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BackgroundPatient safety, concerned with the prevention of harm to patients, has become a fundamental component of the global healthcare system. The evidence regarding the status of the patient safety culture in Arab countries in general shows that it is at a suboptimal level due to a punitive approach to errors and deficits in the openness of communications.ObjectivesTo identify factors contributing to the patient safety culture in Saudi Arabia.DesignSystematic review.MethodsA systematic search was carried out in May 2018 in five electronic databases and updated in July 2020—MEDLINE, CINAHL, Embase, PsycINFO and the Cochrane Database of Systematic Reviews. Relevant journals and reference lists of included studies were also hand-searched. Two independent reviewers verified that the studies met the inclusion criteria, assessed the quality of studies and extracted their relevant characteristics. The Yorkshire Contributory Factors Framework (YCFF) was used to categorise factors affecting safety culture in the included papers.Results14 papers were included and the majority of studies were appraised as being of good quality. Strength and weakness factors that contribute to patient safety culture were identified. Ineffective leadership, a blame culture, workload/inadequate staffing and poor communication are reported as the main factors hindering a positive patient safety culture in Saudi Arabia. Conversely, ‘strength’ factors contributing to a positive patient safety culture included supportive organisational attitudes to learning/continuous improvement, good teamwork within units and support from hospital management for patient safety. There is an absence of patient perspectives regarding patient safety culture in Saudi Arabia.ConclusionPolicymakers in the Saudi healthcare system should pay attention to the factors that may contribute to a positive patient safety culture, especially establishing a blame-free culture, improving communications and leadership capacity, learning from errors and involving patient perspectives in safety initiatives. Further research is required to understand in depth the barriers and facilitators to the implementation of a positive patient safety culture in Saudi Arabia.

The objective of this study was to investigate the effect of diet crude protein (CP) content and metabolisable energy (ME) intake on skeletal growth and associated parameters of growing steers prior to and during compensatory growth in weight and catch-up growth in skeletal elongation. The experiment was a factorial design with two cattle genotypes [Brahman crossbred (BX, 178 ± 6 kg) and Holstein-Friesian (HF, 230 ± 34 kg)] and three nutritional treatments; high CP content and high ME intake (HCP-HME), high CP content and low ME intake (HCP-LME) and low CP content and low ME intake (LCP-LME) with the ME intake of HCP-LME matched to that of LCP-LME. Nutritional treatments were imposed over a 103 d period (Phase 1), and after this, all steers were offered ad libitum access to the HCP-HME nutritional treatment for 100 d (Phase 2). Steers fed the high CP content treatment with a low ME intake, showed higher hip height gain ( P = 0.04), larger terminal hypertrophic chondrocytes ( P = 0.02) and a higher concentration of total triiodothyronine in plasma ( P = 0.01) than steers with the same ME intake of the low CP content treatment. In addition, the low CP treatment resulted in significant decreases in bone volume ( P = 0.03), bone surface area ( P = 0.03) and the concentration of bone-specific alkaline phosphatase in plasma ( P < 0.001) compared to steers fed the HCP-HME treatment. A significant interaction between genotype and nutritional treatment existed for the concentration of thyroxine (T4) in plasma where HF steers fed LCP-LME had a lower T4 concentration in plasma ( P = 0.05) than BX steers. All steers with a restricted ME intake during Phase 1 demonstrated compensatory growth during Phase 2. However, HF steers fed the LCP treatment during Phase 1 showed a tendency ( P = 0.07) for a greater LWG during Phase 2 without any increase in dry matter intake. Results observed at the growth plate and hip height growth suggest that catch-up growth in cattle may also be explained by the growth plate senescence hypothesis. Contrary to our initial hypothesis, the results demonstrate that greater CP intake during ME restriction does not increase compensatory gain in cattle during re-alimentation.

This study investigated the effect of five post-weaning supplementation strategies and two weaning weight groups on long-term growth, puberty and pregnancy percentage of Brahman crossbred heifers. Early-weaned (118 ± 6 kg liveweight) and normally-weaned (183 ± 6 kg liveweight) heifers were allocated to group pens (n = 4 and n = 5/pen for early- and normally-weaned respectively) and offered one of five levels of post-weaning protein supplementation: 0, 1, 2.5, 5 and 10 g of supplement/kg liveweight.day with ad libitum access to a low quality sabi grass ( Urochloa mosambicensis ) hay during the first dry season (169 days) after weaning. After the post-weaning supplementation period, all heifers grazed the same pastures as a single mob until the end of the experiment and were exposed to fertile bulls from January to May 2016. During the first dry season, supplement intake had a positive linear effect on liveweight gain and hip width gain with no difference in the response between weaning groups. Overall, heifers with higher supplement intakes (i.e. 5 and 10 g/kg) had higher hip height gain ( P < 0.005), hip width gain ( P < 0.001), body condition score ( P < 0.001), and concentration of insulin-like growth factor-1 ( P = 0.001), triiodothyronine ( P = 0.04) and insulin ( P = 0.05) in plasma compared to unsupplemented heifers. These changes resulted in thicker proliferative and hypertrophic zones (both P = 0.03) of the tuber coxae growth plate, larger diameter of terminal hypertrophic chondrocytes (both P = 0.004) at the end of the post-weaning supplementation period when comparing the highest level of supplementation with unsupplemented group. Unsupplemented heifers from both weaning weight groups demonstrated compensatory liveweight gain over the first wet season while evidence of catch-up growth in skeletal dimensions was observed in the second wet season. The main determining factor for pregnancy status of two-year-old Brahman crossbred heifers was pre-mating liveweight ( P < 0.001), the pre-mating liveweight was in turn affected by post-weaning supplementation ( P = 0.02) or weaning weight group ( P < 0.001). This study further demonstrated the positive relationship between premating weight and the occurrence of pregnancy, with an approximate 300 kg pre-mating liveweight required to achieve approximately 80% (67.1–90.3% for a 95% confidence interval) probability of pregnancy in two-year-old Brahman crossbred heifers mated for 4 months.

Background Social skills interventions (SSIs) are effective for enhancing social skills and decreasing mental health problems in adolescents with autism spectrum disorder (ASD). However, these interventions have been designed and their effectiveness has been established in Western countries. Lack of culturally acceptable SSIs for Asian nations is a possible barrier to implementing effective and tailored interventions that address the unique requirements of ASD individuals across countries and cultures. This study aims to explore the needs and preferences of adolescents with ASD, their caregivers, and healthcare professionals (HPs) in Thailand regarding the components, delivery formats, and cultural adaptation required for an outpatient-based social skills intervention. Methods Qualitative data was collected via three focus groups of HPs (n = 20) and 24 paired interviews with adolescents with ASD and their caregivers from a child psychiatric hospital in Thailand. Purposive sampling was employed, and thematic analysis was used to analyse the data. Results Nine themes emerged from the data generated by HPs, and seven from adolescents with ASD and their caregivers. SSIs for Thai adolescents with ASD and their caregivers should emphasise specific social skills training and assess the abilities of adolescents as required. Incorporating various learning strategies is important. Parental involvement is essential and provides knowledge of an adolescent’s symptoms and coaching skills, which are best used to support their adolescents. Cultural considerations include the need for social knowledge of Thai culture, promoting assertiveness and praising parents’ abilities, implementing a programme in time to not interrupt academic achievement, and renaming a programme from social skills intervention to social communication intervention. Barriers to implementing a programme included HPs’ need for specialised training and education and decreased workload. Also, the caregivers’ and adolescents’ stigma reduced attendance in a programme. Increased extra compensation and relocation days off are provided as policy support for staff who deliver the intervention. Conclusion The results suggest that SSIs for Thai adolescents with ASD should be tailored to meet the needs for specific knowledge, skills, and parental collaboration as coaches for their adolescents. Additionally, it should incorporate Thai culture. It is necessary to consider staff knowledge, workload, and stigma in order to reduce barriers to implementation in practice.

Background The coronavirus disease (COVID-19) pandemic has had a negative impact on the health and mental health of adolescents and adolescents with autism spectrum disorders (ASD) and their caregivers, have been disproportionally affected. The purpose of this study was to investigate the impact of COVID-19 on Thai caregivers and adolescents with ASD. Methods This study used an online survey with closed and free text questions to investigate how the pandemic had impacted on social skills development and psychological variables, and perceived needs for support. The survey link was shared to parents via the Yuwaprasart Withayopathum Child and Adolescent Hospital and the social media platforms of known ASD stakeholder networks in Thailand. Binary logistic regression was used to investigate the relationships between sociodemographic characteristics, service use, and social skills problems experienced by adolescents during the pandemic. Content analysis was applied to analyse free-text data. Results A total of 376 caregivers of adolescents with ASD aged 10–19 years completed the survey, of which 364 were included in the analysis. In total, 38.7% of caregivers reported that during the pandemic the social skills of their adolescent family member had worsened. Most families reported that they were able to continue to access support from healthcare and educational services, albeit in different ways than pre-pandemic, during the acute stages of the pandemic which benefited the maintenance of ASD symptoms and social skills. Factors identified as reducing the odds of a worsening in social skills during the pandemic included; regular access to treatment for adolescents (odds ratio [OR] = 0.55, confidence interval 95% (CI) 0.32–0.98, p  = 0.044), caregivers feeling that they had sufficient support from hospitals (OR = 0.46, 95% CI 0.26–0.81, p  = 0.007) and older age of adolescents (OR = 0.53, CI 0.29–0.99, p  = 0.047). The qualitative free text comments showed that the caregivers felt that greater information on managing adolescent behaviours, opportunities for adolescents to practice social skills, and the provision of greater emotional support and material assistance from healthcare professionals during the pandemic would have helped them to care for the adolescents with ASD. Conclusion Regular access to services, support from hospitals during the pandemic and older age in adolescence may have helped prevent the worsening of the social skills problems of adolescents with ASD.

The provision of supported self-management (SSM) is recommended in contemporary guidelines to address the longer-term needs and outcomes of stroke survivors and their families, yet its implementation across stroke pathways has been inconsistent. This paper presents a secondary analysis of qualitative data, which aims to identify and offer insight into the challenges of implementing SSM from the perspectives of community stroke nurses (n = 14). The findings revealed that the implementation of SSM in stroke is influenced by factors operating at multiple levels of the healthcare system. Contextual challenges arise because of different understandings and interpretations of what SSM is, what it comprises and professionals’ perceptions of their roles in its implementation in practice. A professionally controlled, one-size-fits-all model of SSM continues to be reinforced within organizations, offering few opportunities for nurses to deliver contextually tailored and person-centred SSM. In conclusion, there are many professional concerns and organizational tensions that need to be addressed across multiple layers of the healthcare system to achieve the consistent implementation of contextually tailored and person-centred SSM following a stroke. Attempts to address these challenges will help to narrow the gap between policy and practice of implementing SSM, ensuring that stroke survivors and families benefit from SSM in the longer-term.

Musculoskeletal injuries (MSI) continue to affect Thoroughbred racehorses internationally. There is a strong interest in developing training and management strategies to reduce their impact, however, studies of risk factors report inconsistent findings. Furthermore, many injuries and fatalities occur during training rather than during racing, yet most studies report racing data only. By combining racing and training data a larger exposure to risk factors and a larger number of musculoskeletal injuries are captured and the true effect of risk factors may be more accurately represented. Furthermore, modifications to reduce the impact of MSI are more readily implemented at the training level. Our study aimed to: (1) determine the risk factors for musculoskeletal injuries and whether these are different for two-year-old and older horses and (2) determine whether risk factors vary with type of injury. This was performed by repeating analyses by age category and injury type. Data from 202 cases and 202 matched controls were collected through weekly interviews with trainers and analysed using conditional logistic regression. Increasing dam parity significantly reduced the odds of injury in horses of all age groups because of the effect in two-year-old horses (odds ratio (OR) 0.08; 95% confidence interval (CI) 0.02, 0.36; p < 0.001). Increasing total preparation length is associated with higher odds of injury in horses of all ages (OR 5.56; 95% CI 1.59, 19.46; p = 0.01), but particularly in two-year-old horses (OR 8.05; 95% CI 1.92, 33.76; p = 0.004). Increasing number of days exercised at a slow pace decreased the odds of injury in horses of all ages (OR 0.09; 95% CI 0.03, 0.28; p < 0.001). The distance travelled at three-quarter pace and above (faster than 13 m/s; 15 s/furlong; 800 m/min; 48 km/h) and the total distance travelled at a gallop (faster than 15 m/s; 13 s/furlong; 900 m/min; 55 km/h) in the past four weeks significantly affected the odds of injury. There was a non-linear association between high-speed exercise and injury whereby the odds of injury initially increased and subsequently decreased as accumulated high-speed exercise distance increased. None of the racing career and performance indices affected the odds of injury. We identified horses in this population that have particularly high odds of injury. Two-year-old horses from primiparous mares are at increased odds of injury, particularly dorsal metacarpal disease. Two-year-old horses that have had a total preparation length of between 10 and 14 weeks also have increased odds of injury. Horses of all ages that travelled a total distance of 2.4–3.8 km (12–19 furlongs) at a gallop in the last four weeks and horses three years and older that travelled 3.0–4.8 km (15–24 furlongs) at three-quarter pace and above also have increased odds of injury. We recommend that these horses should be monitored closely for impending signs of injury. Increasing the number of days worked at a slow pace may be more effective for preventing injury, if horses are perceived at a higher risk, than resting the horse altogether. Early identification of horses at increased risk and appropriate intervention could substantially reduce the impact of musculoskeletal injuries in Thoroughbred racehorses.

IntroductionA growing evidence base demonstrates the effectiveness of supported self-management in stroke for stroke survivors and their families. However, there is significant variation in its implementation in community stroke care and little understanding about how supported self-management works and is delivered across different settings, models used and contexts of community stroke rehabilitation.Methods and analysisUsing a mixed method, realist approach across two phases, this protocol describes a study on community-based supported self-management. The aim is to identify the mechanisms and outcomes of supported self-management in stroke and to understand how supported self-management is implemented in different contexts of community stroke rehabilitation. Phase 1 involves (1) a realist synthesis, (2) a scoping and mapping of current community rehabilitation settings and (3) a Q-methodology study to develop initial programme theories about how community-based supported self-management works, for whom and in what contexts. Phase 2 involves realist informed interviews/focus groups with stroke survivors, community rehabilitation practitioners and team managers from across Scotland to test and refine programme theories and an explanatory model for how supported self-management works across different contexts of community-based stroke rehabilitation.Ethics and disseminationEthical approval and R&D approvals have been granted from East of Scotland Research Ethics Committee (REC reference number: 19/ES/0055) and participating NHS boards. An understanding of how, for whom and in what contexts community-based supported self-management works will help to strengthen its delivery in practice. Such an understanding will enable the design of context-specific recommendations for policy and practice that genuinely reflect the challenges in implementing supported self-management in community stroke care. Results will be disseminated to clinical partners working in community stroke rehabilitation, stroke survivors and families and to policymakers and third sector partners involved in the provision of long-term support for people affected by stroke.PROSPERO registration numberCRD42020166208.

IntroductionA large and growing number of patients with cancer have comorbid diabetes. Cancer and its treatment can adversely impact glycaemic management and control, and there is accumulating evidence that suboptimal glycaemic control during cancer treatment is a contributory driver of worse cancer-related outcomes in patients with comorbid diabetes. Little research has sought to understand, from the perspective of patients and clinicians, how and why different aspects of cancer care and diabetes care can complicate or facilitate each other, which is key to informing interventions to improve diabetes management during cancer treatments. This study aims to identify and elucidate barriers and enablers to effective diabetes management and control during cancer treatments, and potential intervention targets and strategies to address and harness these, respectively.Methods and analysisQualitative interviews will be conducted with people with diabetes and comorbid cancer (n=30–40) and a range of clinicians (n=30–40) involved in caring for this patient group (eg, oncologists, diabetologists, specialist nurses, general practitioners). Semistructured interviews will examine participants’ experiences of and perspectives on diabetes management and control during cancer treatments. Data will be analysed using framework analysis. Data collection and analysis will be informed by the Theoretical Domains Framework, and related Theory and Techniques Tool and Behaviour Change Wheel, to facilitate examination of a comprehensive range of barriers and enablers and support identification of pertinent and feasible intervention approaches. Study dates: January 2021–January 2023.Ethics and disseminationThe study has approval from National Health Service (NHS) West Midlands—Edgbaston Research Ethics Committee. Findings will be presented to lay, clinical, academic and NHS and charity service–provider audiences via dissemination of written summaries and presentations, and published in peer-reviewed journals. Findings will be used to inform development and implementation of clinical, health services and patient-management intervention strategies to optimise diabetes management and control during cancer treatments.

In March 2020, COVID-19 cases were beginning to emerge in North Florida and concern over hospital bed capacity started to rise. Baptist Health System in Jacksonville, Florida quickly formed a multidisciplinary team to explore how we could increase hospital bed capacity. Utilizing the resources within our affiliated home healthcare agency, an Enhanced Home Support Model (EHSM) with a COVID-19 protocol was developed. The protocol was implemented by home health nurses and included COVID-19 testing, blood tests, and the ability to start oxygen at home on admission. Patients were provided self-monitoring equipment and information about self-isolating and infection control within the home. After the initial visit, the home health nurse and the primary care physician shared collaborative oversight through virtual visits. This article discusses how we initially approached identification of severity and the methods we used to implement the protocol. The results section offers information about the number of patients utilizing this protocol between April and December 2020; patient and physician satisfaction; and considers strengths and weaknesses of the program. In conclusion, the EHSM protocol allowed patients to receive high quality emergent care at home and increased access to hospital emergency departments and inpatient hospital beds for more seriously ill patients.