• Our study shows associations between increased work stress and burnout with mitigated quality of care. • Beyond indirect effects of work stress through emotional exhaustion on quality of care we also observed direct detrimental effects of pediatricians' work stress on mitigated care quality.

BackgroundEmergency departments (ED) are complex and dynamic work environments with various psychosocial work stressors that increase risks for providers’ well-being. Yet, no systematic review is available which synthesizes the current research base as well as quantitatively aggregates data on associations between ED work factors and provider well-being outcomes.ObjectiveWe aimed at synthesizing the current research base on quantitative associations between psychosocial work factors (classified into patient-/ task-related, organizational, and social factors) and mental well-being of ED providers (classified into positive well-being outcomes, affective symptoms and negative psychological functioning, cognitive-behavioural outcomes, and psychosomatic health complaints).MethodsA systematic literature search in eight databases was conducted in December 2017. Original studies were extracted following a stepwise procedure and predefined inclusion criteria. A standardized assessment of methodological quality and risk of bias was conducted for each study with the Quality Assessment Tool for Quantitative Studies from the Effective Public Health Practice Project. In addition to a systematic compilation of included studies, frequency and strength of quantitative associations were synthesized by means of harvest plots. Subgroup analyses for ED physicians and nurses were conducted.ResultsN = 1956 records were retrieved. After removal of duplicates, 1473 records were screened for titles and abstracts. 199 studies were eligible for full-text review. Finally, 39 original studies were included whereof 37 reported cross-sectional surveys. Concerning the methodological quality of included studies, the majority was evaluated as weak to moderate with considerable risk of bias. Most frequently surveyed provider outcomes were affective symptoms (e.g., burnout) and positive well-being outcomes (e.g., job satisfaction). 367 univariate associations and 370 multivariate associations were extracted with the majority being weak to moderate. Strong associations were mostly reported for social and organizational work factors.ConclusionsTo the best of our knowledge, this review is the first to provide a quantitative summary of the research base on associations of psychosocial ED work factors and provider well-being. Conclusive results reveal that peer support, well-designed organizational structures, and employee reward systems balance the negative impact of adverse work factors on ED providers’ well-being. This review identifies avenues for future research in this field including methodological advances by using quasi-experimental and prospective designs, representative samples, and adequate confounder control.Trial registrationProtocol registration number: PROSPERO 2016 CRD42016037220

Zusammenfassung Fragestellung: K?nstliche Ern?hrung im ambulanten Bereich umfasst die heimparenterale Ern?hrung (HPE) und heimenterale Ern?hrung (HEE) sowie die supplement?re Trinknahrung (ONS), die bei Patienten zu Hause oder in Pflegeeinrichtungen durchgef?hrt wird. Meistens beginnen HPE/HEE im Anschluss an einen station?ren Aufenthalt in einer Klinik. Die vorliegende Leitlinie soll evidenzbasierte Empfehlungen zur k?nstlichen Ern?hrung im ambulanten Bereich geben. Methodik: Es wurde eine systematische Literaturrecherche zur HEE, HPE und zu ONS im ambulanten Bereich durchgef?hrt. Die Ergebnisse wurden in einer interdisziplin?ren Arbeitsgruppe aus Medizinern, Apothekern, Ern?hrungswissenschaftlern und Di?tassistenten diskutiert. Auf dieser Basis wurden von der Arbeitsgruppe Empfehlungen erarbeitet, die auf der Konsensuskonferenz am 1. Dezember 2012 vorgestellt, diskutiert, zum Teil modifiziert und verabschiedet wurden. Ergebnisse: Die Leitlinie enth?lt 54 Empfehlungen zur k?nstlichen Ern?hrung im ambulanten Bereich. Die Indikation zur k?nstlichen Ern?hrung im ambulanten Bereich unterscheidet sich nicht grunds?tzlich von der Indikation im station?ren Bereich, wobei die Aspekte Prognose, Lebensqualit?t und Ethik im ambulanten Bereich einen besonders hohen Stellenwert haben. Der geeignete Zufuhrweg f?r eine ambulante k?nstliche Ern?hrung h?ngt von der funktionellen Integrit?t des Magen-Darm-Trakts ab. Bei einer l?ngerfristigen HEE soll eine perkutane endoskopische Gastrostomie (PEG)-Sonde gegen?ber den herk?mmlichen chirurgischen Gastrostomieverfahren aufgrund einer niedrigeren Komplikationsrate bevorzugt werden. Bei relevanten St?rungen der Transport- oder Absorptionskapazit?t des D?nndarms soll eine intraven?se Ern?hrung gew?hlt werden. Die Pflege der Zugangswege bei HEE und HPE sollte durch geschultes Pflegefachpersonal gem?? evidenzbasierten Richtlinien und Pflegestandards durchgef?hrt werden, um eine hohe Hygienequalit?t zu erreichen. F?r die ausschlie?liche und langfristige HEE ?ber gastrointestinale Sonden und f?r die orale Ern?hrung durch Trinknahrung sollen vollst?ndig bilanzierte Trink- bzw. Sondennahrungsprodukte verwendet werden, da diese in ihrer Zusammensetzung den D-A-CH-Empfehlungen entsprechen und den EU-Richtlinien gen?gen. Zur HPE sollten ?All-in-One-N?hrmischungen? bzw. ?Dreikammerbeutel? verwendet werden, denn sie sind als sichere, effektive und risikoreduzierende Standards zur Durchf?hrung der HPE etabliert. Schlussfolgerung: Die HEE und HPE sind anerkannte und sichere Verfahren, wenn sie standardisiert nach aktuellen wissenschaftlichen Erkenntnissen und koordiniert m?glichst durch ein interdisziplin?res Ern?hrungsteam erfolgen. Durch das Ern?hrungsteam k?nnen die Qualit?t der Ma?nahmen erh?ht und die Komplikationsraten reduziert werden. Die k?nstliche Ern?hrung im ambulanten Bereich kann einen entscheidenden Beitrag zur Verbesserung der Lebensqualit?t von unterern?hrten Patienten und zur Steigerung der Kosteneffizienz medizinischer Ma?nahmen beitragen.

The diversity of berry skin flavonoids in grape genotypes has been previously widely investigated with regard to major compounds (nonacylated anthocyanins and flavonols), but much less with regard to acylated anthocyanins and hydroxycinnamoyl tartrates (HCTs). In this study, the composition of the phenolic fraction of the berry skin (free and acylated anthocyanins, flavonols, and HCTs) was assessed on 34 grapevine genotypes grown in a collection vineyard in northwestern Italy. The phenolic fraction was profiled on berries collected in the same vineyard, at the same ripening level across two successive vintages. The anthocyanin, HCT, and flavonol profiles were specific of each genotype, and the first two were relatively little affected by the vintage. A wide diversity in the polyphenolic fraction was shown among cultivars. Besides expected discriminatory effects of free anthocyanins and flavonol profiles, principal component analyses allowed a good discrimination of cultivars on the basis of coumaroylated anthocyanins and of the HCT profile. Anthocyanins were mostly acylated by aromatic acids, and acylation was independent from the anthocyanin substrate. HCTs were present mostly as coumaroyl and caffeoyl derivatives, and no correlation was observed between the same acylation patterns of tartrate and of anthocyanins. The results of this study are discussed in the light of new hypotheses on still unknown biosynthetic steps of phenolic substances and of the potential use of these substances in discrimination and identification of different grape cultivars in wines.

‘Nebbiolo’ (Vitis vinifera) is among the most ancient and prestigious wine grape varieties characterised by a wide genetic variability exhibited by a high number of clones (vegetatively propagated lines of selected mother plants). However, limited information is available for this cultivar at the molecular and genomic levels. The whole-genomes of three ‘Nebbiolo’ clones (CVT 71, CVT 185 and CVT 423) were re-sequenced and a de novo transcriptome assembly was produced. Important remarks about the genetic peculiarities of ‘Nebbiolo’ and its intra-varietal variability useful for clonal identification were reported. In particular, several varietal transcripts identified for the first time in ‘Nebbiolo’ were disease resistance genes and single-nucleotide variants (SNVs) identified in ‘Nebbiolo’, but not in other cultivars, were associated with genes involved in the stress response. Ten newly discovered SNVs were successfully employed to identify some periclinal chimeras and to classify 98 ‘Nebbiolo’ clones in seven main genotypes, which resulted to be linked to the geographical origin of accessions. In addition, for the first time it was possible to discriminate some ‘Nebbiolo’ clones from the others.

BackgroundEmergency departments (EDs) are highly dynamic and stressful care environments that affect provider and patient outcomes. Yet, effective interventions are missing. This study evaluated prospective effects of a multi-professional organizational-level intervention on changes in ED providers’ work conditions and well-being (primary outcomes) and patient-perceived quality of ED care (secondary outcome).MethodsA before and after study including an interrupted time-series (ITS) design over 1 year was established in the multidisciplinary ED of a tertiary referral hospital in Southern Germany. Our mixed-methods approach included standardized provider surveys, expert work observations, patient surveys, and register data. Stakeholder interviews were conducted for qualitative process evaluation. ITS data was available for 20 days pre- and post-intervention (Dec15/Jan16; Dec16/Jan17). The intervention comprised ten multi-professional meetings in which ED physicians and nurses developed solutions to work stressors in a systematic moderated process. Most solutions were consecutively implemented. Changes in study outcomes were assessed with paired t-tests and segmented regression analyses controlling for daily ED workload.ResultsOne hundred forty-nine surveys were returned at baseline and follow-up (response at baseline: 76 out of 170; follow-up: 73 out of 157). Forty-one ED providers participated in both waves. One hundred sixty expert work observations comprising 240 observation hours were conducted with 156 subsequent work stress reports. One thousand four hundred eighteen ED patients were surveyed. Considering primary outcomes, respondents reported more job control and less overtime hours at follow-up. Social support, job satisfaction, and depersonalization deteriorated while respondents’ turnover intentions and inter-professional interruptions increased. Considering the secondary outcome, patient reports indicated improvements in ED organization and waiting times. Interviews revealed facilitators (e.g., comprehensive approach, employee participation) and barriers (e.g., understaffing, organizational constraints) for intervention implementation.ConclusionsTo the best of our knowledge, this is the first study to report prospective effects of an ED work system intervention on provider well-being and patient-perceived quality of ED care. We found inconsistent results with partial improvements in work conditions and patient perceptions of care. However, aspects of provider mental well-being deteriorated. Given the lack of organizational-level intervention research in EDs, our findings provide valuable insights into the feasibility and effects of participatory interventions in this highly dynamic hospital setting.Electronic supplementary materialThe online version of this article (10.1186/s12873-018-0218-x) contains supplementary material, which is available to authorized users.

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ObjectivesDealing with multiple workflow interruptions is a major challenge in emergency department (ED) work. This study aimed to establish a taxonomy of workflow interruptions that takes into account the content and purpose of interruptive communication. It further aimed to identify associations of workflow interruptions with ED professionals’ work stress.DesignCombined data from expert observation sessions and concomitant self-evaluations of ED providers.SettingED of an academic community hospital in Germany.ParticipantsMultidisciplinary sample of ED physicians and nurses. 77 matched observation sessions of interruptions and self-evaluations of work stress were obtained on 20 randomly selected days.Outcome measuresED professionals’ stress evaluations were based on standardised measures. ED workload data on patient load, patient acuity and staffing were included as control variables in regression analyses.ResultsOverall mean rate was 7.51 interruptions/hour. Interruptions were most frequently caused by ED colleagues of another profession (27.1%; mean interruptions/hour rate: 2.04), by ED colleagues of the same profession (24.1%; 1.81) and by telephone/beeper (21%; 1.57). Concerning the contents of interruption events, interruptions most frequently occurred referring to a parallel case under care (30.3%, 2.07), concerning the current case (19.1%; 1.28), or related to coordination activities (18.2%, 1.24). Regression analyses revealed that interruptive communication related to parallel cases significantly increased ED providers’ stress levels (β=0.24, P=0.03). This association remained significant after controlling for ED workload.DiscussionInterruptions that refer to parallel cases under care were associated with increased stress among ED physicians and nurses. Our approach to distinguish between sources and contents of interruptions contributes to an improved understanding of potential benefits and risks of workflow interruptions in ED work environments. Despite some limitations, our findings add to future research on the implications of interruptions for effective and safe patient care and work in complex and dynamic care environments.