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The cover image, by James J. O'Byrne et al., is based on the Clinical Report Bicoronal and metopic craniosynostosis in association with a de novo unbalanced t(2;7) chromosomal translocation, DOI: 10.1002/ajmg.a.38001. [ABSTRACT FROM AUTHOR]

Background: Quality ICU end-of-life-care has been found to be related to good communication. Handover is one form of communication that can be problematic due to lost or omitted information. A first step in improving care is to measure and describe it. Objective: The objective of this study was to describe the quality of ICU nurse handover related to end-of-life care and to compare the practices of different ICUs in three different countries. Design: This was a descriptive comparative study. Settings: The study was conducted in seven ICUs in three countries: Australia (1 unit), Israel (3 units) and the UK (3 units). Participants: A convenience sample of 157 handovers was studied. Methods: Handover quality was rated based on the ICU End-of-Life Handover tool, developed by the authors. Results: The highest levels of handover quality were in the areas of goals of care and pain management while lowest levels were for legal issues (proxy and advanced directives) related to end of life. Significant differences were found between countries and units in the total handover score (country: F(2,154) = 25.97, p = <.001; unit: F(6,150) = 58.24, p = <.001), for the end of life subscale (country: F(2, 154) = 28.23, p < .001; unit: F(6,150) = 25.25, p = <.001), the family communication subscale (country: F(2,154) = 15.04, p = <.001; unit: F(6,150) = 27.38, p = <.001), the family needs subscale (F(2,154) = 22.33, p = <.001; unit: F(6,150) = 42.45, p = <.001) but only for units on the process subscale (F(6,150) = 8.98, p = <.001. The total handover score was higher if the oncoming RN did not know the patient (F(1,155) = 6.51, p = <.05), if the patient was expected to die during the shift (F(1,155) = 89.67, p = <.01) and if the family were present (F(1,155) = 25.81, p = <.01). Conclusions: Practices of end-of-life-handover communication vary greatly between units. However, room for improvement exists in all areas in all of the units studied. The total score was higher when quality of care might be deemed at greater risk (if the nurses did not know the patient or the patient was expected to die), indicating that nurses were exercising some form of discretionary decision making around handover communication; thus validating the measurement tool. [ABSTRACT FROM AUTHOR]

Objective: A commonly adopted intervention to help to reduce wait times for hospital treatment is administrative validation, where administrators write to patients to check if a procedure is still required. The did not return (DNR) rate to validation letters is substantial. We tested whether the DNR rate was reduced by introducing nudges to validation letters., Methods: Participants from eight public hospitals (N = 2855; in 2017) in Ireland were randomized to receive an existing (control group) or a redesigned validation letter including nudges (intervention group)., Results: Participants in the intervention group were less likely not to return it than those in the control group, OR = .756, SE = .069, p = .002. Control and intervention group DNR rates were 23.97% and 19.24%. This is equivalent to 1 in 5 non-responders changing their behaviour because of the redesigned letter., Conclusions: The redesigned letter increased patient compliance with the validation process. The redesign has subsequently been adopted by public hospitals in Ireland., (Copyright © 2024 The Authors. Published by Elsevier Ltd.. All rights reserved.)

Background: As postextubation dysphagia (PED) is correlated with pneumonia, feeding-tube placement, and in-hospital mortality, early identification is paramount. Endotracheal intubation duration of ≥48 h is independently predictive for PED. Therefore, a blanket intensive care unit (ICU) referral protocol was implemented to conduct PED assessment of patients intubated for ≥48 h., Objectives: The objective of this study was to review outcomes of an established blanket referral model for PED assessment in patients intubated for ≥48 h. Outcomes of the model were examined over a 2-year period (June 2015-June 2017) for (i) numbers and clinical characteristics of patients meeting criteria and referred for speech pathology (SP) assessment; (ii) frequency identified with PED on clinical swallow examination; (iii) severity and duration of PED; and (iv) SP management within the ICU., Results: There was 96% adherence to the pathway with 108 participants (68% male) assessed. Median intubation duration was 142 h (mode = 61; interquartile range [IQR] = 131.75), and median ICU admission was 9 days (mode = 8; IQR = 6.75). SP referral occurred at a median of 19.5 h (mode = 4; IQR = 18.75) after extubation. Dysphagia assessment occurred at a median of 22 h (mode = 4; IQR = 19), with 34% assessed on the same day and 77% within 24 h of extubation. PED was observed in 89%, with 26% exhibiting profound PED. Dysphagia recovery occurred at a median of 7 days (mode = 2; IQR = 11). Dysphagia severity was associated with duration to swallow recovery (p = 0.001). A median of two occasions of service and 90 min clinical time was spent by the speech pathologist in the ICU., Conclusion: The blanket referral model enabled timely triage and assessment of dysphagia in a patient cohort at high risk of PED in our facility., Competing Interests: Conflict of interest The authors have no financial or non-financial disclosures to declare in the conduct of this study or preparation of this manuscript., (Crown Copyright © 2023. Published by Elsevier Ltd. All rights reserved.)

Introduction: The Active Kids voucher is a universal, state-wide voucher program, provided by the New South Wales (NSW) Government, Office of Sport. All school-aged children in NSW are eligible to receive a voucher to reduce registration costs of structured physical activity programs. This study explores reasons behind lower uptake among children who are overweight or obese, from cultural and linguistically diverse families and those living in low socio-economic areas., Methods: Participants were recruited through a convenience sample of parent/carers who participated in the NSW Health Go4Fun program. Qualitative data were collected using focus groups. The Framework method was adapted for the analysis, taking an interpretive phenomenological approach., Results: Study participants (n = 54) were all parents of children who were overweight or obese from both low and high socio-economic status (SES). Most reported speaking a primary language other than English at home (65%). Parents were mostly aware of the Active Kids program (91%) and reported that the voucher had a positive impact on their children's participation in structured physical activity. A range of socio-ecological factors, in addition to activity cost, influenced whether parents were able to use an Active Kids voucher and participate in structured physical activity., Conclusions: The Active Kids voucher does not alleviate all barriers, particularly for families living in low socio-economic areas. Engagement of this population in structured physical activities using the Active Kids vouchers could be strengthened through the implementation of effective interventions which comprehensively address the remaining barriers, such as access and flexibility of programs with local stakeholders and activity providers., (© 2021 Australian Health Promotion Association.)

Objective: To externally validate the CIPHER (Collaborative Integrated Pregnancy High-Dependency Estimate of Risk) prognostic model for pregnant and postpartum women admitted to the intensive care unit., Methods: A retrospective and a prospective validation study were conducted at two reference centers in Brazil. A composite outcome was defined as maternal death or need for prolonged organ support (more than 7 days) or acute lifesaving intervention. To evaluate the performance of the CIPHER model, a receiver operating characteristic curve was used and score calibration was assessed by the Hosmer-Lemeshow test. We conducted a descriptive analysis comparing the results of the current study with the results of the model development study., Results: A total of 590 women were included. The composite outcome was observed in 90 (15.2%) women. Of these, 13 (2.2%) were maternal deaths and 77 (13%) required one or more component of organ support or lifesaving intervention. The CIPHER model's area under the curve (AOC) did not show significant predictive ability (AOC 0.53, 95% CI 0.46-0.60), and consequently its calibration was poor (Hosmer-Lemeshow test P<.05)., Conclusion: The CIPHER model for prediction of mortality and need for interventions in critically ill obstetric patients did not perform well in our Brazilian population. Different predictors of morbidity and mortality may need to be used for patients receiving care in public hospitals in low- and middle-income countries., Competing Interests: Financial Disclosure The authors did not report any potential conflicts of interest., (Copyright © 2021 The Author(s). Published by Wolters Kluwer Health, Inc.)

This chapter examines leadership and social class in the context of fraternities and sororities. With no extensive research in this area, recommendations provided may help educators create a plan to address the intersection of social class, leadership education, and membership in a fraternity or sorority., (© 2021 Wiley Periodicals, LLC.)

Issue addressed Anecdotal evidence from teachers in Western Sydney Local Health District (WSLHD) indicated that many primary school children are regularly unable to participate in the Crunch&Sip ® (C&S) program (breaks during class time to eat fruit and/or vegetables and drink water) as they do not bring produce from home. Actual reach of the program may therefore be currently overestimated, and inequitable. This study examined the feasibility, acceptability and efficacy of providing school children supplementary, fresh free produce in supporting equitable participation in C&S. Methods Free fruit and vegetables were provided for 10 weeks to four schools in a socioeconomically-disadvantaged area in Western Sydney. WSLHD sourced the produce at a discounted rate and storage and distribution was arranged in partnership with industry. Schools determined methods of allocation to children who did not have fruit or vegetables for the C&S break. Pre- and late-intervention (Week 9) classroom surveys provided quantitative data of intervention efficacy. Qualitative methods were used with key school persons to explore barriers and enablers to implementation. Results Participation of children in C&S increased significantly from 46.7% pre-intervention to 92.0% in Week 9. The proportion of children bringing fruit or vegetables from home also increased significantly, from 46.7% to 54.0%. Schools perceived the supplementary strategy to be highly feasible and acceptable. Conclusion Expansion of this equity strategy warrants consideration, although issues of sustainability would need to be addressed. The criteria for 'full implementation' should include high proportional participation by students in participating classes. So what? Establishing a system by which schools in disadvantaged areas can supplement their C&S program would effectively increase access to fruit and vegetables among those children most at need.

Objectives: To evaluate the performance of the Modified Early Obstetric Warning System (MEOWS) to predict maternal ICU admission in an obstetric population., Design: Case-control study., Setting: Two maternity units in Vancouver, Canada, one with ICU facilities, between January 1, 2000, and December 31, 2011., Patients: Pregnant or recently delivered (≤6 weeks) women admitted to the hospital for >24 hours. Three control patients were randomly selected per case and matched for year of admission., Measurements and Main Results: Retrospective, observational, case-control validation study investigating the physiologic predictors of admission in the 24-hour period preceding either ICU admission >24 hours (cases) or following admission (control patients). Model performance was assessed based on sensitivity, specificity, and predictive values. Forty-six women were admitted to the ICU for >24 hours (0.51/1000 deliveries); the study included 138 randomly selected control patients. There were no maternal deaths in the cohort. MEOWS had high sensitivity (0.96) but low specificity (0.54) for ICU admission >24 hours, whereas ≥1 one red trigger maintained sensitivity (0.96) and improved specificity (0.73)., Conclusion: Altering MEOWS trigger parameters may improve the accuracy of MEOWS in predicting ICU admission. Formal modelling of a MEOWS scoring system is required to support evidence-based care., (Copyright © 2017 The Authors. Published by Elsevier Inc. All rights reserved.)

Objective: To assess the performance of the Acute Physiology and Chronic Health Evaluation II (APACHE II) mortality prediction model in pregnant and recently pregnant women receiving critical care in low-, middle-, and high-income countries during the study period (1985-2015), using a structured literature review., Data Sources: Ovid MEDLINE, Embase, Web of Science, and Evidence-Based Medicine Reviews, searched for articles published between 1985 and 2015., Study Selection: Twenty-five studies (24 publications), of which two were prospective, were included in the analyses. Ten studies were from high-income countries (HICs), and 15 were from low- and middle-income countries (LMICs). Median study duration and size were six years and 124 women, respectively., Data Synthesis: ICU admission complicates 0.48% of deliveries, and pregnant and recently pregnant women account for 1.49% of ICU admissions. One quarter were admitted while pregnant, three quarters of these for an obstetric indication and for a median of three days. The median APACHE II score was 10.9, with a median APACHE II-predicted mortality of 16.6%. Observed mortality was 4.6%, and the median standardized mortality ratio was 0.36 (interquartile range 0.23 to 0.73). The standardized mortality ratio was < 0.9 in 24 of 25 studies. Women in HICs were more frequently admitted with a medical comorbidity but were less likely to die than were women in LMICs., Conclusion: The APACHE II score consistently overestimates mortality risks for pregnant and recently pregnant women receiving critical care, whether they reside in HICs or LMICs. There is a need for a pregnancy-specific outcome prediction model for these women., (Copyright © 2016 The Authors. Published by Elsevier Inc. All rights reserved.)

Purpose: Progression-free survival (PFS) in metastatic castration-resistant prostate cancer (mCRPC) trials has been inconsistently defined and poorly associated with overall survival (OS). A reproducible quantitative definition of radiographic PFS (rPFS) was tested for association with a coprimary end point of OS in a randomized trial of abiraterone in patients with mCRPC., Patients and Methods: rPFS was defined as ≥ two new lesions on an 8-week bone scan plus two additional lesions on a confirmatory scan, ≥ two new confirmed lesions on any scan ≥ 12 weeks after random assignment, and/or progression in nodes or viscera on cross-sectional imaging, or death. rPFS was assessed by independent review at 15% of deaths and by investigator review at 15% and 40% of deaths. rPFS and OS association was evaluated by Spearman's correlation., Results: A total of 1,088 patients were randomly assigned to abiraterone plus prednisone or prednisone alone. At first interim analysis, the hazard ratio (HR) by independent review was 0.43 (95% CI, 0.35 to 0.52; P < .001; abiraterone plus prednisone: median rPFS, not estimable; prednisone: median rPFS, 8.3 months). Similar HRs were obtained by investigator review at the first two interim analyses (HR, 0.49; 95% CI, 0.41 to 0.60; P < .001 and HR, 0.53; 95% CI, 0.45 to 0.62; P < .001, respectively), validating the imaging data assay used. Spearman's correlation coefficient between rPFS and OS was 0.72., Conclusion: rPFS was highly consistent and highly associated with OS, providing initial prospective evidence on further developing rPFS as an intermediate end point in mCRPC trials., (© 2015 by American Society of Clinical Oncology.)

Objective: We performed a randomized, controlled trial comparing low-dose ultrasound-guided axillary block with general anesthesia evaluating anesthetic and perioperative analgesic outcomes., Methods: Patients were randomized to either ultrasound-guided axillary block or general anesthesia. Ultrasound-guided axillary block was performed using a needle-out-of-plane approach. Up to 5 mL of local anesthetic injectate (equal parts 2% lidocaine with 1:200,000 epinephrine and 0.5% bupivacaine with 7.5 mg/mL clonidine) was injected after identifying the median, ulnar, radial, and musculocutaneous nerves. A maximum of 20 mL local anesthetic injectate was used. General anesthesia was standardized to include induction with fentanyl and propofol, maintenance with sevoflurane in an oxygen/nitrous oxide mixture. Pain scores were measured in the recovery room and at 2, 6, 24, 48 h, and 7 days. Ability to bypass the recovery room and time to achieve hospital discharge criteria were also assessed., Results: All ultrasound-guided axillary block patients achieved satisfactory anesthesia. The ultrasound-guided axillary block group had lower visual analog scale pain scores in the recovery room (0.3 [1.3] vs 55.8 [36.5], P < 0.001), and visual rating scale pain scores at 2 h (0.3 [1.3] vs 45 [29.6], P < 0.001), and at 6 h (1.1 [2.7] vs 4 [2.8], P < 0.01). All ultrasound-guided axillary block patients bypassed the recovery room and attained earlier hospital discharge criteria (30 min vs 120 min 30/240 P < 0.0001 median [range])., Conclusions: Ultrasound-guided axillary brachial plexus block with 20 mL local anesthetic mixture provided satisfactory anesthesia and superior analgesia after upper limb trauma surgery when compared with general anesthesia.

Age-associated changes in power and maximal oxygen consumption (VO2max) were studied in a cross section of endurance trained cyclists. Subjects (n = 56) performed incremental cycling exercise, during which capillary blood lactate [La(-)] was measured. Power output increased by 30 Watts during each 5 minutes stage, with initial power output based on individual ability. When [La(-)] was >4.5 mmol·L(-1), subjects were given a 10 min recovery at a power output approximately 50% below estimated power at [La(-)]4mmol. Subjects then performed an incremental test (1 minute stages) to VO2max. Decline in VO2max was 0.65 ml·kg(-1)·min(-1)·year(-1) (r = -0.72, p < 0.01) for males, and 0.39 ml·kg(-1)·min(-1)·year(-1) (r = -0.54, p < 0.05) for females. Power at VO2max decreased by 0.048 W kg(-1)·year(-1) (r = -0.72, p < 0.01) in males. Power at [La(-)]4mmol decreased by 0.044 W kg(-1)·year(-1) (r = -0.76, p < 0.01) in males, and by 0.019 W kg(-1)·year(-1) (r = -0.53, p < 0.05) in females. Heart rate at VO2max (HRmax) showed a weaker correlation with age in males (r = -0.36, p < 0.05). The age-associated changes in maximum aerobic power and sub-maximal power were gender- specific, thus suggesting different age-related effects on the systems which support exercise in males and females. Key pointsVO2max decreased with age by 0.65 ml·kg(-1)·min(-1)·year(-1) in male, and by 0.39 ml·kg(-1)·min(-1)·year(-1) in female endurance trained cyclists.Power at VO2max decreased with age by 0.048 Watts·kg(-1)·year(-1) in male endurance trained cyclists.Sub-maximal power at a blood lactate concentration of 4mmol·L(-1) decreased by 0.044 Watts·kg(-1)·year(-1) in male, and by 0.019 Watts·kg(-1)·year(-1) in female endurance trained cyclists.