The natural history of self-harm from adolescence to young adulthood : a population-based cohort study

Background Knowledge about the natural history of self-harm is scarce, especially during the transition from adolescence to young adulthood, a period characterised by a sharp rise in self-inflicted deaths. From a repeated measures cohort of a representative sample, we describe the course of self-harm from middle adolescence to young adulthood.

Methods A stratified, random sample of 1943 adolescents was recruited from 44 schools across the state of Victoria, Australia, between August, 1992, and January, 2008. We obtained data pertaining to self-harm from questionnaires and telephone interviews at seven waves of follow-up, commencing at mean age 15·9 years (SD 0·49) and ending at mean age 29·0 years (SD 0·59). Summary adolescent measures (waves three to six) were obtained for cannabis use, cigarette smoking, high-risk alcohol use, depression and anxiety, antisocial behaviour and parental separation or divorce.

Findings 1802 participants responded in the adolescent phase, with 149 (8%) reporting self-harm, More girls (95/947 [10%]) than boys (54/855 [6%]) reported self-harm (risk ratio 1·6, 95% CI 1·2–2·2). We recorded a substantial reduction in the frequency of self-harm during late adolescence. 122 of 1652 (7%) participants who reported self-harm during adolescence reported no further self-harm in young adulthood, with a stronger continuity in girls (13/888) than boys (1/764). During adolescence, incident self-harm was independently associated with symptoms of depression and anxiety (HR 3·7, 95% CI 2·4–5·9), antisocial behaviour (1·9, 1·1–3·4), high-risk alcohol use (2·1, 1·2–3·7), cannabis use (2·4, 1·4–4·4), and cigarette smoking (1·8, 1·0–3·1). Adolescent symptoms of depression and anxiety were clearly associated with incident self-harm in young adulthood (5·9, 2·2–16).

Interpretation Most self-harming behaviour in adolescents resolves spontaneously. The early detection and treatment of common mental disorders during adolescence might constitute an important and hitherto unrecognised component of suicide prevention in young adults.

Funding National Health and Medical Research Council, Australia, and operational infrastructure support programme, Government of Victoria, Australia.

Implementation of a quality care management system for patients with arthritis of the hip and knee

The Orthopaedic Unit of the Repatriation General Hospital (RGH) in Adelaide, South Australia has implemented a quality care management system for patients with arthritis of the hip and knee. The system not only optimises conservative management but ensures that joint replacement surgery is undertaken in an appropriate and timely manner. This new service model addresses identified barriers to service access and provides a comprehensive, coordinated strategy for patient management. Over 4 years the model has reduced waiting times for initial outpatient assessment from 8 to 3 months and surgery from 18 to 8 months, while decreasing length of stay from 6.3 to 5.3 days for hips and 5.8 to 5.3 days for knees. The service reforms have been accompanied by positive feedback from patients and referring general practitioners in relation to the improved coordination of care and enhanced efficiency in service delivery.

What is known about the topic? Several important initiatives both overseas and within Australia have contributed significantly to the development of this model of care. These include the UK National Health Service ‘18 weeks’ Project, the Western Canada Waiting List Project, the New Zealand priority criteria project, the Queensland Health Orthopaedic Physiotherapy Screening Clinic, and most importantly the Melbourne Health–University of Melbourne Orthopaedic Waiting List Project where a wide range of models were explored across Victorian hospitals from 2005 and the Multi-Attribute Prioritisation Tool (MAPT) was developed, validated and tested. This project became the Osteoarthritis Hip and Knee Service (OAHKS) and was operationalised in the Victorian healthcare system from 2012. These initiatives examined and addressed various aspects of management systems for patients with arthritis of the hip and knee in their particular setting.

What does this paper add? The development of this system is an extension of what is already known and is the first to encompass a comprehensive and coordinated strategy across all stages of the care management pathway for this patient group. Their management extends from the initial referral to development and implementation of a management plan, including surgery if assessed as necessary and organisation of long-term post operative follow up as required. By detailing the elements, key processes and measurable outcomes of the service redesign this paper provides a model for other institutions to implement a similar initiative.

What are the implications for practitioners? An important aspect of the design process was practitioner acceptance and engagement and the ability to improve their capacity to deliver services within an efficient and effective model. Intrinsic to the model’s development was assessment of practitioner satisfaction. Data obtained including practitioner surveys indicated an increased level of both satisfaction with the redesigned management service, and confidence in it to deliver its intended improvements.

Intimate partner violence : are Australian nurses and midwives trained to provide care?

Intimate Partner Violence is a significant issue.  In Australia, one in three women will experience Intimate Partner Violence in their lifetime.  Despite nurses and midwives being in an ideal position to be able to assess and care for women experiencing Intimate Partner Violence, they have not been adequately trained to do so.  This article introduces the reader to the issue of Intimate Partner Violence, the severity of it within Australia, and demonstrates the need for Australian nurses and midwives to be adequately trained to respond to this national health burden.  The article finishes by advising the reader that there will be a study commencing in 2014 that aims to promote the ability for Australian nurses and midwives to be able to care for women experiencing Intimate Partner Violence

Light-intensity physical activity and cardiometabolic biomarkers in US adolescents

Active commuting to school and association with physical activity and adiposity among US youth

Background: Walking or bicycling to school (ie, active commuting) has shown promise for improving physical activity and preventing obesity in youth. Our objectives were to examine, among US youth, whether active commuting was inversely associated with adiposity and positively associated with moderate-to-vigorous physical activity (MVPA). We also examined whether MVPA mediated the relationships between active commuting and adiposity.

Methods: Using data of participants aged 12 to 19 years from the US National Health and Nutrition Examination Survey 2003 to 2004 (n = 789 unweighted), we constructed multiple linear regression models that controlled for dietary energy intake and sociodemographics. The main exposure variable was active commuting. The outcomes were BMI z-score, waist circumference, skinfolds and objectively measured MVPA. The product-of-coefficients method was used to test for mediation.

Results: Active commuting was inversely associated with BMI z-score (β = –0.07, P = .046) and skinfolds (β = –0.06, P = .029), and positively associated with overall daily (β = 0.12, P = .024) and before- and after-school (β = 0.20, P < .001) MVPA. Greater before- and after-school MVPA explained part of the relationship between active commuting and waist circumference (Sobel z = –1.98, P = .048).

Conclusions: Active commuting was associated with greater MVPA and lower measures of adiposity among US youth. Before- and after-school MVPA mediated the relationships between active commuting and waist circumference.

The cost-effectiveness of the Dose Adjustment for Normal Eating (DAFNE) structured education programme: an update using the Sheffield Type 1 Diabetes policy model

AIMS: 
To estimate the cost-effectiveness of training in flexible intensive insulin therapy [as provided in the Dose Adjustment for Normal Eating (DAFNE) structured education programme] compared with no training for adults with Type 1 diabetes mellitus in the UK using the Sheffield Type 1 Diabetes Policy Model.

METHODS: 
The Sheffield Type 1 Diabetes Policy Model was used to simulate the development of long-term microvascular and macrovascular diabetes-related complications and the occurrence of diabetes-related adverse events in 5000 adults with Type 1 diabetes. Total costs and quality-adjusted life years were estimated from a National Health Service perspective over a lifetime horizon, discounted at a rate of 3.5%. The treatment effectiveness of DAFNE was modelled as a reduction in HbA1c that affected the risk of developing long-term diabetes-related complications. Probabilistic and structural sensitivity analyses were conducted.

RESULTS:
DAFNE resulted in greater life expectancy and reduced incidence of some diabetes-related complications compared with no DAFNE. DAFNE was found to generate an average of 0.0294 additional quality-adjusted life years for an additional cost of £426 per patient, leading to an incremental cost-effectiveness ratio of £14 400 compared with no DAFNE. There was a 54% probability that DAFNE would be cost-effective at a willingness-to-pay threshold of £20 000 per quality-adjusted life year.

CONCLUSIONS: 
The results of this study suggest that DAFNE is a cost-effective structured education programme for people with Type 1 diabetes and support its provision by the National Health Service in the UK.

Diabetes and risk of physical disability in adults: a systematic review and meta-analysis

Background
According to previous reports, the risk of disability as a result of diabetes varies from none to double. Disability is an important measure of health and an estimate of the risk of disability as a result of diabetes is crucial in view of the global diabetes epidemic. We did a systematic review and meta-analysis to estimate this risk.

Methods
We searched Ovid, Medline, Embase, Cochrane Library, and Cumulative Index to Nursing and Allied Health Literature up to Aug 8, 2012. We included studies of adults that compared the risk of disability—as measured by activities of daily living (ADL), instrumental activities of daily living (IADL), or mobility—in people with and without any type of diabetes. We excluded studies of subpopulations with specific illnesses or of people in nursing homes. From the studies, we recorded population characteristics, how diabetes was diagnosed (by doctor or self-reported), domain and definition of disability, and risk estimates for disability. We calculated pooled estimates by disability type and type of risk estimate (odds ratio [OR] or risk ratio [RR]).

Results
Our systematic review returned 3224 results, from which 26 studies were included in our meta-analyses. Diabetes increased the risk of mobility disability (15 studies; OR 1·71, 95% CI 1·53—1·91; RR 1·51, 95% CI 1·38—1·64), of IADL disability (ten studies; OR 1·65, 95% CI 1·55—1·74), and of ADL disability (16 studies; OR 1·82, 95% CI 1·63—2·04; RR 1·82, 95% CI 1·40—2·36).

Interpretation
Diabetes is associated with a strong increase in the risk of physical disability. Efforts to promote healthy ageing should account for this risk through prevention and management of diabetes.

Funding
Monash University, Baker IDI Bright Sparks Foundation, Australian Postgraduate Award, VicHealth, National Health and Medical Research Council, Australian Research Council, Victorian Government.

Doctors under the microscope: the birth of medical audit

In 1989 a UK government White Paper introduced medical audit as a comprehensive and statutory system of assessment and improvement in quality of care in hospitals. A considerable body of research has described the evolution of medical audit in terms of a struggle between doctors and National Health Service managers over control of quality assurance. In this paper we examine the emergence of medical audit from 1910 to the early 1950s, with a particular focus on the pioneering work of the American surgeons Codman, MacEachern and Ponton. It is contended that medical professionals initially created medical audit in order to articulate a suitable methodology for assessing individual and organisational performance. Rather than a means of protecting the medical profession from public scrutiny, medical auditing was conceived and operationalised as a managerial tool for fostering the active engagement of senior hospital managers and discharging public accountability. These early debates reveal how accounting was implicated in the development of a system for monitoring and improving the work of medical professionals, advancing the quality of hospital care, and was advocated in ways, which included rather than excluded managers.

Is lithium in a class of its own? A brief profile of its clinical use

Lithium is a unique and effective psychotropic agent with a long-standing history of clinical use yet it is increasingly overlooked in lieu of newer agents. The purpose of the present paper was to succinctly review the therapeutic profile of lithium particularly with respect to the treatment of mood disorders and consider its unique properties and clinical utility. A comprehensive literature review pertaining to lithium was undertaken using electronic database search engines to identify relevant clinical trials, meta-analyses and Cochrane reviews. In addition articles and book chapters known to the authors were carefully reviewed, and the authors appraised published guidelines. The evidence from these sources was rated using National Health and Medical Research Council evidence levels and synthesized according to phenotype and mood states. In addition, the authors have drawn upon published guidelines and their own clinical experience. Lithium has specificity for mood disorders with proven efficacy in the treatment of both unipolar depression and bipolar disorder. The recommendations are based predominantly on Level I evidence, but its clinical use has to be tempered against potential side-effects and the need for ongoing monitoring. In practice, lithium should be considered a first-line option in bipolar disorder, especially in prophylaxis and when onset of action is not an imperative. Lithium has been in use in modern medicine for 60 years and as such has been tried and tested across the full range of mood disorders. Arguably, lithium is the only true mood stabilizer and because of its unique properties is in a class of its own.

An examination of the demographic predictors of adolescent breakfast consumption, content, and context

Breakfast consumption is important to health; however, adolescents often skip breakfast, and an increased understanding of the breakfast consumption patterns of adolescents is needed. The purpose of this study was to identify the predictors of breakfast eating, including the content and context, in an adolescent sample from Australia and England.

Young adult sequelae of adolescent cannabis use: an integrative analysis

 Background: Debate continues about the consequences of adolescent cannabis use. Existing data are limited in statistical power to examine rarer outcomes and less common, heavier patterns of cannabis use than those already investigated; furthermore, evidence has a piecemeal approach to reporting of young adult sequelae. We aimed to provide a broad picture of the psychosocial sequelae of adolescent cannabis use. Methods: We integrated participant-level data from three large, long-running longitudinal studies from Australia and New Zealand: the Australian Temperament Project, the Christchurch Health and Development Study, and the Victorian Adolescent Health Cohort Study. We investigated the association between the maximum frequency of cannabis use before age 17 years (never, less than monthly, monthly or more, weekly or more, or daily) and seven developmental outcomes assessed up to age 30 years (high-school completion, attainment of university degree, cannabis dependence, use of other illicit drugs, suicide attempt, depression, and welfare dependence). The number of participants varied by outcome (N=2537 to N=3765). Findings: We recorded clear and consistent associations and dose-response relations between the frequency of adolescent cannabis use and all adverse young adult outcomes. After covariate adjustment, compared with individuals who had never used cannabis, those who were daily users before age 17 years had clear reductions in the odds of high-school completion (adjusted odds ratio 0·37, 95% CI 0·20-0·66) and degree attainment (0·38, 0·22-0·66), and substantially increased odds of later cannabis dependence (17·95, 9·44-34·12), use of other illicit drugs (7·80, 4·46-13·63), and suicide attempt (6·83, 2·04-22·90). Interpretation: Adverse sequelae of adolescent cannabis use are wide ranging and extend into young adulthood. Prevention or delay of cannabis use in adolescence is likely to have broad health and social benefits. Efforts to reform cannabis legislation should be carefully assessed to ensure they reduce adolescent cannabis use and prevent potentially adverse developmental effects. Funding: Australian Government National Health and Medical Research Council. © 2014 Elsevier Ltd.

Trends in body mass index according to educational attainment for urban Australian adults between 1980 and 2007

BackgroundWe have previously demonstrated that between the years 1980 and 2000, the mean body mass index (BMI) of the urban Australian population increased, with greater increases observed with increasing BMI. The current study aimed to quantify trends over time in BMI according to education between 1980 and 2007.MethodsWe compared data from the 1980, 1983 and 1989 National Heart Foundation Risk Factor Prevalence Studies, 1995 National Nutrition Survey, 2000 Australian Diabetes, Obesity and Lifestyle Study and the 2007 National Health Survey. For survey comparability, analyses were restricted to urban Australian residents aged 25-64 years. BMI was calculated from measured height and weight. The education variable was dichotomised at completion of secondary school. Four age-standardised BMI indicators were compared over time by sex and education: mean BMI, mean BMI of the top five percent of the BMI distribution, prevalence of obesity (BMI⩾30 kg/m(2)), prevalence of class II(+) obesity (BMI⩾35 kg/m(2)).ResultsBetween 1980 and 2007, the mean BMI among men increased by 2.5 kg/m(2) and 1.7 kg/m(2) for those with low and high education levels, respectively, corresponding to increases in obesity prevalence of 20(from 12% to 32%) and 11(10% to 21%) %-points. Among women mean BMI increased by 2.9 kg/m(2) and 2.4 kg/m(2) for those with low and high education levels respectively, corresponding to increases in obesity prevalence of 16(12% to 28%) and 12(7% to 19%) %-points. The prevalence of class II(+) obesity among men increased by 9(1% to 10%) and 4(1% to 5%) %-points for those with low and high education levels, and among women increased by 8(4% to 12%) and 4(2% to 6%) %-points. Absolute and relative differences between education groups generally increased over time.ConclusionsEducational differences in BMI have persisted among urban Australian adults since 1980 without improvement. Obesity prevention policies will need to be effective in those with greatest socio-economic disadvantage if we are to equitably and effectively address the population burden of obesity and its corollaries.International Journal of Obesity accepted article preview online, 16 March 2015. doi:10.1038/ijo.2015.27.

Development of a postgraduate interventional cardiac nursing curriculum

Interventional cardiology practices have advanced immensely in the last two decades, but the educational preparation of the workforce in cardiac catheter laboratories has not seen commensurate changes. Although on-the-job training has sufficed in the past, recognition of this workforce as a specialty practice domain now demands specialist educational preparation. The aim of this paper is to present the development of an interventional cardiac nursing curriculum nested within a Master of Nursing Practice in Australia. International and national health educational principles, teaching and learning theories and professional frameworks and philosophies are foundational to the program designed for interventional cardiac specialist nurses. These broader health, educational and professional underpinnings will be described to illustrate their application to the program's theoretical and clinical components. Situating interventional cardiac nursing within a Master's degree program at University provides nurses with the opportunities to develop high level critical thinking and problem solving knowledge and skills.