Understanding clinical implementation coordinators' experiences in deploying evidence-based interventions.

PURPOSE: The fluoroquinolone restriction for the prevention of Clostridioides difficile infection (FIRST) trial is a multisite clinical study in which sites carry out a preauthorization process via electronic health record-based best-practice alert (BPA) to optimize the use of fluoroquinolone antibiotics in acute care settings. Our research team worked closely with clinical implementation coordinators to facilitate the dissemination and implementation of this evidence-based intervention. Clinical implementation coordinators within the antibiotic stewardship team (AST) played a pivotal role in the implementation process; however, considerable research is needed to further understand their role. In this study, we aimed to (1) describe the roles and responsibilities of clinical implementation coordinators within ASTs and (2) identify facilitators and barriers coordinators experienced within the implementation process. METHODS: We conducted a directed content analysis of semistructured interviews, implementation diaries, and check-in meetings utilizing the conceptual framework of middle managers' roles in innovation implementation in healthcare from Urquhart et al. RESULTS: Clinical implementation coordinators performed a variety of roles vital to the implementation's success, including gathering and compiling information for BPA design, preparing staff, organizing meetings, connecting relevant stakeholders, evaluating clinical efficacy, and participating in the innovation as clinicians. Coordinators identified organizational staffing models and COVID-19 interruptions as the main barriers. Facilitators included AST empowerment, positive relationships with staff and oversight/governance committees, and using diverse implementation strategies. CONCLUSION: When implementing healthcare innovations, clinical implementation coordinators facilitated the implementation process through their roles and responsibilities and acted as strategic partners in improving the adoption and sustainability of a fluoroquinolone preauthorization protocol.

Investigating Pathways to Minimize Sensor Power Usage for the Internet of Remote Things.

The Internet of Remote Things (IoRT) offers an exciting landscape for the development and deployment of remote wireless sensing nodes (WSNs) which can gather useful environmental data. Low Power Wide Area Networks (LPWANs) provide an ideal network topology for enabling the IoRT, but due to the remote location of these WSNs, the power and energy requirements for such systems must be accurately determined before deployment, as devices will be running on limited energy resources, such as long-life batteries or energy harvesting. Various sensor modules that are available on the consumer market are suitable for these applications; however, the exact power requirements and characteristics of the sensor are often not stated in datasheets, nor verified experimentally. This study details an experimental procedure where the energy requirements are measured for various sensor modules that are available for Arduino and other microcontroller units (MCUs). First, the static power consumption of continually powered sensors was measured. The impact of sensor warm-up time, associated with powering on the sensor and waiting for reliable measurements, is also explored. Finally, the opportunity to reduce power for sensors which have multiple outputs was investigated to see if there is any significant reduction in power consumption when obtaining readings from fewer outputs than all that are available. It was found that, generally, CO2 and soil moisture sensors have a large power requirement when compared with temperature, humidity and pressure sensors. Limiting multiple sensor outputs was shown not to reduce power consumption. The warm-up time for analog sensors and digital sensors was generally negligible and in the order of 10-50 ms. However, one CO2 sensor had a large overhead warm-up time of several seconds which added a significant energy burden. It was found that more, or as much, power could be consumed during warm-up as during the actual measurement phase. Finally, this study found disparity between power consumption values in datasheets and experimental measurements, which could have significant consequences in terms of battery life in the field.

Carbon Dioxide Monitoring inside an Australian Brewery Using an Internet-of-Things Sensor Network.

Maintaining a high standard of indoor air quality (IAQ) is vital to ensuring good human health. The concentration of CO2 in air is a good proxy for IAQ, while high levels of CO2 have been shown to cause cognitive or physiological impairment. Work environments that generate CO2 as an inherent part of their business present a unique and significant risk in terms of poor IAQ. Craft breweries generate CO2 and, unlike larger breweries, often lack the technology to capture and re-use the fermentation CO2 for beer carbonation. The purpose of this study is to demonstrate that the venting of fermentation CO2 and the unintentional venting of CO2 during the filling of CO2 storage tanks can cause the indoor CO2 levels to rise significantly. This is shown by monitoring CO2 levels inside an Australian craft brewery using a newly developed system containing three Internet of Things (IoT) sensor nodes positioned strategically in different sections of the brewery. The maximum CO2 level recorded was in excess of 18,000 ppm, with the maximum time period levels exceeding 1000 and 10,000 ppm being equivalent to 425 and 26 min, respectively. The identification of differences in measured CO2 at different times and locations throughout the brewery reveals that a single hard-wired CO2 sensor may be inadequate to support IAQ monitoring. For this purpose, a network of portable or wearable CO2 sensor nodes may be most suitable. The battery life of the sensors is a key consideration, and the current sensor battery life is too short. Low-power sensors and communication protocols are recommended for this task.

A population-based study on the epidemiology of firearm-related injury in Nova Scotia.

OBJECTIVE: Firearm-related trauma is a significant cause of preventable mortality. In 2020, Nova Scotia experienced the largest mass shooting in Canadian history. The objective of this study was to describe the epidemiology of firearm-related injury and death in Nova Scotia and to assess for factors associated with mortality. METHODS: A retrospective observational study of all major trauma patients in Nova Scotia who sustained firearm-related injuries between 2001 and 2020 was conducted. Data was collected from the Nova Scotia Trauma Registry and the Nova Scotia Medical Examiner Service. Injury rates were evaluated over time, by age/sex, and by intent (assault/homicide, self-harm, other), and were mapped by municipality. Characteristics of survivors and non-survivors were compared using t-tests and chi-square analysis. A multivariate logistic regression model was created to assess for predictors of mortality. RESULTS: A total of 776 firearm-related injuries occurred over the 19-year study period, for an overall age- and sex-adjusted firearm injury rate of 4.44 per 100,000 population. Patients ranged in age from 6 to 92 years (mean 45.0±19.2 years) and most were male (95.6%; 742/776). Injuries were predominantly self-inflicted (65%; 504/776). The majority of patients died from their injuries (72%; 558/776); 64% (497/776) died at the scene. The overall age- and sex-adjusted firearm mortality rate was 3.18 per 100,000. Most non-survivors had injuries that were self-inflicted (83.2%; 464/558). Increasing age (OR 1.02, 95% CI 1.00-1.04) and increasing Injury Severity Score (OR 1.11, 95% CI 1.07-1.15) were associated with greater likelihood of mortality. Activation of the trauma team was associated with survival (OR 0.04, 95% CI 0.02-0.10). CONCLUSION: Trauma patients with firearm-related injuries were predominantly male and most injuries were self-inflicted among middle-aged to older patients. Younger patients tended to be victims of homicide/assault and were more likely to survive their injuries.

Design optimization of a magnesium-based metal hydride hydrogen energy storage system.

Metal hydrides (MH) are known as one of the most suitable material groups for hydrogen energy storage because of their large hydrogen storage capacity, low operating pressure, and high safety. However, their slow hydrogen absorption kinetics significantly decreases storage performance. Faster heat removal from MH storage can play an essential role to enhance its hydrogen absorption rate, resulting in better storage performance. In this regard, the present study aims to improve heat transfer performance to positively impact the hydrogen absorption rate of MH storage systems. A novel semi-cylindrical coil is first designed and optimized for hydrogen storage and embedded as an internal heat exchanger with air as the heat transfer fluid (HTF). The effect of novel heat exchanger configurations is analyzed and compared with normal helical coil geometry, based on various pitch sizes. Furthermore, the operating parameters of MH storage and HTF are numerically investigated to obtain optimal values. ANSYS Fluent 2020 R2 is utilized for the numerical simulations. Results from this study demonstrate that MH storage performance is significantly improved by using a semi-cylindrical coil heat exchanger (SCHE). The hydrogen absorption duration reduces by 59% compared to a normal helical coil heat exchanger. The lowest coil pitch from SCHE leads to a 61% reduction of the absorption time. In terms of operating parameters for the MH storage with SCHE, all selected parameters provide a major improvement in the hydrogen absorption process, especially the inlet temperature of the HTF.

Internet-of-Things-Enabled Smart Bed Rail for Application in Hospital Beds.

This article presents an atypical offline based LoRaWAN application for use in hospital settings, where the ability to maintain network connectivity during internet connection disruption is paramount. A prototype bed rail is demonstrated, providing advanced functionality compared to traditional bed rails. The manufactured prototype provides data to a nurses station reliably and operates under battery backup. The power consumption of the system under different transmission intervals was tested, allowing appropriate battery sizing for different applications to be specified accurately. It is expected that a single LoRaWAN gateway will be able to cover bed rails across an entire modern hospital, allowing minimal infrastructure cost to implement the device or application in a rapidly deployed field hospital.

The effect of legislation on firearm-related deaths in Canada: a systematic review.

BACKGROUND: Firearm misuse is common in cases of homicide, suicide and unintentional injury; this is a major public health issue, with societal and economic costs extending beyond the immediate injury or loss of life. We sought to review the evidence on the effectiveness of Canadian legislation in reducing deaths caused by firearms. METHODS: Five databases (PubMed, Embase, CINAHL, Web of Science and Scopus) were searched from inception to May 2021 for studies evaluating the effect of Canadian gun control laws Bill C-51 (1977), Bill C-17 (1991) and Bill C-68 (1995) on rates of firearm-related death. Two reviewers performed article screening independently and in duplicate. We synthesized data using descriptive statistics. The primary outcome of interest was firearm-related mortality rates. Because of study heterogeneity, a meta-analysis was not performed. RESULTS: Overall, 1479 articles were screened, and 18 studies were included. Ten studies examined the effect on homicides, of which 5 reported a reduction during the postlegislation period; 1 study reported evidence of substitution from firearms to other methods of homicide among people aged 15-24 years. Eleven studies evaluated the effect on suicides, with 9 finding a reduction in suicide rates. Eight of these studies reported evidence of substitution from firearms to other suicide methods. Two studies investigated accidental deaths; neither reported any benefit after legislation. INTERPRETATION: Evidence supporting the effectiveness of Canadian firearms legislation in the reduction of homicide and accidental death rates is inconclusive; a decrease in firearm-related suicide rates was observed by most studies, but evidence of method substitution was also identified. Re-evaluation of existing laws may be beneficial to build an improved and effective evidence-based national framework for prevention of gun violence. PROSPERO REGISTRATION: CRD42020192486.

Mandatory gunshot wound reporting in Nova Scotia: a pre-post-evaluation of firearm-related injury rates.

OBJECTIVE: Mandatory gunshot wound reporting laws have been enacted in much of Canada, yet there is a lack of evidence on whether these laws are effective in preventing firearm injuries. Our objective was to determine if the Gunshot Wounds Reporting Act in Nova Scotia had an effect on the number of firearm-related injuries in the province. METHODS: Pre-post-study of major trauma patients in Nova Scotia who sustained a gunshot wound injury before and after enactment of the Gunshot Wounds Reporting Act (Bill 10) in 2008. Data were collected from the Nova Scotia Trauma Registry and the Nova Scotia Medical Examiner Service for a 6-year pre-period (2002-2007) and an 11-year post-period (2009-2019), allowing for a 1-year washout period. Patient characteristics in the pre- and post-periods were compared using t tests and Chi-square analysis. Gunshot wound traumas were analyzed as a time series using the AutoRegressive Integrated Moving Average (ARIMA) model. RESULTS: A total of 722 firearm injuries were observed during the study period (pre-period = 259, post-period = 463). Mean age was 45.2 ± 19.3 years with males accounting for 95.3% (688/722) of cases. The majority of injuries were self-inflicted (65.1%; 470/722). The mean overall annualized rate of firearm injuries was 4.61 per 100,000 population in the pre-period and 4.45 per 100,000 in the post-period (reduction of 3.4%). No linear trends in the annual number of firearm injuries were observed over the study period. ARIMA modelling was an extremely poor predictor for gunshot wound trauma (R2 = 0.012). CONCLUSIONS: Although our findings suggest that there is no association between the Gunshot Wounds Reporting Act and the incidence of firearm injury, it is difficult to draw firm conclusions due to the complexity of this topic. Physicians need to be aware of the legal requirements of mandatory reporting when they encounter patients with gunshot wounds.

RéSUMé: OBJECTIF: Des lois obligatoires sur le signalement des blessures par balle ont été promulguées dans une grande partie du Canada, mais on manque de données probantes sur l'efficacité de ces lois pour prévenir les blessures par balle. Notre objectif était de déterminer si la Gunshot Wounds Reporting Act de la Nouvelle-Écosse a eu un effet sur le nombre de blessures liées aux armes à feu dans la province. MéTHODES: Étude pré-post des patients souffrant de traumatismes majeurs en Nouvelle-Écosse et ayant subi une blessure par balle avant et après la promulgation de la loi sur la déclaration des blessures par balle (projet de loi 10) en 2008. Les données ont été recueillies auprès du Nova Scotia Trauma Registry et du Nova Scotia Medical Examiner Service pour une période de 6 ans avant (2002­2007) et de 11 ans après (2009­2019), en tenant compte d'une période d'élimination d'un an. Les caractéristiques des patients avant et après les périodes ont été comparées à l'aide de tests- t et d'une analyse du chi-carré. Les traumatismes liés aux blessures par balle ont été analysés comme une série chronologique à l'aide du modèle ARIMA (AutoRegressive Integrated Moving Average). RéSULTATS: Au total, 722 blessures par arme à feu ont été observées au cours de la période d'étude (avant la période = 259, après la période = 463). L'âge moyen était de 45,2 ± 19,3 ans, les hommes représentant 95,3% (688/722) des cas. La majorité des blessures étaient auto-infligées (65,1%; 470/722). Le taux global moyen annualisé de blessures par arme à feu était de 4,61 pour 100 000 habitants pendant la période antérieure et de 4,45 pour 100 000 pendant la période postérieure (réduction de 3,4%). Aucune tendance linéaire du nombre annuel de blessures par arme à feu n'a été observée au cours de la période d'étude. Le modèle ARIMA s'est avéré être un très mauvais prédicteur des traumatismes liés aux blessures par balle (R2 = 0,012). CONCLUSIONS: Bien que nos résultats suggèrent qu'il n'y a pas de lien entre la loi sur le signalement des blessures par balle et l'incidence des blessures par arme à feu, il est difficile de tirer des conclusions définitives en raison de la complexité de ce sujet. Les médecins doivent être conscients des obligations légales de déclaration obligatoire lorsqu'ils rencontrent des patients présentant des blessures par balle.

Energy Performance Analysis and Modelling of LoRa Prototyping Boards.

LoRaWAN has gained significant attention for Internet-of-Things (IOT) applications due to its low power consumption and long range potential for data transmission. While there is a significant body of work assessing LoRA coverage and data transmission characteristics, there is a lack of data available about commercially available LoRa prototyping boards and their power consumption, in relation to their features. It is currently difficult to estimate the power consumption of a LoRa module operating under different transmission profiles, due to a lack of manufacturer data available. In this study, power testing has been carried out on physical hardware and significant variation was found in the power consumption of competing boards, all marketed as "extremely low power". In this paper, testing results are presented alongside an experimentally-derived power model for the lowest power LoRa module, and power requirements are compared to firmware settings. The power analysis adds to existing work showing trends in data-rate and transmission power settings effects on electrical power consumption. The model's accuracy is experimentally verified and shows acceptable agreement to estimated values. Finally, applications for the model are presented by way of a hypothetical scenario and calculations performed in order to estimate battery life and energy consumption for varying data transmission intervals.

PURL: How old is too old for statins?

When to start, continue, or stop statins in those ages ≥ 75 years has been a quandary. Here's what 2 studies have to say.

PURL: NPH insulin: It remains a good option.

NPH insulin holds its own against basal insulin analogs-and it's cheaper.

PURL: Best timing for measuring orthostatic vital signs?

We typically take a blood pressure within 3 minutes of a patient rising from a supine to a standing position. But is that too long?

PURL: Supplemental oxygen: More isn't always better.

A recent study says that in certain populations, supplemental oxygen above certain levels can increase mortality.

Erratum: A better approach to the diagnosis of PE.

The author list for the June 2019 PURL ("A better approach to the diagnosis of PE." J Fam Pract. 2019;68:286,287,295) should have read: Andrew H. Slattengren, DO; Shailendra Prasad, MBBS, MPH; David C. Bury, DO; Michael M. Dickman, DO; Nick Bennett, DO; Ashley Smith, MD; Robert Oh, MD, MPH, FAAFP; Robert Marshall, MD, MPH, MISHM, FAAFP.

PURL: A better approach to the diagnosis of PE.

A simple diagnostic algorithm is all that's needed to safely and effectively reduce our reliance on CT pulmonary angiography to diagnose PE.

PURL: Can vitamin D prevent acute respiratory infections?

A systematic review and meta-analysis says Yes, but the dosages used may not be what you'd expect.

PURL: First-time, mild diverticulitis: Antibiotics or watchful waiting?

Don't jump to antibiotic Tx for mild, uncomplicated diverticulitis, a recent RCT says. Observation may be just as effective.

Unexpected medical undergraduate simulation training (UMUST): can unexpected medical simulation scenarios help prepare medical students for the transition to foundation year doctor?

BACKGROUND: Preparing medical students with the skills necessary to deal with emergency situations as junior doctors can be challenging due to the complexities of creating authentic 'real life' experiences in artificial environments. The following paper is an evaluation of the UMUST (Unexpected Medical Undergraduate Simulation Training) project; a high-fidelity simulation based training programme designed to emulate the experience of dealing with medical emergencies for final year medical students preparing for practice as Foundation Year trainees. METHODS: Final year medical students from Liverpool University who undertake their clinical placements at Blackpool Teaching Hospitals NHS Foundation Trust and St. Helens & Knowsley Teaching Hospitals NHS Trust were randomly allocated into groups and took part in a series of four unexpected simulation based scenarios. At the beginning of the week in which the scenarios ran, participants were issued with a hospital bleep which they carried with them during their placement. At an unknown time to them, the participants were bleeped to attend a simulated emergency scenario, and on arrival to the Clinical Skills and Simulation facility, members of the education team undertook a standardised simulation scenario. Each session was recorded on video which the participants subsequently watched as part of a debriefing process. An assessment tool was developed to gauge whether the participants made progress in their learning over the course of the four sessions. Focus groups were held with the participants in order to evaluate their experience of the programme, and questionnaires were later distributed to all participants once they had begun working as a Foundation Year trainee. The questionnaires asked them how relevant UMUST was in preparing them for dealing with medical emergencies. RESULTS: The questionnaires and the focus groups clearly showed that the doctors felt like UMUST was very valuable in preparing them to work as junior doctors. They had enjoyed taking part in UMUST and thought was a realistic and useful part of their undergraduate training. CONCLUSIONS: The feedback from the focus groups and the subsequent questionnaires clearly demonstrate that participants felt the UMUST programme helped to prepare them as junior doctors in terms of dealing with emergency situations.