Pilot Remote Clinical Communication Skill Session During COVID-19 Pandemic: Medical Education in New Normal

IntroductionClinical Communication teaching has relied heavily on face-to-face teaching using Patient Partners. The current situation with COVID-19 has led to lockdown, social isolation and travel difficulty. This leads to challenges in delivering this teaching. The study aim is to pilot a clinical communication teaching session remotely, using a virtual learning environment and video conferencing. This study evaluates the pilot about achieving learning outcomes on Musculo Skeleton disease and experience of student’s and patient partner.MethodsMixed qualitative and quantitative data are obtained through an online survey. The thematic framework is used to analyse the qualitative data and the descriptive statistics are used to evaluate the quantitative responses. Results The study provided satisfaction on proceeding this new pilot remote communication session to the routine medical curriculum, with 100% recommendation by the students. The majority of students had transformed their theoretical knowledge in the Musculo Skeleton disease system to consult with patient partners. The study also finds some gaps such as delays due to internet and device faults, limited time to build rapport with patients, nonverbal expressions are not being conveyed via the screen and difficulties in adapting to new remote sessions in short transition.ConclusionLooking into the future of new normal. Remote clinical communication session worked well during the pilot study. New innovatory methods in delivering remote teaching and more studies on different diseases topics should be implemented to analyse the sustainability and validity of the remote session for continuous delivery in medical education.

Assessing the generalisability of a multicentre qualitative dementia research: the experience and challenges faced by the MinD project in Europe

Background: Generalisation of findings is an important aspect of research and essential for evidence-based practice. While generalisation is common in quantitative research, there is a lack of generalisability in qualitative research. This paper presents the experience and challenges faced by the Designing for People with Dementia (MinD) project in meeting the requirements to strengthen the generalisation of findings on the lived experience of people living with dementia and their engagement to co-create designs to empower their everyday living. Methods: Polit and Beck (2010)’s strategies to generalise qualitative findings were applied: (1) replication in sampling; (2) replication of studies; (3) meta-synthesis of findings; (4) reflexivity and conceptualization; (5) immersion with the data; and (6) thick description. Results: While it is possible to increase the generabilisabilty of qualitative evidence through the replication of the sampling to attain a large, heterogeneous sample in different and multiple contexts and environments; implementation of sound and robust research; conducting in-depth analysis and interpretation collaboratively for emergent themes; and meeting the thick description requirement, there are challenges that the project team faced in implementing some of the Polit and Beck’s strategies because of the condition, namely dementia, that our participants are having. Other challenges faced were: the language and cultural diversity in the team; diverse work and organisational procedures; and the inter-disciplinary differences relating to the methods of enquiry, approaches and techniques to conduct research. These challenges will need to be identified and addressed at the start of the project with a strong leadership to ensure a seamless journey to complete the project successfully. Trust between the researchers and participants, and time to build this trust are critical to recruitment and participation in the study; these factors are of utmost important in research involving participants with condition such as dementia.

Field Study on Deformation and Stress Characteristics of Large Open Caisson during Excavation in Deep Marine Soft Clay

Oujiang River North Estuary Bridge in Wenzhou is the world’s first double-deck suspension bridge under construction with three-tower and four-span. It is the first time to build large open caisson foundation in the deep marine soft clay in estuary with strong tide, extending the application scope of caisson. To study the deformation and stress characteristics of large open caisson during excavation and ensure the safety of anchorage excavation, a large number of sensors are arranged in the caisson. By analyzing the change of tip resistance, lateral soil pressure, and posture parameters during caisson excavation, the stress characteristics and deformation of caisson are described. The result shows the following. (1) Because of the thixotropy of soft clay, the reaction force of partition wall in deep soft soil area of caisson is similar to that of blade foot, and the reaction force of blade foot can be effectively reduced through the layering construction of caisson. (2) The height of caisson construction and the sand-bearing stratum will obviously affect the plane torsion angle of caisson. When the caisson enters the sand-bearing stratum, the lateral soil pressure increases significantly, which leads to the increase of the plane torsion angle. (3) The inclination and central deviation of caisson are sensitive to the caisson construction and stratum property. It can be found that the lateral soil pressure, plane torsion angle, inclination, and central deviation of caisson are sensitive to stratum property, and inhomogeneity of stratum easily leads to inclination of caisson. Based on the field monitoring data, the stress characteristics and geometric posture of caisson during sinking are studied, which provide technical guidance for scheme design and subsidence prediction analysis of caisson in deep marine soft clay. It can provide a good opportunity to study the behaviors of large caisson foundation constructed in deep marine soft clay and has great significance and reference value for construction optimization of anchorage structure.

Clonal Evolution Characteristics and Reduced Dimension Prognostic Model for Non-Metastatic Metachronous Bilateral Breast Cancer

Background:How to evaluate the prognosis and develop overall treatment strategies of metachronous bilateral breast cancer (MBBC) remains confused in clinical practice.Methods:Data from Surveillance, Epidemiology, and End Results (SEER) database and the first hospital of Jilin university were analyzed for breast cancer-specific cumulative mortality (BCCM) by competing risk model. Whole-exome sequencing was applied for 10 lesions acquired at spatial-temporal distinct regions from 5 patients to reconstruct clonal evolutionary characteristics of MBBC. Dimensional reduction (DR) cumulative incidence function (CIF) curves of MBBC features were established on different point in diagnostic interval time, to build a novel DR nomogram.Results:Significant heterogeneity in genome and clinical features of MBBC was widespread. The mutational diversity of contralateral BC (CBC) was significantly higher than that in primary BC (PBC), and the most effective prognostic MATH ratio was significantly correlated with interval time (R2=0.85, p < .05). In SEER cohort study (n=13304), the interval time was not only significantly affected the BCCM by multivariate analysis (p < .000), but determined the weight of clinical features (T/N stage, grade and ER status) on PBC and CBC in prognostic evaluation. Thus, clinical parameters after DR based on interval time were incorporated into the nomogram for prognostic predicting BCCM. Concordance index was 0.773 (95% CI, 0.769 to 0.776) in training cohort (n=8869), and 0.819 (95% CI, 0.813 to 0.826) in validation cohort (n=4435).Conclusions:Bilateral heterogeneous characteristics and interval time were determinant prognostic factors of MBBC. The DR nomogram may help clinical prognostic evaluation.

A framework for modelling cash flow lags

Traditional models of irreversible investment problems assume that the investment starts generating cash flows immediately, i.e., at the same time as the investment is undertaken. Real-world investment situations are characterized by time-to-build or investment lags, which means that there is a time difference between when the investment is made and when the investment starts generating cash flows. We combine two existing models of investment lags to obtain a flexible, yet simple, way of modelling and analyzing the effects of investment lags. Both traditional models, and models that incorporate the effects of time-to-build, typically assume that the expected future cash flows generated by an investment are represented by a single cash flow that reflects the size of the market value of an investment. To reflect real-world cases where investments generate cash flows in several time periods, we present a framework in which cash flows are explicitly allowed to be spread out in time. Our model can be used to incorporate cases where an investment is partially sold in different time periods. Using an irreversible optimal investment timing problem case study, we show how our framework makes it possible to easily compare the effect of different cash flow timings. In this case, the value and the timing of the investment depend on a constant that in a natural way can be decomposed into three parts, thereby showing the influence of the value and timing from the respective parts of the framework.

Assessing the generalisability of a multicentre qualitative dementia research: the experience and challenges faced by the MinD project in Europe

Background: Generalisation of findings is an important aspect of research and essential for evidence-based practice. While generalisation is common in quantitative research, there is a lack of generalisability in qualitative research. This paper presents the experience and challenges faced by the Designing for People with Dementia (MinD) project in meeting the requirements to strengthen the generalisation of findings on the lived experience of people living with dementia and their engagement to co-create designs to empower their everyday living. Methods: Polit and Beck (2010)’s strategies to generalise qualitative findings were applied: (1) replication in sampling; (2) replication of studies; (3) meta-synthesis of findings; (4) reflexivity and conceptualization; (5) immersion with the data; and (6) thick description. Results: While it is possible to increase the generabilisabilty of qualitative evidence through the replication of the sampling to attain a large, heterogeneous sample in different and multiple contexts and environments; implementation of sound and robust research; conducting in-depth analysis and interpretation collaboratively for emergent themes; and meeting the thick description requirement, there are challenges that the project team faced in implementing some of the Polit and Beck’s strategies because of the condition, namely dementia, that our participants are having. Other challenges faced were: the language and cultural diversity in the team; diverse work and organisational procedures; and the inter-disciplinary differences relating to the methods of enquiry, approaches and techniques to conduct research. These challenges will need to be identified and addressed at the start of the project with a strong leadership to ensure a seamless journey to complete the project successfully. Trust between the researchers and participants, and time to build this trust are critical to recruitment and participation in the study; these factors are of utmost important in research involving participants with condition such as dementia.

‘Health in All Policies’—A Key Driver for Health and Well-Being in a Post-COVID-19 Pandemic World

Policy in all sectors affects health, through multiple pathways and determinants. Health in all policies (HiAP) is an approach that seeks to identify and influence the health and equity impacts of policy decisions, to enhance health benefits and avoid harm. This usually involves the use of health impact assessment or health lens analysis. There is growing international experience in these approaches, and some countries have cross-sectoral governance structures that prioritize the assessment of the policies that are most likely to affect health. The fundamental elements of HiAP are inter-sectoral collaboration, policy influence, and holistic consideration of the range of health determinants affected by a policy area or proposal. HiAP requires public health professionals to invest time to build partnerships and engage meaningfully with the sectors affecting the social determinants of health and health equity. With commitment, political will and tools such as the health impact assessment, it provides a powerful approach to integrated policymaking that promotes health, well-being, and equity. The COVID-19 pandemic has raised the profile of public health and highlighted the links between health and other policy areas. This paper describes the rationale for, and principles underpinning, HiAP mechanisms, including HIA, experiences, challenges and opportunities for the future.

Exploration of a quality improvement process to standardised preoperative tests for a surgical procedure to reduce waste

BackgroundPreoperative tests are done to determine a patient’s fitness for anaesthesia and surgery.Local problemAlthough routine tests before surgery in the absence of specific clinical indications are not recommended, we observed high volumes of routine preoperative tests were performed in our institution. We describe a process to implement a standardised preoperative investigational approach to reduce unnecessary testing before surgeries.MethodsA series of six Plan-Do-Study-Act (PDSA) cycles was conducted for root cause analysis and process mapping, development of standardised tool (GRID), collection of baseline data, education and feedback, pilot testing and implementation and uptake of GRID.Root cause analysis revealed a lack of awareness of guidelines and a lack of a standardised tool to guide preoperative testing. We undertook a pilot quality improvement project to reduce unnecessary testing before knee and hip arthroplasty by developing and implementing a standardised tool (GRID) and engaging all stakeholders.InterventionsA clinical development team (CDT) was formed, including all the stakeholders. Our CDT focused on a continuous rapid cycle improvement strategy.ResultsAfter implementation of the tool in a subgroup of patients undergoing elective hip or knee arthroplasty, unnecessary coagulation tests (activated partial thromboplastin time and the international normalised ratio), electrolyte/renal panel tests and electrocardiograms were reduced by 81% (91%–17%), 81% (41%–7%) and 68% (35%–11%), respectively. No surgery was delayed or cancelled due to tests not performed before surgery.ConclusionsA standardised preoperative investigational approach based on patients’ medical conditions rather than routine testing can reduce unnecessary tests before surgery. Further, implementing guidelines is more complex than developing guidelines. Hence, continuous PDSA cycles are essential to evaluate the processes in a quality improvement project. It can take time to build teams and have shared goals; however, once this is achieved, the success of a quality improvement project is certain.