriers and enablers were identified, and a successful implementation strategy was developed. This study uses theoretical frameworks to identify barriers and enablers to develop a data-driven, behavioural-focused implementation strategy to optimise the uptake of HIRAID in geographically diverse emergency departments which can be used to inform future implementation efforts involving emergency nurses., Reporting Method: The CROSS reporting method (Supporting Information S3) was used to adhere to EQUATOR guidelines., Patient or Public Contribution: No Patient or Public Contribution., Trial Registration: Australian New Zealand; Clinical Trials Registry (ANZCTR) number: ACTRN12621001456842, registered 25/10/2021., (Journal of Advanced Nursing© 2024 The Author(s). Journal of Advanced Nursing published by John Wiley & Sons Ltd.)

Background: There is a desire in orthopaedics to have soft tissue, particularly tendon, grow into metallic implants. With the introduction of three-dimensional (3D) printed porous metal implants, we hypothesized that tendons could directly attach to the implants. However, the effects of the porous metal structure on tissue growth and penetration into the pores are unknown. Using a rat model, we investigated the effect of pore size on tendon repair fixation using 3D printed titanium implants., Methods: There were three experimental groups of eight Sprague Dawley rats (n = 24) plus control (n = 3). Implants had defined pore sizes of 400µm (n = 8), 700µm (n = 8), and 1000µm (n = 8). A defect was created in the Achilles tendon and the implant positioned between cut ends and secured with suture. Specimens were harvested at twelve weeks. Half the specimens underwent mechanical testing to assess tensile load to failure. The remaining specimens were fixed and processed for hard tissue histological analysis., Results: The average load to failure was 72.6N for controls (SD 10.04), 29.95N for 400µm (SD 17.95), 55.08N for 700µm (SD 13.47), and 63.08N for 1000µm (SD 1.87). The load to failure was generally better in the larger pore sizes. The 700µm and 1000µm specimens performed similarly, while the 400µm showed significant differences vs control (p = 0.039), vs 1000µm (p = 0.010), and approached significance vs 700µm (p = 0.066). There was increasing ingrowth as pore size increased. Histology showed fibrous tendon tissue within and around the implants, with collagen fibers organized in bundles., Conclusions: Tendon repair utilizing implants with 700µm and 1000µm pores exhibited similar load to failure as controls. Using a defined pore structure at the attachment points of tendons to implants may allow predictable tendon ingrowth onto/into an implant at the time of revision arthroplasty., Competing Interests: The senior author, David Markel, is a paid consultant for Stryker and Smith & Nephew. Dr. Markel serves on the editorial board of the Journal of Arthroplasty and Arthroplasty Today, and he is a board member for MARCQI and the Michigan Orthopedic Society. The rest of the authors have no conflict of interest to declare.

Background: Emergency nurses are the first clinicians to see patients in the ED; their practice is fundamental to patient safety. To reduce clinical variation and increase the safety and quality of emergency nursing care, we developed a standardised consensus-based emergency nurse career pathway for use across Australian rural, regional, and metropolitan New South Wales (NSW) emergency departments., Methods: An analysis of career pathways from six health services, the College for Emergency Nursing Australasia, and NSW Ministry of Health was conducted. Using a consensus process, a 15-member expert panel developed the pathway and determined the education needs for pathway progression over six face-to-face meetings from May to August 2023., Results: An eight-step pathway outlining nurse progression through models of care related to different ED clinical areas with a minimum 172 h protected face-to-face and 8 h online education is required to progress from novice to expert. Progression corresponds with increasing levels of complexity, decision making and clinical skills, aligned with Benner's novice to expert theory., Conclusion: A standardised career pathway with minimum 180 h would enable a consistent approach to emergency nursing training and enable nurses to work to their full scope of practice. This will facilitate transferability of emergency nursing skills across jurisdictions., Competing Interests: Declaration of Competing Interest Authors KC, MM, MF, RZS, JC, SK are creators HIRAID® education materials which are the subject of an intellectual property agreement with the University of Sydney. RZS is Editor-in-Chief and JC and MF are Senior Editors of Australasian Emergency Care but none of them had any role to play in the peer review and editorial decision-making of this paper whatsoever. An independent Backspace Acting Editor-in-Chief managed this paper. Other authors have no competing interests to declare., (Crown Copyright © 2024. Published by Elsevier Ltd. All rights reserved.)

Background: Periprosthetic joint infection (PJI) remains common and problematic. We hypothesized that using a bioceramic that provided rapid release of the antibiotics (vancomycin [VAN] or VAN and tobramycin [VAN and TOB]) from a polyvinyl-alcohol-composite (PVA) combined with a delayed and sustained antibiotic release from polymeric-dicalcium-phosphate-dihydrate (PDCPD) ceramic would inhibit S. aureus-associated implant infections., Methods: A total of 50 male Sprague Dawley rats were randomly divided into 5 groups-I: negative control; II: bacteria only; III: bacteria + saline wash; IV: bacteria + PVA-VAN-PDCPD, and V: bacteria + PVA-VAN-TOB-PDCPD. A porous titanium (Ti) implant was press-fit into the rat knee. S. aureus-containing broth was added into the joint space creating a PJI. After 1 week, the joints from groups III to V were washed with saline and the fluid collected for bacterial quantification. This was followed by saline irrigation treatment (groups III to V) and application of the antibiotic-loaded PVA-PDCPD bioceramic (groups IV and V). On day 21, joint fluid was collected, and the implants harvested for bacterial quantification., Results: No bacteria were isolated from the negative control (group I). The positive control (group II) was positive on both days 7 and 21. Bacteria were still present on day 21 in the fluid and implant in group III. Groups (IV and V) showed a decrease in the bacterial burden in the fluid and implant on day 21. There were significant differences in bacteria levels in the collected wash fluid and on the implant at day 21 between the saline wash (group III) and treatment groups (IV and V)., Conclusions: In this animal model of acute periprosthetic infection, treatment with PVA-VAN-PDCPD and PVA-VAN/TOB-PDCPD reduced bacterial load in the infected joint and the infected Ti implant. Application of PVA-VAN-PDCPD and/or PVA-VAN/TOB-PDCPD after saline irrigation could be used as an addition to the treatment of PJI., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Background: Implementing evidence that changes practice in emergency departments (EDs) is notoriously difficult due to well-established barriers including high levels of uncertainty arising from undifferentiated nature of ED patients, resource shortages, workload unpredictability, high staff turnover, and a constantly changing environment. We developed and implemented a behaviour-change informed strategy to mitigate these barriers for a clinical trial to implement the evidence-based emergency nursing framework HIRAID ® (History including Infection risk, Red flags, Assessment, Interventions, Diagnostics, communication, and reassessment) to reduce clinical variation, and increase safety and quality of emergency nursing care., Aim: To evaluate the behaviour-change-informed HIRAID ® implementation strategy on reach, effectiveness, adoption, quality (dose, fidelity) and maintenance (sustainability)., Methods: An effectiveness-implementation hybrid design including a step-wedge cluster randomised control trial (SW-cRCT) was used to implement HIRAID ® with 1300 + emergency nurses across 29 Australian rural, regional, and metropolitan EDs. Evaluation of our behaviour-change informed strategy was informed by the RE-AIM Scoring Instrument and measured using data from (i) a post HIRAID ® implementation emergency nurse survey, (ii) HIRAID ® Instructor surveys, and (iii) twelve-week and 6-month documentation audits. Quantitative data were analysed using descriptive statistics to determine the level of each component of RE-AIM achieved. Qualitative data were analysed using content analysis and used to understand the 'how' and 'why' of quantitative results., Results: HIRAID ® was implemented in all 29 EDs, with 145 nurses undertaking instructor training and 1123 (82%) completing all four components of provider training at 12 weeks post-implementation. Modifications to the behaviour-change informed strategy were minimal. The strategy was largely used as intended with 100% dose and very high fidelity. We achieved extremely high individual sustainability (95% use of HIRAID ® documentation templates) at 6 months and 100% setting sustainability at 3 years., Conclusion: The behaviour-change informed strategy for the emergency nursing framework HIRAID ® in rural, regional, and metropolitan Australia was highly successful with extremely high reach and adoption, dose, fidelity, individual and setting sustainability across substantially variable clinical contexts., Trial Registration: ANZCTR, ACTRN12621001456842 . Registered 25 October 2021., (© 2024. Crown.)

Aim: To describe the pre-implementation context and implementation approach, for a clinician researcher career pathway., Background: Clinician researchers across all health disciplines are emerging to radically influence practice change and improve patient outcomes. Yet, to date, there are limited clinician researcher career pathways embedded in clinical practice for nurses and midwives., Methods: A qualitative descriptive design was used., Data Sources: Data were collected from four online focus groups and four interviews of health consumers, nursing and midwifery clinicians, and nursing unit managers (N = 20) between July 2022 and September 2023., Results: Thematic and content analysis identified themes/categories relating to: Research in health professionals' roles and nursing and midwifery, and Research activity and culture (context); with implementation approaches within coherence, cognitive participation, collective action and reflexive monitoring (Normalization Process Theory)., Conclusions: The Pathway was perceived to meet organizational objectives with the potential to create significant cultural change in nursing and midwifery. Backfilling of protected research time was essential., Implications for the Profession And/or Patient Care: The Pathway was seen as an instrument to empower staff, foster staff retention and extend research opportunities to every nurse and midwife, while improving patient experiences and outcomes., Impact: Clinicians, consumers and managers fully supported the implementation of clinician researchers with this Pathway. The Pathway could engage all clinicians in evidence-based practice with a clinician researcher leader, effect practice change with colleagues and enhance patient outcomes., Reporting Method: This study adheres to relevant EQUATOR guidelines using the COREG checklist., Patient or Public Contribution: Health consumers involved in this research as participants, did not contribute to the design or conduct of the study, analysis or interpretation of the data, or in the preparation of the manuscript., (© 2024 The Author(s). Journal of Advanced Nursing published by John Wiley & Sons Ltd.)

Background: Many education interventions in emergency nursing are aimed at changing nurse behaviours. This scoping review describes and synthesises the published research education interventions and emergency nurses' clinical practice behaviours., Methods: Arksey and O'Malley's methodological framework guided this review, which is reported according to Preferred Reporting Items for Systematic reviews and Meta-Analyses Extension for Scoping Reviews (PRISMA-ScR). CINAHL, MEDLINE complete, ERIC, and Psycinfo were searched on 3 August 2023. Two pairs of researchers independently conducted all screening. Synthesis was guided by the Behaviour Change Wheel and Bloom's Taxonomy of Educational Objectives., Results: Twenty-five studies were included. Educational interventions had largely positive effects on emergency nurses' clinical practice behaviours. Ten different interventions were identified, the most common was education sessions (n = 24). Seven studies reported underpinning theoretical frameworks. Of the essential elements of behaviour change, seven interventions addressed capability, four addressed motivation and one addressed opportunity. Mapping against Bloom's taxonomy, thirteen studies addressed analysis, eleven studies addressed synthesis and two studies addressed evaluation., Conclusion: Few studies addressed elements of behaviour change theory or targeted cognitive domains. Future studies should focus on controlled designs, and more rigorous reporting of the education intervention(s) tested, and theoretical underpinning for intervention(s) selected., Competing Interests: Declaration of Competing Interest Author Professor Ramon Z. Shaban is the Editor in Chief of the Australian Emergency Care but had no role or part in the peer review or editorial decision-making of this paper whatsoever, and was blinded to the manuscript in the Elsevier Editorial System. Authors Professors Julie Considine and Margaret Fry are the Senior Editors of the Australian Emergency Care but had no role or part in the peer review or editorial decision-making of this paper whatsoever, and were blinded to the manuscript in the Elsevier Editorial System. Author Professor Kate Curtis is Associate Editor (Trauma) of the Australian Emergency Care but had no role or part in the peer review or editorial decision-making of this paper whatsoever, and was blinded to the manuscript in the Elsevier Editorial System., (Copyright © 2023 The Authors. Published by Elsevier Ltd.. All rights reserved.)

Background: Musculoskeletal (MSK) complaints often present initially to primary care physicians; however, physicians may lack appropriate instruction in MSK procedures. Diagnostic and therapeutic injections are useful orthopedic tools, but inaccuracy leads to unnecessary costs and inadequate treatment. The authors hypothesized that trainees afforded the opportunity to practice on a cadaver versus those receiving visual-aided instruction on subacromial injections (SAI) will demonstrate differences in accuracy and technique., Methods: During Spring of the year 2022, 24 Internal Medicine and Family Medicine residents were randomly divided into control and intervention groups to participate in this interventional randomized cadaveric study. Each group received SAI instruction via lecture and video; the intervention group practiced on cadavers under mentored guidance. Subjects underwent a simulated patient encounter culminating in injection of latex dye into a cadaveric shoulder. Participants were evaluated based on a technique rubric, and accuracy of injections was assessed via cadaver dissection., Results: Twenty-three of twenty-four participants had performed at least one MSK injection in practice, while only 2 (8.3%) of participants had performed more than 10 SAIs. There was no difference in technique between control 18.4 ± 3.65 and intervention 19.2 ± 2.33 (p = 0.54). Dissections revealed 3 (25.0%) of control versus 8 (66.7%) of intervention injections were within the subacromial space. Chi-Square Analysis revealed that the intervention affected the number of injections that were within the subacromial space, in the tissues bordering the subacromial space, and completely outside the subacromial space and bordering tissues (p = 0.03). The intervention group had higher self-confidence in their injection as opposed to controls (p = 0.04). Previous SAI experience did not affect accuracy (p = 0.76)., Conclusions: Although primary care physicians and surgeons develop experience with MSK procedures in practice, this study demonstrates a role for early integrated instruction and simulation to improve accuracy and confidence. The goal of improving accuracy in MSK procedures amongst all primary care physicians may decrease costs and avoid unnecessary referrals, diagnostic tests, and earlier than desired surgical intervention., (© 2024. The Author(s).)

Background: Blunt chest injury is associated with significant adverse health outcomes. A chest injury care bundle (ChIP) was developed for patients with blunt chest injury presenting to the emergency department. ChIP implementation resulted in increased health service use, decreased unplanned Intensive Care Unit admissions and non-invasive ventilation use. In this paper, we report on the financial implications of implementing ChIP and quantify costs/savings., Methods: This was a controlled pre-and post-test study with two intervention and two non-intervention sites. The primary outcome measure was the treatment cost of hospital admission. Costs are reported in Australian dollars (AUD). A generalised linear model (GLM) estimated patient episode treatment costs at ChIP intervention and non-intervention sites. Because healthcare cost data were positive-skewed, a gamma distribution and log-link function were applied., Results: A total of 1705 patients were included in the cost analysis. The interaction (Phase x Treatment) was positive but insignificant (p = 0.45). The incremental cost per patient episode at ChIP intervention sites was estimated at $964 (95 % CI, -966 - 2895). The very wide confidence intervals reflect substantial differences in cost changes between individual sites Conclusions: The point estimate of the cost of the ChIP care bundle indicated an appreciable increase compared to standard care, but there is considerable variability between sites, rendering the finding statistically non-significant. The impact on short- and longer-term costs requires further quantification., Competing Interests: Declaration of competing interest The authors have nothing to disclose., (Copyright © 2024 The Author(s). Published by Elsevier Ltd.. All rights reserved.)

Aims and Objectives: To identify the reasons and/or risk factors for hospital admission and/or emergency department attendance for older (≥60 years) residents of long-term care facilities., Background: Older adults' use of acute services is associated with significant financial and social costs. A global understanding of the reasons for the use of acute services may allow for early identification and intervention, avoid clinical deterioration, reduce the demand for health services and improve quality of life., Design: Systematic review registered in PROSPERO (CRD42022326964) and reported following PRISMA guidelines., Methods: The search strategy was developed in consultation with an academic librarian. The strategy used MeSH terms and relevant keywords. Articles published since 2017 in English were eligible for inclusion. CINAHL, MEDLINE, Scopus and Web of Science Core Collection were searched (11/08/22). Title, abstract, and full texts were screened against the inclusion/exclusion criteria; data extraction was performed two blinded reviewers. Quality of evidence was assessed using the NewCastle Ottawa Scale (NOS)., Results: Thirty-nine articles were eligible and included in this review; included research was assessed as high-quality with a low risk of bias. Hospital admission was reported as most likely to occur during the first year of residence in long-term care. Respiratory and cardiovascular diagnoses were frequently associated with acute services use. Frailty, hypotensive medications, falls and inadequate nutrition were associated with unplanned service use., Conclusions: Modifiable risks have been identified that may act as a trigger for assessment and be amenable to early intervention. Coordinated intervention may have significant individual, social and economic benefits., Relevance to Clinical Practice: This review has identified several modifiable reasons for acute service use by older adults. Early and coordinated intervention may reduce the risk of hospital admission and/or emergency department., Reporting Method: This systematic review was conducted and reported following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) methodology., Patient or Public Contribution: No patient or public contribution., (© 2024 The Authors. Journal of Clinical Nursing published by John Wiley & Sons Ltd.)

Observational and experimental discoveries of new factual entities such as objects, systems, or processes, are major contributors to some advances in the life sciences. Yet, whereas discovery of theories was extensively deliberated by philosophers of science, very little philosophical attention was paid to the discovery of factual entities. This paper examines historical and philosophical aspects of the experimental discovery by Carl Woese of archaea, prokaryotes that comprise one of the three principal domains of the phylogenetic tree. Borrowing Kuhn's terminology, this discovery of a major biological entity was made during a 'normal science' project of building molecular taxonomy for prokaryotes. Unexpectedly, however, an observed anomaly instigated the discovery of archaea. Substantiation of the existence of the new archaeal entity and consequent reconstruction of the phylogenetic tree prompted replacement of a long-held model of a prokarya and eukarya bipartite tree of life by a new model of a tripartite tree comprising of bacteria, archaea, and eukarya. This paper explores the history and philosophical implications of the progression of Woese's project from normal science to anomaly-instigated model-changing discovery. It is also shown that the consequential discoveries of RNA splicing and of ribozymes were similarly prompted by unexpected irregularities during normal science activities. It is thus submitted that some discoveries of factual biological entities are triggered by unforeseen observational or experimental anomalies., (© 2024. The Author(s).)

Aims: A novel large surface area microparticle paclitaxel (LSAM-PTX) has unique properties of long retention in cystic spaces while maintaining high drug concentration. We prospectively evaluated the safety and response of EUS-guided fine needle injection (EUS-FNI) of LSAM-PTX to chemoablate branch duct (BD)-IPMNs., Methods: Subjects diagnosed with BD-IPMNs exhibiting at least one worrisome criteria and considered non-surgical were enrolled in a multicenter clinical trial (NCT03188991) and subsequently included in an Expanded Access Protocol (EAP) where they received EUS-FNI of LSAM-PTX (15 mg/mL)., Results: Six BD-IPMNs measuring (mean ± SD) 3.18 ± 0.76 cm in diameter among 5 subjects (mean age: 66 years) were treated by EUS-FNI of LSAM-PTX. A mean of 4 doses of LSAM-PTX (mean dose/cyst: 73 ± 31 mg) were administered, and subjects were followed for up to 32 months. The mean volume reduction/cyst ranged from 42 to 89% (9.58 ± 5.1 ml to 2.2 ± 1.1 ml (p = 0.016)). The mean surface area reduction ranged from 31 to 83% (21.9 ± 8.7 cm 2 to 5.7 ± 2.5 cm 2 (p = 0.009)). Higher dosing-frequency of EUS-FNI of LSAM-PTX significantly correlated with a reduction in cyst volume (R 2  = 0.87, p = 0.03) and surface area (R 2  = 0.83, p = 0.04). Comparing pre- and post-ablation samples, molecular analysis of the cyst fluid revealed a loss of IPMN-associated mutations in 5 cases (83.3%), while reemergence was observed in 1 case and persistence in 1 case. Intracystic changes (fibrosis/calcification) were observed in 83.3% (n = 5). One subject developed mild acute pancreatitis (1 of 22 EUS-FNIs of LSAM-PTX)., Conclusion: In this EAP, EUS-FNI of LSAM-PTX into BD-IPMNs was safe and resulted in volume and surface area reduction, morphological changes, and loss of pathogenic mutations., (Copyright © 2024 IAP and EPC. Published by Elsevier B.V. All rights reserved.)

The interplay of contaminated sites, climate change, and disadvantaged communities are a growing concern worldwide. Worsening extreme events may result in accidental contaminant releases from sites and waste facilities that may impact nearby communities. If such communities are already suffering from environmental, economic, health, or social burdens, they may face disproportionate impacts. Equitable resilience planning to address effects of extreme events requires information on where the impacts may be, when they may occur, and who might be impacted. Because resources are often scarce for these communities, conducting detailed modeling may be cost-prohibitive. By considering indicators for four sources of vulnerability (changing extreme heat conditions, contaminated sites, contaminant transport via wind, and population sensitivities) in one holistic framework, we provide a scientifically robust approach that can assist planners with prioritizing resources and actions. These indicators can serve as screening measures to identify communities that may be impacted most and isolate the reasons for these impacts. Through a transdisciplinary case study conducted in Maricopa County (Arizona, USA), we demonstrate how the framework and geospatial indicators can be applied to inform plans for preparedness, response, and recovery from the effects of extreme heat on contaminated sites and nearby populations. The indicators employed in this demonstration can be applied to other locations with contaminated sites to build community resilience to future climate impacts., Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.

Detection of environmental cues is essential for all vertebrates and is typically established by the olfactory epithelium and olfactory sensory neurons (OSNs). In fishes, microvillous and ciliated OSNs are the principal types, typically detecting amino acids and bile salts, respectively. Activation of OSN receptors by specific ligands initiate downstream signal processing often leading to behavioural responses. In this study we used electrophysiological and behavioural techniques to evaluate olfactory detection and behaviour in juvenile lake sturgeon Acipenser fulvescens in response to hatchery- and natural dietary cues. We hypothesized that electro-olfactogram (EOG) and behavioural responses would be dependent on diet type. We predicted that inhibition of the phospholipase C/inositol 1,4,5-triphosphate (PLC/IP 3 ) secondary transduction pathway would reduce EOG responses to dietary cues and, inhibition of the adenylyl cyclase/adenosine 3,5-cyclic monophosphate (cAMP) pathway, would have no effect. Furthermore, we predicted a strong EOG response would be manifested in a change in behaviour. We observed that both the PLC/IP 3 and cAMP pathways were significantly involved in the detection of dietary cues. However, EOG responses did not manifest to behavioural responses, although the foraging activity to the hatchery cue was significantly greater compared to the control. Our results support the notion that lake sturgeon raised in a hatchery and fed a commercial pelleted diet may become accustomed to it prior to release into the wild. Further, this study suggests that, in conservation aquaculture settings, lake sturgeon should be exposed to natural dietary cues prior to release as one strategy to promote food recognition., Competing Interests: Declaration of Competing Interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2023 Elsevier Inc. All rights reserved.)

Purpose: Busyness as a construct within modern healthcare is complex and multidimensional. To date, few studies have sought to explore how busyness influences family-centred care. This study explored the influence of busyness on the delivery of family-centred care for nurses and parents., Design and Method: Ethnography was selected as the research design. The study site was a metropolitan tertiary hospital inpatient paediatric unit in Sydney, Australia. Semi-structured interview and non-participant observation techniques were used for data collection. Ten paediatric nurses and 10 parents were interviewed and 40 h of non-participant observations were undertaken. The COREQ was used to report the study., Results: The findings are presented as three key themes: (i) 'Supporting family-centred care' in which participants detail beliefs about the nurse-parent relationships and how despite busyness nurses sought out moments to engage with parents; (ii) 'Being present at the bedside' identified the challenges in optimising safety and how parents adapted their way of being and interacting on the unit; and (iii) 'The emotional cost of busyness' and how this influenced nurse-parent interactions, care delivery and family-centred care., Conclusions: The ethnography has given shape to social understandings of busyness, the complexities of paediatric nursing and family-centred care. The culture of care changed in moments of busyness and transformed parent and nursing roles, expectations and collaborative care that at time generated internal emotional conflict and tension., Practice Implications: Given the increasing work demands across health systems, new agile ways of working need to ensure maintenance of a family-centred approach. Strategies need to be developed during periods of busyness to better support collaborative connections and the well-being of paediatric nurses and parents. At an organisational level, fostering a positive workplace culture that shares a vision for family-centred care and collaboration is essential., Patient or Public Contribution: Parents of sick children admitted to an acute paediatric inpatient ward were invited to be a participant in a single interview. Parents were aware of the study through ward advertisement and informal discussions with the researchers or senior clinical staff. Engagement with parents was important as healthcare delivery in paediatrics is focused on the delivery of family-centred care. To minimise the risk of child distress and separation anxiety, children were present during the parent interview. Whist children and young people voices were not silenced during the interview process, for this study the parent's voice remained the focus. While important, due to limited resources, parents were not involved in the design analysis or interpretation of the data or in the preparation of this manuscript., Data Sharing: The data that support the findings of this study are available from the corresponding author upon reasonable request., (© 2023 The Authors. Journal of Clinical Nursing published by John Wiley & Sons Ltd.)

Communities across the world are facing extreme events, such as excessive heat, droughts, floods, and wildfires. In the presence of contaminated sites and waste management facilities, communities must consider the impacts of potential releases from these sites due to such events. Impacts of extreme events on sites and consequently on surrounding, often disadvantaged communities result from complex interactions between natural, physical, and social factors. A conceptual framework was developed to identify and provide a shared understanding of key vulnerabilities and pathways that transcend disciplines. A transparent and replicable method was developed to create mappable indicators that represent contaminated sites, waste facilities, contaminant transport via air and water, and population sensitivities. This method can be applied as a screening step to assist states and local communities in prioritizing targeted strategies and resources and determining where in-depth assessments are needed. These indicators can facilitate communication with a broad audience more easily than complex modeling approaches or aggregated indices. Case study results demonstrate the importance of considering indicators in conjunction with each other. The indicator method was developed together with U.S.-based partners, but can be adapted for other countries seeking to understand the potential impacts of extreme events on contaminated sites and communities.