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Background Diabetic ketoacidosis (DKA) is a life-threatening emergency that can result from delayed diagnosis of type 1 diabetes mellitus (T1DM). Three-quarters of Australian children with a new diagnosis of T1DM visit their general practitioner (GP) the week prior to developing DKA, with similar trends observed internationally.Objective To summarise interventions in general practice to reduce diagnostic delay in paediatric T1DM and to evaluate their effectiveness.Methods Six databases (Ovid, Web of Science, CINAHL, Evidence-Based Medicine Reviews, Google Scholar and EMBASE) were searched. Any English language, less than 20 years study involving interventions targeting GPs specifically in the prevention of paediatric DKA, was included. Primary outcomes were (a) the number of children presenting to the hospital in DKA following diagnostic delay after a GP visit and (b) DKA rate. The secondary outcome was changes in GPs’ behaviour regarding timeliness of referrals. Two reviewers completed title, abstract and full-text review, with conflicts resolved by a third reviewer. ROBINS-I risk of bias was used for appraisal. High heterogeneity among studies rendered meta-analysis unsuitable. Structured tabulation of results was completed for analysis. The date of last search was 2 July 2023.Results Eight studies were included (three conference abstracts and five peer-reviewed publications.) We identified six intervention types attempting to facilitate timely diagnosis of type 1 diabetes in the general practice setting: direct communication, indirect communication, education sessions, electronic clinical decision support tools, updated referral pathways and provision of glucose and/or ketone monitors. Due to the limited number of peer-reviewed studies identified by this review, we were not able to identify the extent to which these interventions were successful.Conclusion Paucity of information regarding study methodology and high heterogeneity among study design and outcome measures limited our conclusions regarding acceptability, effectiveness and reach. Future studies should include GPs in their design and consider the sustainability of interventions in the long term.PROSPERO registration number CRD42023412504.

BackgroundUp to half of the children with new-onset type 1 diabetes present to the hospital with diabetic ketoacidosis, a life-threatening condition that can develop because of diagnostic delay. Three-quarters of Australian children visit their general practitioner (GP) the week before presenting to the hospital with diabetic ketoacidosis. Our prototype, DIRECT-T1DM (Decision-Support for Integrated, Real-Time Evaluation and Clinical Treatment of Type 1 Diabetes Mellitus), is an electronic clinical decision support tool that promotes immediate point-of-care testing in general practice to confirm the suspicion of diabetes. This avoids laboratory testing, which has been documented internationally as a cause of diagnostic delay. ObjectiveIn this investigation, we aimed to pilot and assess the feasibility and acceptability of our prototype to GP end users. We also explored the challenges of diagnosing type 1 diabetes in the Australian general practice context. MethodsIn total, 4 GPs, a pediatric endocrinologist, and a PhD candidate were involved in conceptualizing the DIRECT-T1DM prototype, which was developed at the Department of General Practice and Primary Care at the University of Melbourne. Furthermore, 6 GPs were recruited via convenience sampling to evaluate the tool. The study involved 3 phases: a presimulation interview, simulated clinical scenarios, and a postsimulation interview. The interview guide was developed using the Consolidated Framework for Implementation Research (CFIR) as a guide. All phases of the study were video, audio, and screen recorded. Audio recordings were transcribed by the investigating team. Analysis was carried out using CFIR as the underlying framework. ResultsMajor themes were identified among three domains and 7 constructs of the CFIR: (1) outer setting—time pressure, difficulty in diagnosing pediatric type 1 diabetes, and secondary care considerations influenced GPs’ needs regarding DIRECT-T1DM; (2) inner setting—DIRECT-T1DM fits within existing workflows, it has a high relative priority due to its importance in patient safety, and GPs exhibited high tension for change; and (3) innovation—design recommendations included altering coloring to reflect urgency, font style and bolding, specific language, information and guidelines, and inclusion of patient information sheets. ConclusionsEnd-user acceptability of DIRECT-T1DM was high. This was largely due to its implications for patient safety and its “real-time” nature. DIRECT-T1DM may assist in appropriate management of children with new-onset diabetes, which is an uncommon event in general practice, through safety netting.

Background Early diagnosis of type 1 diabetes in children is critical to prevent deterioration to diabetic ketoacidosis (DKA), a state where the body’s insulin levels are critically low resulting in the use of fat for fuel and the accumulation of ketones. DKA is a life-threatening emergency where dehydration and cerebral oedema can quickly develop and lead to death. Despite treatment, DKA also has harmful impacts on cognition and brain development. Most children admitted to a hospital with DKA see their general practitioner in the week leading up to their admission. A delay in referral from general practice can result in delays in commencing lifesaving insulin therapy. Prior systematic reviews have explored publicity campaign interventions aimed at recognising type 1 diabetes earlier; however, no reviews have explored these interventions targeted at reducing the delay after presentation to the general practitioner. This systematic review aims to summarise interventions that target the diagnostic delay emerging from general practice and to evaluate their effectiveness in reducing DKA admissions.Methods Six databases (Ovid (MEDLINE), Web of Science, EMBASE, CINAHL, Evidence-Based Medicine Reviews (EBMR) and Google Scholar) will be searched to identify studies exploring interventions to reduce diagnostic delay in children with type 1 diabetes, and hence DKA, in general practice. The primary outcome will be the number of DKA admissions to a hospital following a delay in general practice. The secondary outcome will be the behaviour of general practitioners with respect to urgent referral of children with type 1 diabetes. Title, abstract and full-text screening for exclusion and inclusion of publications will be completed by two independent reviewers. Any risks of bias within individual studies will be assessed by two independent reviewers, using the Risk Of Bias In Non-Randomized Studies of Interventions tool. Our confidence in the overall body of evidence will be assessed using the Grading of Recommendations, Assessment, Development and Evaluation.Ethics and dissemination The systematic review will be disseminated via publication and potentially in conference presentations. Ethics is not required for a systematic review of secondary data.PROSPERO registration number CRD42023412504

Plain English Summary Patients and caregivers who have lived with a condition have an important and unique perspective researchers should consider. To this end, patients and caregivers have expanded their involvement in the design and conduct of clinical research, joining research teams and being engaged in the research process from start to finish. Researchers have reported on the positive impact that these “patient partners” or “patient advisors” have on research. But few papers report on the impact on the patient partners/advisors from being on a research team. Here we report the lived experiences of the 16 Patient Partners who served on the research team for a large study of 1200 African American/Black (AA/B) and Hispanic/Latinx (H/L) adults with asthma. These Patient Partners offered their input over 7 years, spanning from study design, study conduct, understanding results, to sharing results. To understand the Patient Partners’ experiences, we conducted interviews asking about their journey on the research team. Motivations and reasons they became Patient Partners Initial experiences with the research team If and how over time, they became comfortable and developed confidence If and how the research team made them feel valued and respected The personal and professional impact of being a Patient Partner Their advice to researchers and fellow patients considering including or joining as Patient Partners or advisors By reporting the perspectives of these 16 Patient Partners, we hope to support continued movement toward broader and better inclusion of patients and caregivers on research teams.

Background: Financial hardship is a social determinant of health but is rarely assessed by healthcare services. This study (1) investigated the feasibility and acceptability of asking caregivers about financial hardship during a routine clinical encounter, and (2) described associations between financial hardship and caregiver and child mental health. Methods: Design: Cross-sectional survey. Setting: Day Medical Unit of Australia's largest public paediatric hospital, 1 April-31 July 2021. Participants: Families with children aged 2–17 years with chronic medical conditions. Measures: Caregiver-reported: financial hardship (3 study-designed items dichotomised into any (yes) versus none (no)) and mental health (Depression Anxiety Stress Scales (DASS), with subscales classified as poor (moderate/severe/extremely severe) versus not (none/mild)). Caregivers and young people aged 11–17 years reported child mental health (Strengths and Difficulties Questionnaire (SDQ), categorised as normal/borderline/abnormal). Analysis: Feasibility and acceptability were assessed by response proportions. Chi square tests assessed associations between mental health and financial hardship. Results: 160/193 (83%) of caregivers and 50/79 (63%) of 11–17-year-olds consented and completed the surveys. 22% of families reported financial hardship and 24% of caregivers reported moderate-to-severe mental health on at least one DASS subscale. Abnormal mental health (SDQ) was common for children according to caregivers (40%) and young people themselves (43%). Financial hardship was associated with poorer mental health when reported by caregivers for themselves and their children, but not when reported by the young person (noting numbers were small). Discussion: Tertiary healthcare may offer a feasible setting for identifying and responding to common and adverse social conditions such as financial hardship and mental health.

Abstract Background Teaching and assessing clinical procedures requires a clear delineation of the individual steps required to successfully complete the procedure. For decades, human reliability analysis (HRA) has been used to identify the steps required to complete technical procedures in higher risk industries. However, the use of HRA is uncommon in healthcare. HRA has great potential supporting simulation-based education (SBE) in two ways: (1) to support training through the identification of the steps required to complete a clinical procedure; and (2) to support assessment by providing a framework for evaluating performance of a clinical procedure. The goal of this study was to use HRA to identify the steps (and the risk associated with each of these steps) required to complete a bronchoscope-assisted percutaneous dilatational tracheostomy (BPDT). BPDT is a potentially high-risk minimally invasive procedure used to facilitate tracheostomy placement at the bedside or in the operating theatre. Methods The subgoals, or steps, required to complete the BPDT procedure were identified using hierarchical task analysis. The Systematic Human Error Reduction and Prediction Approach (SHERPA) was then used to identify potential human errors at each subgoal, the level of risk and how these potential errors could be prevented. Results The BPDT procedure was broken down into 395 subgoals, of which 18% were determined to be of high-risk. The most commonly identified remediation strategies for reducing the risk of the procedure included: checklist implementation and audit, statutory and mandatory training modules, simulation training, consultant involvement in all procedures, and fostering a safety-focused hospital culture. Conclusion This study provides an approach for how to systematically identify the steps required to complete a clinical procedure for both training and assessment. An understanding of these steps is the foundation of SBE. HRA can identify ‘a correct way’ for teaching learners how to complete a technical procedure, and support teachers to give systematic and structured feedback on performance.

Background. Hospital-acquired blood stream infections are a common and serious complication in critically ill patients. Methods. A retrospective case series was undertaken investigating the incidence and causes of bacteraemia in an adult intensive care unit with a high proportion of postoperative cardiothoracic surgical and oncology patients. Results. 405 eligible patients were admitted to the intensive care unit over the course of nine months. 12 of these patients developed a unit-acquired blood stream infection. The average Acute Physiology And Chronic Health Evaluation II (APACHE II) score of patients who developed bacteraemia was greater than that of those who did not (19.8 versus 16.8, respectively). The risk of developing bacteraemia was associated with intubation and higher rates of invasive procedures. The mortality rate amongst the group of patients that developed bacteraemia was 33%; this is in contrast to the mortality rate in our unit as 27.2%. There was a higher proportion of Gram-negative bacteria isolated on blood cultures (9 out of 13 isolates) than in intensive care units reported in other studies. Conclusion. Critical-care patients are at risk of secondary bloodstream infection. This study highlights the importance of measures to reduce the risk of infection in the intensive-care setting, particularly in patients who have undergone invasive procedures.

This study tests an instructional model designed to empower students in an early childhood classroom as emerging digital storytellers. Educators can use digital storytelling to support students’ learning by encouraging them to organize and express their ideas and knowledge in an individual and meaningful way while developing voice and facility in child–computer interactions. This work also helps develop traditional communication skills, fosters collaboration, and strengthens emergent literacy practices. Students develop enhanced communication skills by learning to organize their ideas, ask questions, express opinions, and construct narratives as they interact with others and computers in the creation of digital stories. The “Emerging Digital Storytellers” instructional model focuses on social-emotional development and finding student voice through writing and digital content construction in the early childhood educational context.

This paper investigates the origin of the fixed positive oxide charge often experimentally observed in Metal Oxide Semiconductor (MOS) structures of SiO2 formed on cubic silicon carbide (3C-SiC). The electrical properties of MOS structures including either thermally grown SiO2 or deposited SiO2 by Plasma Enhanced Chemical Vapour Deposition (PECVD) on epitaxial 3C-SiC layers grown directly on Si are investigated. MOS structures with a range of oxide thickness values subjected to different thermal treatments were studied. It was found that both thermally grown and deposited SiO2 on 3C-SiC exhibit similar positive charge levels indicating that the charge originates from interface states at the 3C-SiC surface and not from the oxide. The nature of this surface charge in the SiO2/3C-SiC system is also discussed based on the current data and previously published results.

Introduction. Severe sepsis in humans may be related to an underlying profound immune suppressive state. We investigated the link between gene expression of immune regulatory cytokines and the range of illness severity in patients with infection and severe sepsis. Methods. A prospective observational study included 54 ICU patients with severe sepsis, 53 patients with infection without organ failure, and 20 healthy controls. Gene expression in peripheral blood mononuclear cells (PBMC) was measured using real-time polymerase chain reaction. Results. Infection differed from health by decreased expression of the IL2, and IL23 and greater expression of IL10 and IL27. Severe sepsis differed from infection by having decreased IL7, IL23, IFNγ, and TNFα gene expression. An algorithm utilising mRNA copy number for TNFα, IFNγ, IL7, IL10, and IL23 accurately distinguished sepsis from severe sepsis with a receiver operator characteristic value of 0.88. Gene expression was similar with gram-positive and gram-negative infection and was similar following medical and surgical severe sepsis. Severity of organ failure was associated with serum IL6 protein levels but not with any index of cytokine gene expression in PBMCs. Conclusions. Immune regulatory cytokine gene expression in PBMC provides a robust method of modelling patients’ response to infection.

Doing sensitive research presents particular problems over and above other social science research because of the nature of the issues being asked about and their potential impact on both the participant and the researcher. In some instances, the factors that engage the researcher in the project may also be of interest to advocates who are working for the benefit of the participants in the research. In the current instance, the researcher was interested in understanding the impact of "life without" the possibility of parole on the lives of women convicted of killing their abusers, as well as the impact of their imprisonment and clemency on their families. At the same time, a powerful advocacy group was devoted to gaining clemency for the women. The resulting clash between the goals and purposes of these two entities resulted in a significant impasse and unanticipated consequences for the research agenda as well as the researcher. Analysis of one specific research project and the problems resulting from the clash between researcher and advocates can contribute to the literature on sensitive research as well as on the clashes between advocacy and social science research.