ASEAN countries' environmental policies for the Sustainable Development Goals (SDGs).

This study's objective is to examine how ASEAN countries reported their environment-related policies for the Sustainable Development Goals (SDGs) in their Voluntary National Reviews (VNRs), and a dataset of their environmental policies was developed. This is a necessary first step in analyzing the reasons for insufficient progress on the environmental dimension of the SDGs, since policies are key means of implementation. Previous studies of SDG progress and VNRs examined many aspects such as achievement levels, indicators, data, governance, and VNR preparation procedures, but surprisingly, there has been little discussion of countries' actual policy efforts. Progress on the SDGs' environmental dimensions is widely considered insufficient, including in Asia. This study showed that insufficient progress on the environmental dimension of the SDGs is not due to a lack of environmental policies or a lower prioritization of policies for environmental SDG targets. ASEAN countries included almost 600 concrete environment-related policies in their VNRs, widely distributed among most SDGs, accounting for about 40 percent of their total reported SDG-related policies. The number of environmental policies was not closely related to GDP, GDP per capita, or VNR date. Many policies appeared substantial, including national action plans, strategies, laws, and regulations, not just small projects or programs. However, some major existing environmental policies, for example on air pollution, were usually not included in the VNRs. Further research is needed to explore other possible factors such as insufficient policy implementation or effectiveness, which this study could not examine. This study's environmental policy dataset provides the necessary baseline for future research on policy implementation and effectiveness, especially to help future studies identify ASEAN countries' environmental policies in specific areas such as climate, energy, or water. This will also facilitate comparative analysis. Supplementary Information: The online version contains supplementary material available at 10.1007/s10668-022-02514-0.

The Use of Different Sepsis Risk Stratification Tools on the Wards and in Emergency Departments Uncovers Different Mortality Risks: Results of the Three Welsh National Multicenter Point-Prevalence Studies.

OBJECTIVES: To compare the performance of Sequential Organ Failure Assessment, systemic inflammatory response syndrome, Red Flag Sepsis, and National Institute of Clinical Excellence sepsis risk stratification tools in the identification of patients at greatest risk of mortality from sepsis in nonintensive care environments. DESIGN: Secondary analysis of three annual 24-hour point-prevalence study periods. SETTING: The general wards and emergency departments of 14 acute hospitals across Wales. Studies were conducted on the third Wednesday of October in 2017, 2018, and 2019. PATIENTS: We screened all patients presenting to the emergency department and on the general wards. MEASUREMENTS AND MAIN RESULTS: We recruited 1,271 patients, of which 724 (56.9%) had systemic inflammatory response syndrome greater than or equal to 2, 679 (53.4%) had Sequential Organ Failure Assessment greater than or equal to 2, and 977 (76.9%) had Red Flag Sepsis. When stratified according to National Institute of Clinical Excellence guidelines, 450 patients (35.4%) were in the "High risk" category in comparison with 665 (52.3%) in "Moderate to High risk" and 156 (12.3%) in "Low risk" category. In a planned sensitivity analysis, we found that none of the tools accurately predicted mortality at 90 days, and Sequential Organ Failure Assessment and National Institute of Clinical Excellence tools showed only moderate discriminatory power for mortality at 7 and 14 days. Furthermore, we could not find any significant correlation with any of the tools at any of the mortality time points. CONCLUSIONS: Our data suggest that the sepsis risk stratification tools currently utilized in emergency departments and on the general wards do not predict mortality adequately. This is illustrated by the disparity in mortality risk of the populations captured by each instrument, as well as the weak concordance between them. We propose that future studies on the development of sepsis identification tools should focus on identifying predicator values of both the short- and long-term outcomes of sepsis.

Randomised feasibility study of prehospital recognition and antibiotics for emergency patients with sepsis (PhRASe).

Severe sepsis is a time critical condition which is known to have a high mortality rate. Evidence suggests that early diagnosis and early administration of antibiotics can reduce morbidity and mortality from sepsis. The prehospital phase of emergency medical care may provide the earliest opportunity for identification of sepsis and delivery of life-saving treatment for patients. We aimed to assess the feasibility of (1) paramedics recognising and screening patients for severe sepsis, collecting blood cultures and administering intravenous antibiotics; and (2) trial methods in order to decide whether a fully-powered trial should be undertaken to determine safety and effectiveness of this intervention. Paramedics were trained in using a sepsis screening tool, aseptic blood culture collection and administration of intravenous antibiotics. If sepsis was suspected, paramedics randomly allocated patients to intervention or usual care using scratchcards. Patients were followed up at 90 days using linked anonymised data to capture length of hospital admission and mortality. We collected self-reported health-related quality of life at 90 days. We pre-specified criteria for deciding whether to progress to a fully-powered trial based on: recruitment of paramedics and patients; delivery of the intervention; retrieval of outcome data; safety; acceptability; and success of anonymised follow-up. Seventy-four of the 104 (71.2%) eligible paramedics agreed to take part and 54 completed their training (51.9%). Of 159 eligible patients, 146 (92%) were recognised as eligible by study paramedics, and 118 were randomised (74% of eligible patients, or 81% of those recognised as eligible). Four patients subsequently dissented to be included in the trial (3%), leaving 114 patients recruited to follow-up. All recruited patients were matched to routine data outcomes in the Secure Anonymised Information Linkage Databank. Ninety of the 114 (79%) recruited patients had sepsis or a likely bacterial infection recorded in ED. There was no evidence of any difference between groups in patient satisfaction, and no adverse reactions reported. There were no statistically significant differences between intervention and control groups in Serious Adverse Events (ICU admissions; deaths). This feasibility study met its pre-determined progression criteria; an application will therefore be prepared and submitted for funding for a fully-powered multi-centre randomised trial.Trial registration: ISRCTN36856873 sought 16th May 2017; https://doi.org/10.1186/ISRCTN36856873.

Prehospital recognition and antibiotics for 999 patients with sepsis: protocol for a feasibility study.

BACKGROUND: Sepsis is a common condition which kills between 36,000 and 64,000 people every year in the UK. Early recognition and management of sepsis has been shown to reduce mortality and improve the health and well-being of people with sepsis. Paramedics frequently come into contact with patients with sepsis and are well placed to provide early diagnosis and treatment.We aim to determine the feasibility of undertaking a fully powered randomised controlled trial (RCT) to test the clinical and cost-effectiveness of paramedics obtaining blood cultures from and administering IV antibiotics to patients with sepsis, so we can make a decision about whether to proceed to a fully powered randomised controlled trial, which will answer questions regarding safety and effectiveness for patients and benefit to the National Health Service (NHS). METHODS/DESIGN: This is an individually randomised, two-arm feasibility study for a randomised controlled trial with a 1:1 ratio. Sixty paramedics will receive training to assist them to recognise sepsis using a screening tool, obtain blood cultures, and provide IV antibiotics. If sepsis is suspected, paramedics will randomly allocate patients to intervention or usual care using their next sequential individually issued scratch card. Patients will be followed up at 90 days using linked anonymised data to capture length of hospital admission and mortality. We will also collect self-reported health-related quality of life (using SF-12) at this time. We will interview ten patients by telephone and hold a focus group with paramedics, to find out what they think about the intervention. DISCUSSION: At the end of this study, we will make a recommendation about whether a full randomised controlled trial of paramedics obtaining blood cultures and administering IV antibiotics for sepsis is warranted, and if so, we will develop a proposal for research funding in order to take the work forward. TRIAL REGISTRATION: ISRCTN, ISRCTN36856873.

Sepsis Prevalence and Outcome on the General Wards and Emergency Departments in Wales: Results of a Multi-Centre, Observational, Point Prevalence Study.

Data on sepsis prevalence on the general wards is lacking on the UK and in the developed world. We conducted a multicentre, prospective, observational study of the prevalence of patients with sepsis or severe sepsis on the general wards and Emergency Departments (ED) in Wales. During the 24-hour study period all patients with NEWS≥3 were screened for presence of 2 or more SIRS criteria. To be eligible for inclusion, patients had to have a high clinical suspicion of an infection, together with a systemic inflammatory response (sepsis) and evidence of acute organ dysfunction and/or shock (severe sepsis). There were 5317 in-patients in the 24-hour study period. Data were returned on 1198 digital data collection forms on patients with NEWS≥3 of which 87 were removed, leaving 1111 for analysis. 146 patients had sepsis and 144 patients had severe sepsis. Combined prevalence of sepsis and severe sepsis was 5.5% amongst all in-patients. Patients with sepsis had significantly higher NEWS scores (3 IQR 3-4 for non-sepsis and 4 IQR 3-6 for sepsis patients, respectively). Common organ dysfunctions in severe sepsis were hypoxia (47%), hypoperfusion (40%) and acute kidney injury (25%). Mortality at 90 days was 31% with a median (IQR) hospital free stay of 78 (36-85) days. Screening for sepsis, referral to Critical Care and completion of Sepsis 6 bundle was low: 26%, 16% and 12% in the sepsis group. Multivariable logistic regression analysis identified higher National Early Warning Score, diabetes, COPD, heart failure, malignancy and current or previous smoking habits as independent variables suggesting the diagnosis of sepsis. We observed that sepsis is more prevalent in the general ward and ED than previously suggested before and that screening and effective treatment for sepsis and severe sepsis is far from being operationalized in this environment, leading to high 90 days mortality.

Vantage point - Prudent health care.

DESPITE PRODUCTIVITY improvement programmes in the NHS, the Nuffield Trust warns us that the NHS in Wales is likely to face a funding gap of £2.5 billion by 2025. Obviously then, we need to keep searching for ways to ensure long-term sustainability that does not compromise quality.

Patient safety education - a description and evaluation of an international, interdisciplinary e-learning programme.

Patient safety is a priority within healthcare across the globe. Delivering safer healthcare demands a system wide approach and educators have a responsibility to play a full role. This article describes how e-learning can be a means of engaging and educating an international group of critical care professionals studying at Masters level. Using online tools such as blogs, wikis and discussion boards students are introduced to quality and safety subjects and tools to help them improve care at a local level. Working together as a collaborative of different professionals has engaged the student group helping them understand their role in reducing harm and has resulted in improvements to care.

Reducing pressure damage: care bundles and collaborative learning.

Reduction of hospital-acquired pressure ulcers is a patient and nursing priority. Although evidence-based interventions to prevent such ulcers are well known, reducing this healthcare burden has proven consistently difficult. Via case studies, this article describes how a bundle approach to pressure ulcer prevention may be adapted for use within different clinical areas. It illustrates how collaborative learning may facilitate the spread of improvement work across a health board and build improvement skills within nursing.

Continuity of care for people with non-psychotic disorders.

BACKGROUND: Service users with non-psychotic disorders are rarely studied. How continuity of care functions for this group is unknown. AIMS: To compare users of community mental health teams with non-psychotic disorders to those with psychotic disorders in terms of demographic and illness characteristics, continuity of care and clinical and social functioning. METHODS: Service users with non-psychotic disorders (N = 98) were followed up for one year and compared to 180 service users with psychotic disorders. Continuity of care factors were tested for association with user, illness and service variables. RESULTS: Service users with non-psychotic disorders experienced more care transitions, but there were no differences in team practices in relation to these two different groups. CONCLUSION: The underlying concepts of continuity of care derived from users with psychotic disorders appear to be meaningful for users with non-psychotic disorders. Their greater likelihood of experiencing disruptive and distressing care transitions needs to be addressed.

Attachment to the clinical team and its association with therapeutic relationships, social networks, and clinical well-being.

OBJECTIVES: To determine (1) inter-relationships between social network size and quality and therapeutic relationship ratings and (2) inter-relationships between attachment style, team attachment, therapeutic relationships, social networks, and clinical and social functioning. DESIGN: A cross-sectional survey. METHOD: A sample of 93 people using community mental health teams were assessed on their attachment status, social networks, relationship to the keyworker, attachment to the team, characteristics, and clinical and social functioning. Network size and the number friends and confidants were tested for associations with user- and professional-rated therapeutic relationship. Regression analysis was used to determine variables associated with team attachment. RESULTS: There was no evidence that network size or number of confidants was associated with therapeutic relationship ratings. Therapeutic relationship was strongly associated with team attachment, but of the four attachment dimensions, only preoccupied attachment was associated with team attachment. CONCLUSION: There is no evidence that therapeutic relationships are associated with the service user's 'affability' or predisposition to form relationships, suggesting that measures of therapeutic relationship and service attachment do measure something distinct about service users' experience of their care. Team attachment and therapeutic relationship measures seem likely to be measuring very similar constructs. It is possible that service users with more preoccupied attachment styles may find it particularly difficult to form positive attachments to services undergoing frequent change.

Negotiating control: patients' experiences of unsuccessful weight-loss surgery.

Interviews were carried out with 10 men and women who had undergone weight-loss surgery (WLS) up to 10 years ago and felt that it had failed. Seven had had a further successful procedure. Data were analysed using Interpretative Phenomenological Analysis. Weight regain following surgery was explained in terms of either the mechanics of the operation or with participants describing ways to 'cheat' as food continued to be used for emotional regulation. Everyone spoke of how surgery neglected their mind. Following the second successful surgery, participants described changes in both their eating behaviour and cognitions emphasising how their mind had been brought 'in gear' through the investment of two invasive procedures. Transcending all accounts was the mind/body relationship and the issue of control with attributions for both failed and successful surgery shifting from the self to the surgical mechanism as the participants negotiated the pathway between self-blame and responsibility and utilised conflicting frameworks in which the mind and body were either divided or united. Whereas failed surgery is characterised by a battle for control, successful surgery involves handing control over to their restricted stomachs or considering WLS as a tool to be worked with.

Vantage point.

IN CRITICAL care, there is an increasing amount of evidence that over-sedating patients to prevent them from removing life-sustaining appliances can be harmful ( Young et al 2000 ).

Piperidine dispiro-1,2,4-trioxane analogues.

Dispiro N-Boc-protected 1,2,4-trioxane 2 was synthesised via Mo(acac)(2) catalysed perhydrolysis of N-Boc spirooxirane followed by condensation of the resulting beta-hydroperoxy alcohol 10 with 2-adamantanone. N-Boc 1,2,4-trioxane 2 was converted to the amine 1,2,4-trioxane hydrochloride salt 3 which was subsequently used to prepare derivatives (4-7). Several of these novel 1,2,4-trioxanes had nanomolar antimalarial activity versus the 3D7 strain of Plasmodium falciparum. Amine intermediate 3 represents a versatile derivative for the preparation of achiral arrays of trioxane analogues with antimalarial activity.

Two-step synthesis of achiral dispiro-1,2,4,5-tetraoxanes with outstanding antimalarial activity, low toxicity, and high-stability profiles.

A rapid, two-step synthesis of a range of dispiro-1,2,4,5-tetraoxanes with potent antimalarial activity both in vitro and in vivo has been achieved. These 1,2,4,5-tetraoxanes have been proven to be superior to 1,2,4-trioxolanes in terms of stability and to be superior to trioxane analogues in terms of both stability and activity. Selected analogues have in vitro nanomolar antimalarial activity and good oral activity and are nontoxic in screens for both cytotoxicity and genotoxicity. The synthesis of a fluorescent 7-nitrobenza-2-oxa-1,3-diazole (NBD) tagged tetraoxane probe and use of laser scanning confocal microscopy techniques have shown that tagged molecules accumulate selectively only in parasite infected erythrocytes and that intraparasitic formation of adducts could be inhibited by co-incubation with the iron chelator desferrioxamine (DFO).

An efficient route into synthetically challenging bridged achiral 1,2,4,5-tetraoxanes with antimalarial activity.

Here we present an efficient route into synthetically challenging bridged 1,2,4,5-tetraoxanes. The key to the success of this route is the use of H(2)O(2) and catalytic I(2) to form the gem-dihydroperoxide followed by a Ag(2)O mediated alkylation using 1,3-diiodopropane. Using this methodology a range of bridged tetraoxanes which display good in vitro antimalarial activity were synthesized.