The reliability of the College of Intensive Care Medicine of Australia and New Zealand "Hot Case" examination.

BACKGROUND: High stakes examinations used to credential trainees for independent specialist practice should be evaluated periodically to ensure defensible decisions are made. This study aims to quantify the College of Intensive Care Medicine of Australia and New Zealand (CICM) Hot Case reliability coefficient and evaluate contributions to variance from candidates, cases and examiners. METHODS: This retrospective, de-identified analysis of CICM examination data used descriptive statistics and generalisability theory to evaluate the reliability of the Hot Case examination component. Decision studies were used to project generalisability coefficients for alternate examination designs. RESULTS: Examination results from 2019 to 2022 included 592 Hot Cases, totalling 1184 individual examiner scores. The mean examiner Hot Case score was 5.17 (standard deviation 1.65). The correlation between candidates' two Hot Case scores was low (0.30). The overall reliability coefficient for the Hot Case component consisting of two cases observed by two separate pairs of examiners was 0.42. Sources of variance included candidate proficiency (25%), case difficulty and case specificity (63.4%), examiner stringency (3.5%) and other error (8.2%). To achieve a reliability coefficient of > 0.8 a candidate would need to perform 11 Hot Cases observed by two examiners. CONCLUSION: The reliability coefficient for the Hot Case component of the CICM second part examination is below the generally accepted value for a high stakes examination. Modifications to case selection and introduction of a clear scoring rubric to mitigate the effects of variation in case difficulty may be helpful. Increasing the number of cases and overall assessment time appears to be the best way to increase the overall reliability. Further research is required to assess the combined reliability of the Hot Case and viva components.

The relationship between patient volume and mortality in NSW major trauma service hospitals.

INTRODUCTION: Conventional wisdom is that Major Trauma Services (MTS) treating larger volumes of severe trauma patients will have better outcomes than lower volume centres, but recent studies from Europe have questioned this relationship. We aimed to determine if there is a relationship between patient volume and outcome in New South Wales (NSW) MTS hospitals. MATERIALS AND METHODS: Retrospective observational study using data from the NSW State Trauma Registry from 2010 to 2019 inclusive. Adult patients with Injury Severity Score >15 transported directly to a NSW MTS were included. Outcome measures were mortality at hospital discharge, and intensive care unit and hospital length of stay. Generalised estimating equation models were created to determine the adjusted relationship between patient volume and the main outcome measures. RESULTS: The mean annual patient volume of the MTS ranged from 127.4 to 282.0 patients whilst the observed mortality rates p.a. ranged from 10.4 % to 17.19 %. Multivariate analysis, using low volume MTS as the reference, did not demonstrate a significant difference in mortality between high and low volume MTS (adjusted OR: 1.14 95 % CI: 0.98-1.25, P = 0.087). There was however a significant correlation between volume and length of hospital stay (adjusted ß; 0.024, 95 % CI, 0.182 - 1.089, P = 0.006). CONCLUSIONS: There was no mortality difference between high and low volume MTS demonstrated. Length of hospital stay significantly increased with increasing volume however.

Homogeneous Environmental Selection Structures the Bacterial Communities of Benthic Biofilms in Proglacial Floodplain Streams.

In proglacial floodplains, glacier recession promotes biogeochemical and ecological gradients across relatively small spatial scales. The resulting environmental heterogeneity induces remarkable microbial biodiversity among proglacial stream biofilms. Yet the relative importance of environmental constraints in forming biofilm communities remains largely unknown. Extreme environmental conditions in proglacial streams may lead to the homogenizing selection of biofilm-forming microorganisms. However, environmental differences between proglacial streams may impose different selective forces, resulting in nested, spatially structured assembly processes. Here, we investigated bacterial community assembly processes by unraveling ecologically successful phylogenetic clades in two stream types (glacier-fed mainstems and non-glacier-fed tributaries) draining three proglacial floodplains in the Swiss Alps. Clades with low phylogenetic turnover rates were present in all stream types, including Gammaproteobacteria and Alphaproteobacteria, while the other clades were specific to one stream type. These clades constituted up to 34.8% and 31.1% of the community diversity and up to 61.3% and 50.9% of the relative abundances in mainstems and tributaries, respectively, highlighting their importance and success in these communities. Furthermore, the proportion of bacteria under homogeneous selection was inversely related to the abundance of photoautotrophs, and these clades may therefore decrease in abundance with the future "greening" of proglacial habitats. Finally, we found little effect of physical distance from the glacier on clades under selection in glacier-fed streams, probably due to the high hydrological connectivity of our study reaches. Overall, these findings shed new light on the mechanisms of microbial biofilm assembly in proglacial streams and help us to predict their future in a rapidly changing environment. IMPORTANCE Streams draining proglacial floodplains harbor benthic biofilms comprised of diverse microbial communities. These high-mountain ecosystems are rapidly changing with climate warming, and it is therefore critical to better understand the mechanisms underlying the assembly of their microbial communities. We found that homogeneous selection dominates the structuring of bacterial communities in benthic biofilms in both glacier-fed mainstems and nonglacier tributary streams within three proglacial floodplains in the Swiss Alps. However, differences between glacier-fed and tributary ecosystems may impose differential selective forces. Here, we uncovered nested, spatially structured assembly processes for proglacial floodplain communities. Our analyses additionally provided insights into linkages between aquatic photoautotrophs and the bacterial taxa under homogeneous selection, potentially by providing a labile source of carbon in these otherwise carbon-deprived systems. In the future, we expect a shift in the bacterial communities under homogeneous selection in glacier-fed streams as primary production becomes more important and streams become "greener".

Decrypting the stream periphyton physical habitat of recently deglaciated floodplains.

The rapid recession of glaciers is exposing large zones to the development of embryonic phototrophic ecosystems and eventual ecological succession. Traditionally, succession patterns in glacial forefields have been seen as a response to time since deglaciation, but nowadays forefield exposure is so rapid that this theory may be less applicable. In this succession process, periphyton are potential pioneer organisms because of their role in modifying the local environment (e.g. access to water) to create conditions conducive to plant colonization. In this paper, we aim to decrypt the physical properties of the habitats that define the spatial and temporal assemblage of periphyton during the melt-season of an Alpine temperate glacier in the context of rapid climate change. We show that periphyton develop in glacial floodplains throughout the melt-season and could extend to cover significant surfaces. However, development is only possible when the combined conditions of stability and water accessibility are met. In glacial floodplains, stable zones exist and are typically located on terraces; but they can also be locally found for much shorter periods in the more active, glacial-stream reworked zone. On terraces, water accessibility can be a limit due to well-drained sediments, but when present, often aided by the role that biofilms play in creating an impermeable layer, it provides a stable and clear water source that biofilms could exploit. In the active part of the braid plain, whilst water availability is very high, the water is harsh (low temperature, high turbidity) and erosive. Therein, periphyton can rapidly exploit short windows of opportunity but the habitat conditions rarely remain stable for long enough for continuous periphyton cover to develop. Thus, the role of periphyton in ecosystem succession is strongly conditioned by the spatial extent of the active zone, itself a function of high rates of glacier melt and sediment supply associated with rapid glacier retreat.

Leadership behaviours in interprofessional student teamwork.

BACKGROUND: Effective leaders support high-quality patient care and improve patient safety by embodying a collective leadership style. Training in leadership skills needs to be integrated longitudinally throughout a clinician's career. Models of leadership drawn from organisational theories can provide a conceptual framework for cultivating student leadership qualities during teamwork and the evaluation of emergent outcomes. Using the conceptual framework of Situational Leadership Theory, we sought to explore the leadership qualities identified by students of their team members, during a large scale interprofessional learning activity. METHODS: In 2018, 1674 students from 11 health disciplines were required to participate in the "Health Collaboration Challenge" (HCC). The HCC required students to work in small interprofessional teams of five or six students. Following team activities, students were required to provide constructive written feedback to their team members. Peer feedback data were coded and categorised into themes using the conceptual framework of Situational Leadership Theory. Data were then quantified within each theme. RESULTS: A total of 1282 comments were analysed. The most frequent comments related to 'delegating' (456/1282, 36%) and 'supporting' (402/1282, 31%). This was followed by comments categorised as 'directing' (244/1282, 19%), and 'coaching' (180/1282, 14%) leadership styles. Notably, a total of 1112/2597 (43%) of comments were unconstructive. A total of 298 comments provided by students informed their peers of areas for self-improvement. The most frequent comments were recommendations relating to 'active team member contribution' (111/298; 37%), followed by 'communication' (83/298; 28%), 'interprofessional practice' (77/298; 26%), and 'disciplinary knowledge' (27/298; 9%). CONCLUSION: Although most students demonstrated a reasonable ability to display leadership behaviours appropriate to teamwork, further development is needed through training. Leadership skills are an expectation of health professional graduates, and should be explicitly taught and vertically integrated within interprofessional education curricula. Further research is warranted in how students contribute to and understand the requirements of leadership within interprofessional teams.

Student Interprofessional Facilitator Training (SIFT) program: building capacity in clinical education leadership.

BACKGROUND: While there are many teacher training programs for health professional students, few are interprofessional, and few integrate assessment and feedback prior to participation as peer teachers. In 2021, The Student Interprofessional Facilitator Training (SIFT) program was developed to allow senior students, already trained in peer teaching, to revise, build on, and practice their newly acquired skills in an interprofessional context. The aim of this study was to explore participant perception and performance, and the contextual factors that influence student aspirations as clinical teachers. METHODS: Alumni of the 2021 Peer Teacher Training program (n = 74) were invited to participate in the SIFT program. Those who participated were invited to attend individual semi-structured interviews. Thematic analysis was used to code and categorise data into themes, using Communities of Practice as a conceptual framework. Skills in interprofessional facilitation were observed, assessed and students were provided with individual feedback. Assessment data were analysed using descriptive statistics. RESULTS: Sixteen students from six disciplines joined the SIFT program, and 13/16 (81%) completed. Students were from medicine, nursing, diagnostic radiography, medical imaging, dentistry and speech pathology. Students reported an increased recognition of teaching as a learned skill, development of clinician identity formation as educators, development of interprofessional communication skills, increased awareness of the roles of other health professions, and an increased understanding of leadership. Participants expressed a desire for additional opportunities for interprofessional networking and peer teaching. A good level of competence in facilitation skills was reached by participants. CONCLUSION: The SIFT program provided a sustainable framework for health professional students to develop and evidence their teaching and leadership skills in an interprofessional context. This study highlighted the important role of observation, assessment and feedback in student teacher training programs. The process of clear assessment guidelines, direct observation with feedback from supervisors provided a way to ensure quality improvement in peer teaching. The SIFT program will help to build capacity of interprofessional programs where large numbers of teachers are required for small group teaching. The next step will be to ensure a variety of opportunities within interprofessional contexts, and with face-to-face engagement.

Spatial patterns of benthic biofilm diversity among streams draining proglacial floodplains.

Glacier shrinkage opens new proglacial terrain with pronounced environmental gradients along longitudinal and lateral chronosequences. Despite the environmental harshness of the streams that drain glacier forelands, their benthic biofilms can harbor astonishing biodiversity spanning all domains of life. Here, we studied the spatial dynamics of prokaryotic and eukaryotic photoautotroph diversity within braided glacier-fed streams and tributaries draining lateral terraces predominantly fed by groundwater and snowmelt across three proglacial floodplains in the Swiss Alps. Along the lateral chronosequence, we found that benthic biofilms in tributaries develop higher biomass than those in glacier-fed streams, and that their respective diversity and community composition differed markedly. We also found spatial turnover of bacterial communities in the glacier-fed streams along the longitudinal chronosequence. These patterns along the two chronosequences seem unexpected given the close spatial proximity and connectivity of the various streams, suggesting environmental filtering as an underlying mechanism. Furthermore, our results suggest that photoautotrophic communities shape bacterial communities across the various streams, which is understandable given that algae are the major source of organic matter in proglacial streams. Overall, our findings shed new light on benthic biofilms in proglacial streams now changing at rapid pace owing to climate-induced glacier shrinkage.

Student perspectives on programmatic assessment in a large medical programme: A critical realist analysis.

BACKGROUND: Fundamental challenges exist in researching complex changes of assessment practice from traditional objective-focused 'assessments of learning' towards programmatic 'assessment for learning'. The latter emphasise both the subjective and social in collective judgements of student progress. Our context was a purposively designed programmatic assessment system implemented in the first year of a new graduate entry curriculum. We applied critical realist perspectives to unpack the underlying causes (mechanisms) that explained student experiences of programmatic assessment, to optimise assessment practice for future iterations. METHODS: Data came from 14 in-depth focus groups (N = 112/261 students). We applied a critical realist lens drawn from Bhasker's three domains of reality (the actual, empirical and real) and Archer's concept of structure and agency to understand the student experience of programmatic assessment. Analysis involved induction (pattern identification), abduction (theoretical interpretation) and retroduction (causal explanation). RESULTS: As a complex educational and social change, the assessment structures and culture systems within programmatic assessment provided conditions (constraints and enablements) and conditioning (acceptance or rejection of new 'non-traditional' assessment processes) for the actions of agents (students) to exercise their learning choices. The emergent underlying mechanism that most influenced students' experience of programmatic assessment was one of balancing the complex relationships between learner agency, assessment structures and the cultural system. CONCLUSIONS: Our study adds to debates on programmatic assessment by emphasising how the achievement of balance between learner agency, structure and culture suggests strategies to underpin sustained changes (elaboration) in assessment practice. These include; faculty and student learning development to promote collective reflexivity and agency, optimising assessment structures by enhancing integration of theory with practice, and changing learning culture by both enhancing existing and developing new social structures between faculty and the student body to gain acceptance and trust related to the new norms, beliefs and behaviours in assessing for and of learning.

Comparison of 6-Month Outcomes of Survivors of COVID-19 versus Non-COVID-19 Critical Illness.

Rationale: The outcomes of survivors of critical illness due to coronavirus disease (COVID-19) compared with non-COVID-19 are yet to be established. Objectives: We aimed to investigate new disability at 6 months in mechanically ventilated patients admitted to Australian ICUs with COVID-19 compared with non-COVID-19. Methods: We included critically ill patients with COVID-19 and non-COVID-19 from two prospective observational studies. Patients were eligible if they were adult (age ⩾ 8 yr) and received ⩾24 hours of mechanical ventilation. In addition, patients with COVID-19 were eligible with a positive laboratory PCR test for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). Measurements and Main Results: Demographic, intervention, and hospital outcome data were obtained from electronic medical records. Survivors were contacted by telephone for functional outcomes with trained outcome assessors using the World Health Organization Disability Assessment Schedule 2.0. Between March 6, 2020, and April 21, 2021, 120 critically ill patients with COVID-19, and between August 2017 and January 2019, 199 critically ill patients without COVID-19, fulfilled the inclusion criteria. Patients with COVID-19 were older (median [interquartile range], 62 [55-71] vs. 58 [44-69] yr; P = 0.019) with a lower Acute Physiology and Chronic Health Evaluation II score (17 [13-20] vs. 19 [15-23]; P = 0.011). Although duration of ventilation was longer in patients with COVID-19 than in those without COVID-19 (12 [5-19] vs. 4.8 [2.3-8.8] d; P < 0.001), 180-day mortality was similar between the groups (39/120 [32.5%] vs. 70/199 [35.2%]; P = 0.715). The incidence of death or new disability at 180 days was similar (58/93 [62.4%] vs. 99/150 [66/0%]; P = 0.583). Conclusions: At 6 months, there was no difference in new disability for patients requiring mechanical ventilation for acute respiratory failure due to COVID-19 compared with non-COVID-19. Clinical trial registered with www.clinicaltrials.gov (NCT04401254).

Too hot to handle? Assessing the validity and reliability of the College of Intensive Care Medicine "Hot Case" examination.

The College of Intensive Care Medicine of Australia and New Zealand is responsible for credentialling trainees for specialist practice in intensive care medicine for the safety of patients and the community. This involves defining trainees' performance standards and testing trainees against those standards to ensure safe practice. The second part examination performed towards the end of the training program is a high-stakes assessment. The two clinical "Hot Cases" performed in the examination have a low pass rate, with most candidates failing at least one of the cases. There is increasing expectation for medical specialist training colleges to provide fair and transparent assessment processes to enable defensible decisions regarding trainee progression. Examinations are a surrogate marker of clinical performance with advantages, disadvantages and inevitable compromises. This article evaluates the Hot Case examination using Kane's validity framework and van der Vleuten's utility equation, and identifies issues with validity and reliability which could be managed through an ongoing improvement process.

The impact of COVID-19 critical illness on new disability, functional outcomes and return to work at 6 months: a prospective cohort study.

BACKGROUND: There are few reports of new functional impairment following critical illness from COVID-19. We aimed to describe the incidence of death or new disability, functional impairment and changes in health-related quality of life of patients after COVID-19 critical illness at 6 months. METHODS: In a nationally representative, multicenter, prospective cohort study of COVID-19 critical illness, we determined the prevalence of death or new disability at 6 months, the primary outcome. We measured mortality, new disability and return to work with changes in the World Health Organization Disability Assessment Schedule 2.0 12L (WHODAS) and health status with the EQ5D-5LTM. RESULTS: Of 274 eligible patients, 212 were enrolled from 30 hospitals. The median age was 61 (51-70) years, and 124 (58.5%) patients were male. At 6 months, 43/160 (26.9%) patients died and 42/108 (38.9%) responding survivors reported new disability. Compared to pre-illness, the WHODAS percentage score worsened (mean difference (MD), 10.40% [95% CI 7.06-13.77]; p < 0.001). Thirteen (11.4%) survivors had not returned to work due to poor health. There was a decrease in the EQ-5D-5LTM utility score (MD, - 0.19 [- 0.28 to - 0.10]; p < 0.001). At 6 months, 82 of 115 (71.3%) patients reported persistent symptoms. The independent predictors of death or new disability were higher severity of illness and increased frailty. CONCLUSIONS: At six months after COVID-19 critical illness, death and new disability was substantial. Over a third of survivors had new disability, which was widespread across all areas of functioning. Clinical trial registration NCT04401254 May 26, 2020.

Management of straddling thrombus through patent foramen ovale complicating pulmonary embolism.

A 60-year-old man was admitted to intensive care unit with the diagnosis of pulmonary embolism. Bedside transthoracic echocardiography revealed the extension of the thrombus into left atrium and ventricle through patent foramen ovale (PFO). A straddling thrombus also described as impending paradoxical embolism is a rare condition when thrombus embolised to the heart gets caught in PFO. Morbidity is extremely high in case of systemic embolisation. Due to rarity, the treatment options are mainly individualised and no guidelines exist. There are few treatment strategies described in literature from surgical to interventional radiology to conservative approach. Treatment strategy should take individual parameters such as patient's age, haemodynamic stability, bleeding risk and comorbidities into consideration. Our patient successfully underwent emergency surgical thrombectomy.

Evaluating a large-scale introductory interprofessional education workshop for developing interprofessional socialisation in medical, nursing and pharmacy students: A quasi-experimental pre-test post-test study.

BACKGROUND: Traditionally, healthcare students have been educated in discipline-specific silos with minimal interprofessional socialisation. Interprofessional education is fundamental for interprofessional socialisation and is an essential component of healthcare education. OBJECTIVES: To evaluate the effect of a large-scale interprofessional workshop implemented for first year medical, nursing and pharmacy students on changes in attitudes towards interprofessional socialisation and its perceived value. DESIGN: A quasi-experimental study design using pre and post questionnaires. SETTING: A Faculty of Medicine and Health at a large university in Australia. PARTICIPANTS: 1008 students from the 2018 and 2019 cohorts of pre-qualification first year medical students (n = 444), nursing (n = 461) and pharmacy (n = 103) enrolled in a graduate entry degree program participated in the workshop. Complete data sets were collected from 37.1% (n = 374) of the participants. METHODS: The short-form Interprofessional Socialisation and Valuing Scale (ISVS-9) was administered before and after the IPE workshop. Linear mixed models were used to compare both the within group and between group pre- and post- questionnaire data. Percentages and frequencies were used to analyse data pertaining to participants' perceptions and experience of the workshop. Descriptive qualitative analysis of free-text responses was undertaken. RESULTS: Findings indicated that 80.8% (n = 440) of participants rated their workshop experience as good/very good. 64.6% (n = 352) of participants reported that it had changed how they considered other health professionals. Significant higher (p < 0.001) post questionnaire mean scores were demonstrated for nursing (5.63, SE0.05) and pharmacy students (5.82, SE 0.11). CONCLUSION: Findings provide support for the implementation of IPE for nursing, and pharmacy students. It is recommended that these initiatives are introduced at an early stage in their education to promote interprofessional socialisation and are repeated throughout the curricula.

What Does It Mean for a Case to be 'Local'?: the Importance of Local Relevance and Resonance for Bioethics Education in the Asia-Pacific Region.

Contemporary bioethics education has been developed predominately within Euro-American contexts, and now, other global regions are increasingly joining the field, leading to a richer global understanding. Nevertheless, many standard bioethics curriculum materials retain a narrow geographic focus. The purpose of this article is to use local cases from the Asia-Pacific region as examples for exploring questions such as 'what makes a case or example truly local, and why?', 'what topics have we found to be best explained through local cases or examples?', and 'how does one identify a relevant local case?' Furthermore, we consider the global application of local cases to help extend the possible scope of the discussion, opening new avenues for the development of practical bioethics educational materials. We begin with a background description and discussion of why local cases enhance bioethics education, move to an overview of what is currently available and what is not for the region, and then outline a discussion of what it means to be local using example cases drawn from Hong Kong, Australia, Pakistan, and Malaysia. We are not creating a casebook but rather constructing by example a toolbox for designing active and dynamic learning cases using regional diversity as contextualised cases with generalised principles.

Summer is in winter: Disturbance-driven shifts in macroinvertebrate communities following hydroelectric power exploitation.

In Alpine streams, humans have strongly modified the interactions between hydraulic processes, geomorphology and aquatic life through dams, flow abstraction at water intakes and river channel engineering. To mitigate these impacts, research has addressed both minimum flows and flow variability to sustain aquatic ecosystems. Whilst such environmental flows might work downstream of dams, this may not be the case for water intakes. Intakes, generally much smaller than dams, are designed to abstract water and to leave sediment behind. Sediment accumulation then results in the need to flush intakes periodically, often more frequently than daily in some highly glaciated basins. Sediment delivery downstream is then maintained through short duration floods with very high sediment loads. Here we tested the hypothesis that sediment flushing, and the associated high frequency of bed disturbance, controls in-stream habitat and macroinvertebrate assemblages. We collected macroinvertebrates over a 17-month period from an Alpine stream as well as a set of lateral unperturbed tributaries that served as controls. In contrast to established conceptual models, our results showed that the stream is largely void of life during summer, but that populations recover rapidly as the frequency of intake flushing falls in early autumn, producing richer and larger populations in winter and early spring. The recovery in autumn may be due to the recruitment of individuals from tributaries. We conclude that intake flushing in summer inverts expected summer-winter macroinvertebrate abundances, and questions the extent to which environmental flows in intake-impacted Alpine streams will lead to improvements in instream macrofauna unless sediment also is managed.

Survival and predictors of outcome among patients with decompensated liver disease in a non-liver transplant intensive care unit. Pessimism is historical and unjustified.

BACKGROUND: Recent literature emanating from the United Kingdom and United States has reported decreasing mortality rates in patients with decompensated cirrhosis and organ failures presenting to the intensive care unit (ICU). AIM: To determine if there were comparable outcomes in a single-centre non-transplant unit in Australia. METHODS: A retrospective observational study was conducted in a tertiary, non-liver transplant unit in Sydney, Australia. Admission data and mortality outcomes were collected from patients with cirrhosis non-electively admitted to ICU between 2013 and 2017. Liver-specific and general intensive care scoring tools were also assessed for their discriminative ability to predict short-term prognostic outcomes. RESULTS: Sixty-three patients were admitted with decompensated liver disease who fulfilled the inclusion criteria. The overall hospital mortality was 37% (95% CI: 0.26-0.49). There was no difference in survival based on aetiology of liver disease (P = 0.96) but a significant difference was found based on the presenting diagnosis, with greater survival among patients diagnosed with hepatic encephalopathy on ICU admission (P = 0.02). There was 4% mortality in patients with no organ failure and 52% mortality in those with ≥3 organs in failure (P < 0.001). The ICU prognostic Sequential Organ Failure Assessment score was the better discriminative tool in predicting short-term outcomes when compared to liver prognostic scores. CONCLUSION: The outcomes of this single-centre Australian study align with current overseas literature. These results reinforce and expand on limited local evidence, corroborating the former universal prognostic pessimism towards cirrhotic patients with organ failure as unwarranted.

Post-partum catastrophic antiphospholipid syndrome presenting with shock and digital ischaemia - A diagnostic and management challenge.

Catastrophic antiphospholipid syndrome is a rare multisystem autoimmune condition characterised by rapid development of widespread thrombotic disease and subsequent multi-organ failure. It is the most severe complication of antiphospholipid syndrome, carrying significant morbidity and mortality. We report a patient with post-partum catastrophic antiphospholipid syndrome with cardiac, hepatic, renal and cutaneous manifestations. The diagnostic challenges in establishing a definitive diagnosis in catastrophic antiphospholipid syndrome is discussed, along with the difficulties in managing these patients in the intensive care unit.

Changes in User Perceptions of a Telemedicine System Over Time: From Initial Implementation to Everyday Use.

BACKGROUND: Benefits associated with telemedicine are contingent upon positive user perceptions. Despite this, research on user perceptions of telemedicine remains limited. INTRODUCTION: Usability approaches offer a robust way to assess user perceptions, but have rarely been applied in telemedicine. In this study, a usability approach was employed to examine how user perceptions toward a telemedicine system changed over the course of everyday use. MATERIALS AND METHODS: A telemedicine system was introduced to a hospital in the home service. Ten mobile nurses completed the System Usability Scale (SUS) after initial use, then again after 18 months of everyday use. Results were compared. Analysis included Bangor et al.'s (2009) adjective rating scale. RESULTS: The initial SUS mean was 83 (standard deviation [SD] = 7.98), indicating "excellent" usability. After 18 months, the SUS mean was 64.38, indicating "OK" usability (SD = 14.25, p < 0.05, 95% confidence interval [CI]). Over time, users had lower desire to use the system frequently (p < 0.05, 95% CI), found it more complex (p < 0.05, 95% CI), and perceived greater inconsistency in its design (p < 0.05, 95% CI). DISCUSSION: Considered with existing evidence, our usability findings indicate that a temporary period of positive user perceptions occurs when new telemedicine systems are used for the first few months. This fades with everyday use, with design inconsistency and perceived complexity becoming more noticeable. Although other factors such as user satisfaction and efficiency may also contribute, further studies are needed for confirmation. CONCLUSIONS: User perceptions of telemedicine vary with time. To help maximize the benefits and longevity of telemedicine systems, responding to intermittent user appraisal is desirable.

A restatement of the natural science evidence concerning catchment-based 'natural' flood management in the UK.

Flooding is a very costly natural hazard in the UK and is expected to increase further under future climate change scenarios. Flood defences are commonly deployed to protect communities and property from flooding, but in recent years flood management policy has looked towards solutions that seek to mitigate flood risk at flood-prone sites through targeted interventions throughout the catchment, sometimes using techniques which involve working with natural processes. This paper describes a project to provide a succinct summary of the natural science evidence base concerning the effectiveness of catchment-based 'natural' flood management in the UK. The evidence summary is designed to be read by an informed but not technically specialist audience. Each evidence statement is placed into one of four categories describing the nature of the underlying information. The evidence summary forms the appendix to this paper and an annotated bibliography is provided in the electronic supplementary material.

Does the canopy mixing layer model apply to highly flexible aquatic vegetation? Insights from numerical modelling.

Vegetation is a characteristic feature of shallow aquatic flows such as rivers, lakes and coastal waters. Flow through and above aquatic vegetation canopies is commonly described using a canopy mixing layer analogy which provides a canonical framework for assessing key hydraulic characteristics such as velocity profiles, large-scale coherent turbulent structures and mixing and transport processes for solutes and sediments. This theory is well developed for the case of semi-rigid terrestrial vegetation and has more recently been applied to the case of aquatic vegetation. However, aquatic vegetation often displays key differences in morphology and biomechanics to terrestrial vegetation due to the different environment it inhabits. Here we investigate the effect of plant morphology and biomechanical properties on flow-vegetation interactions through the application of a coupled LES-biomechanical model. We present results from two simulations of aquatic vegetated flows: one assuming a semi-rigid canopy and the other a highly flexible canopy and provide a comparison of the associated flow regimes. Our results show that while both cases display canopy mixing layers, there are also clear differences in the shear layer characteristics and turbulent processes between the two, suggesting that the semi-rigid approximation may not provide a complete representation of flow-vegetation interactions.