Decision making in childhood asthma exacerbation – a clinical judgement analysis

Background: Clinical decisions which impact directly on patient safety and quality of care are made during acute asthma attacks by individual doctors on the basis of their knowledge and experience. These include administration of systemic corticosteroids (CS), oral antibiotics, and admission to hospital. Clinical judgement analysis provides a methodology for comparing decisions between practitioners with different training and experience, and improving decision making. Methods: Stepwise linear regression was used to select clinical cues based on visual analogue scale assessments of the propensity of 62 clinicians to prescribe a short course of oral CS (decision 1), a course of antibiotics (decision 2), and/or admit to hospital (decision 3) for 60 â??paperâ?? patients. Results:When compared by specialty, paediatriciansâ?? models for decision 1 were more likely to include as a cue level of alertness (54% v. 16%); for decision 2 presence of crepitations (49% v. 16%), and less likely to include inhaled CS (8% v. 40%), respiratory rate (0% v. 24%), and air entry (70% v. 100%). When compared to other grades, the models derived for decision 3 by consultants/general practitioners were more likely to include wheeze severity as a cue (39% v. 6%). Conclusions: Clinicians differed in their use of individual cues and the number included in their models. Patient safety and quality of care will benefit from clarification of decision making strategies as general learning points during medical training, in the development of guidelines and care pathways, and by clinicians developing self-awareness of their own preferences.

Chironomid-based reconstructions of summer air temperature from lake deposits in Lyndon Stream, New Zealand spanning the MIS 3/2 transition

We present chironomid-based temperature reconstructions from lake sediments deposited between ca 26,600 cal yr BP and 24,500 cal yr BP from Lyndon Stream, South Island, New Zealand. Summer (February mean) temperatures averaged 1 1C cooler, with a maximum inferred cooling of 3.7 1C. These estimates corroborate macrofossil and beetle-based temperature inferences from the same site and suggest climate amelioration (an interstadial) at this time. Other records from the New Zealand region also show a large degree of variability during the late Otiran glacial sequence (34,000–18,000 cal yr BP) including a phase of warming at the MIS 2/3 transition and a maximum cooling that did not occur until the global LGM (ca 20,000 cal yr BP). The very moderate cooling identified here at the MIS 2/3 transition confirms and enhances the long-standing discrepancy in New Zealand records between pollen and other proxies. Low abundances (o20%) of canopy tree pollen in records from late MIS 3 to the end of MIS 2 cannot be explained by the minor (o5 1C) cooling inferred from this and other studies unless other environmental parameters are considered. Further work is required to address this critical issue.