Stress, the hippocampus and the HPA axis: Implications for the development of psychotic disorders

The experience of stress is commonly implicated in models of the onset of psychotic disorders. However, prospective studies investigating associations between biological markers of stress and the emergence of psychotic disorders are limited and inconclusive. One biological system proposed as the link between the psychological experience of stress and the development of psychosis is the Hypothalamic-Pituitary-Adrenal (HPA) axis. This paper summarizes and discusses evidence supporting a role for HPA-axis dysfunction in the early phase of schizophrenia and related disorders. METHOD A selective review of psychiatric and psychological research on stress, coping, HPA-axis, the hippocampus and psychotic disorders was performed, with a particular focus on the relationship between HPA-axis dysfunction and the onset of psychotic disorders. RESULTS Individual strands of past research have suggested that the HPA-axis is dysfunctional in at least some individuals with established psychotic disorders; that the hippocampus is an area of the brain that appears to be implicated in the onset and maintenance of psychotic disorders; and that an increase in the experience of stress precedes the onset of a psychotic episode in some individuals. Models of the onset and maintenance of psychotic disorders that link these individual strands of research and strategies for examining these models are proposed in this paper. CONCLUSIONS The current literature provides some evidence that the onset of psychotic disorders may be associated with a higher rate of stress and changes to the hippocampus. It is suggested that future research should investigate whether a relationship exists between psychological stress, HPA-axis functioning and the hippocampus in the onset of these disorders. Longitudinal assessment of these factors in young people at 'ultra' high risk of psychosis and first-episode psychosis cohorts may enhance understanding of the possible interaction between them in the early phases of illness.

A taste of best practice in engineering sustainable solutions

This paper asks the question to what scale and speed does society need to reduce its ecological footprint and improve resource productivity to prevent further overshoot and return within the ecological limits of the earth’s ecological life support systems? How fast do these changes need to be achieved? The paper shows that now a large range of studies find that engineering sustainable solutions need to be roughly an order or magnitude resource productivity improvement (sometimes called a Factor of 10, or a 90% reduction) by 2050 to achieve real and lasting ecological sustainability. This marks a significant challenge for engineers – indeed all designers and architects, where best practice in engineering sustainable solutions will need to achieve large resource productivity targets. The paper brings together examples of best practice in achieving these large targets from around the world. The paper also highlights key resources and texts for engineers who wish to learn how to do it. But engineers need to be realistic and patient. Significant barriers exist to achieving Factor 4-10 such as the fact that infrastructure and technology rollover and replacement is often slow. This slow rollover of the built environment and technology is the context within which most engineers work, making the goal of achieving Factor 10 all the more challenging. However, the paper demonstrates that by using best practice in engineering sustainable solutions and by addressing the necessary market, information and institutional failures it is possible to achieve Factor 10 over the next 50 years. This paper draws on recent publications by The Natural Edge Project (TNEP) and partners, including Hargroves, K. Smith, M. (Eds) (2005) The Natural Advantage of Nations: Business Opportunities, Innovation and Governance for the 21st Century, and the TNEP Engineering Sustainable Solutions Program - Critical Literacies for Engineers Portfolio. Both projects have the significant support of Engineers Australia. its College of Environmental Engineers and the Society of Sustainability and Environmental Engineering.

‘True Blood’ the critical care story: An audit of blood sampling practice across three adult, paediatric and neonatal intensive care settings

Background Anaemia is common in critically ill patients, and has a significant negative impact on patients' recovery. Blood conservation strategies have been developed to reduce the incidence of iatrogenic anaemic caused by sampling for diagnostic testing. Objectives Describe practice and local guidelines in adult, paediatric and neonatal Australian intensive care units (ICUs) regarding blood sampling and conservation strategies. Methods Cross-sectional descriptive study, conducted July 2013 over one week in single adult, paediatric and neonatal ICUs in Brisbane. Data were collected on diagnostic blood samples obtained during the study period, including demographic and acuity data of patients. Institutional blood conservation practice and guidelines were compared against seven evidence-based recommendations. Results A total of 940 blood sampling episodes from 96 patients were examined across three sites. Arterial blood gas was the predominant reason for blood sampling in each unit, accounting for 82% of adult, 80% of paediatric and 47% of neonatal samples taken (p <. 0.001). Adult patients had significantly more median [IQR] samples per day in comparison to paediatrics and neonates (adults 5.0 [2.4]; paediatrics 2.3 [2.9]; neonatal 0.7 [2.7]), which significantly increased median [IQR] blood sampling costs per day (adults AUD$101.11 [54.71]; paediatrics AUD$41.55 [56.74]; neonatal AUD$8.13 [14.95]; p <. 0.001). The total volume of samples per day (median [IQR]) was also highest in adults (adults 22.3. mL [16.8]; paediatrics 5.0. mL [1.0]; neonates 0.16. mL [0.4]). There was little information about blood conservation strategies in the local clinical practice guidelines, with the adult and neonatal sites including none of the seven recommendations. Conclusions There was significant variation in blood sampling practice and conservation strategies between critical care settings. This has implications not only for anaemia but also infection control and healthcare costs.

Association of ERAP1, but not IL23R, with ankylosing spondylitis in a Han Chinese population

Objective The results of a recent genome-wide association study have shown that ERAP1 and IL23R are associated with ankylosing spondylitis (AS) in Caucasian populations from North America and the UK. Based on these findings, we undertook the current study to investigate whether single-nucleotide polymorphisms (SNPs) covering the genes ERAP1 and IL23R are associated with AS in a Han Chinese population. Methods A case-control study was performed in Han Chinese patients with AS (n = 527) and controls (n = 945) from Shanghai and Nanjing. All patients met the modified New York criteria for AS. The Sequenom iPlex platform was used to genotype cases and controls for 21 tag SNPs covering IL23R and 38 tag SNPs covering ERAP1. Statistical analysis was performed using the Cochran-Armitage test for trend. Results Multiple SNPs in ERAP1 were significantly associated with AS (for rs27980, P = 0.0048; for rs7711564, P = 0.0081). However, no association was observed between IL23R and AS (for all SNPs, P > 0.1). The nonsynonymous SNP in IL23R, rs11209026, widely thought to be the primary AS-associated SNP in IL23R in Europeans, was found not to be polymorphic in Chinese. Conclusion Our results demonstrate that genetic polymorphisms in ERAP1 are associated with AS in Han Chinese, suggesting a common pathogenic mechanism for the disease in Chinese and Caucasian populations, and that IL23R is not associated with AS in Chinese, indicating a difference in the mechanism of disease pathogenesis between Chinese and Caucasian populations. This may result from the fact that rs11209026, the nonsynonymous SNP in IL23R, is not polymorphic in Chinese patients, providing further evidence that rs11209026 is the key polymorphism associated with AS (and likely inflammatory bowel disease and psoriasis) in this gene.

Effects of different instructional constraints on task performance and emergence of coordination in children

The objectives of this study were to determine the impact of different instructional constraints on standing board jump (sbj) performance in children and understand the underlying changes in emergent movement patterns. Two groups of novice participants were provided with either externally or internally focused attentional instructions during an intervention phase. Pre- and post-test sessions were undertaken to determine changes to performance and movement patterns. Thirty-six primary fourth-grade male students were recruited for this study and randomly assigned to either an external, internal focus or control group. Different instructional constraints with either an external focus (image of the achievement) or an internal focus (image of the act) were provided to the participants. Performance scores (jump distances), and data from key kinematic (joint range of motion, ROM) and kinetic variables (jump impulses) were collected. Instructional constraints with an emphasis on an external focus of attention were generally more effective in assisting learners to improve jump distances. Intra-individual analyses highlighted how enhanced jump distances for successful participants may be concomitant with specific changes to kinematic and kinetic variables. Larger joint ROM and adjustment to a comparatively larger horizontal impulse to a vertical impulse were observed for more successful participants at post-test performance. From a constraints-led perspective, the inclusion of instructional constraints encouraging self-adjustments in the control of movements (i.e., image of achievement) had a beneficial effect on individuals performing the standing broad jump task. However, the advantage of using an external focus of attentional instructions could be task- and individual-specific.

Workplace stress: What is the role of positive mental health?

Objective: To examine whether positive mental health (PMH)—a positively focused well-being construct—moderates the job stress–distress relationship. Methods: Longitudinal regression was used to test two waves of matched, population-level data from a sample of older, working Australian adults (n = 3291) to see whether PMH modified the relationship between work stress and later psychological distress. Results: Time 1 work stress was positively associated with distress at both time points. Positive mental health was negatively associated with work stress at both time points. Positive mental health modified the impact of work stress on psychological distress. This effect only occurred for those with the highest levels of PMH. Conclusions: Positive mental health may help protect workers from the effect of workplace stress but only in a small proportion of the population. Therefore, to improve workplace mental health, workplaces need to both prevent stress and promote PMH.

General practitioners learning qualitative research: A case study of postgraduate education

Background Qualitative research is increasingly being recognised as a vital aspect of primary healthcare research. Teaching and learning how to conduct qualitative research is especially important for general practitioners and other clinicians in the professional educational setting. This article examines a case study of postgraduate professional education in qualitative research for clinicians, for the purpose of enabling a robust discussion around teaching and learning in medicine and the health sciences. Method A series of three workshops was delivered for primary healthcare academics. The workshops were evaluated using a quantitative survey and qualitative free-text responses to enable descriptive analyses. Results Participants found qualitative philosophy and theory the most difficult areas to engage with, and learning qualitative coding and analysis was considered the easiest to learn. Discussion Key elements for successful teaching were identified, including the use of adult learning principles, the value of an experienced facilitator and an awareness of the impact of clinical subcultures on learning.

Australian data do not support current pharmaceutical benefits scheme criteria for use of tumour necrosis factor-α inhibitors in ankylosing spondylitis

On the basis of local data, we write in support of the conclusions of Smith and Ahern that current Pharmaceu- tical Benefits Scheme (PBS) criteria for tumour necrosis factor (TNF)-a inhibitors in ankylosing spondylitis (AS) are not evidence-based. 1 As a prerequisite to the appropriate use of biological therapy in AS, three aspects of the disease need to be defined: (i) diagnosis, (ii) activity and (iii) therapeutic failure (Table 1)....

Factors influencing sustainability of health service innovation: Emergency nurse practitioner services

Introduction: Emergency department nurse practitioner services are one of the most frequently implemented service delivery models in Australian hospitals. This research examined factors influencing sustainability of this innovative service delivery model and offers some recommendations for future service integration. Background Many health service innovations have been implemented in an attempt to meet the growing demand for efficient, cost effective health care however, sustainability of many of these innovations has not been evaluated and is poorly understood. Aim The aim of the research was to identify factors that influence sustainability of emergency department nurse practitioner services and to operationalise a theoretical framework for evaluating innovation sustainability. Methodology The research used case study methodology. The case was emergency nurse practitioner services, and units of analysis were emergency department staff, emergency nurse practitioners and documents relating to nurse practitioner services. The data collection methods included, survey, one-on-one interviews, document analysis and telephone survey. Results This research shows that emergency nurse practitioner services partially comply with the factors of sustainability as described in the Sustainability of Innovation theoretical framework: Political, Organisational, Workforce, Financial and Innovation specific factors. Where services do not entirely meet the factors the existing benefits of the service may outweigh the barriers and other means of working around shortfalls are also implemented by staff to ensure patient safety. Conclusion The rapidly expanding emergency nurse practitioner service has been examined using case study methodology to find that certain factors may be threatening the sustainability of this health service innovation. Potentially an innovation may be sustained when only some factors are met in the short term, however, long term sustainability may be challenged if factors are not addressed and supported.

The experience of forging new emergency nursing curriculum development, through a course advisory network

Queensland University of Technology (QUT), School of Nursing (SoN), has offered a postgraduate Graduate Certificate in Emergency Nursing since 2003, for registered nurses practising in an emergency clinical area, who fulfil key entry criteria. Feedback from industry partners and students evidenced support for flexible and extended study pathways in emergency nursing. Therefore, in the context of a growing demand for emergency health services and the need for specialist qualified staff, it was timely to review and redevelop our emergency specialist nursing courses. The QUT postgraduate emergency nursing study area is supported by a course advisory group, whose aim is to provide input and focus development of current and future course planning. All members of the course advisory were invited to form an expert panel to review current emergency course documents. A half day “brainstorm session”, planning and development workshop was held to review the emergency courses to implement changes from 2009. Results from the expert panel planning day include: proposal for a new emergency specialty unit; incorporation of the College of Emergency Nurses (CENA) Standards for Emergency Nursing Specialist in clinical assessment; modification of the present core emergency unit; enhancing the focus of the two other units that emergency students undertake; and opening the emergency study area to the Graduate Diploma in Nursing (Emergency Nursing) and Master of Nursing (Emergency Nursing). The conclusion of the brainstorm session resulted in a clearer conceptualisation, of the study pathway for students. Overall, the expert panel group of enthusiastic emergency educators and clinicians provided viable options for extending the career progression opportunities for emergency nurses. In concluding, the opportunity for collaboration across university and clinical settings has resulted in the design of a course with exciting potential and strong clinical relevance.

Observations of road safety behaviours and practices of motorcycle rickshaw drivers in Lahore, Pakistan

Motorcycle Rickshaws (MRs) are an informal paratransit mode in Pakistan. They are locally manufactured and very popular but there are concerns about their crash involvement and overall safety. The first study of the current PhD program revealed that rickshaws (both MRs and auto-rickshaws) were involved in 51,992 road crashes attended by emergency ambulances in Punjab province, Pakistan between 2011-2013. This study aims to examine the road safety behaviours and practices of Motorcycle Rickshaw Drivers (MRDs) that may be contributing to these crashes. MRDs were observed at 12 major signalised intersections in Lahore. Vehicle characteristics and driver behaviours were recorded using a paper-based survey between 9am-7pm for a full week in May 2015. Of the 500 MRDs observed, about 23.4% appeared to be younger than the minimum driver licensing age of 18 years. More than half (52.6%) of the MRDs entered on the red light and 17.4% crossed when the signal was turning from yellow to green or red. MR traffic conflicts were observed in 62.8% of cases and one crash and 15 near-miss crashes were witnessed. Additionally, about half of MRs were overloaded, no MRD wore a helmet, and 3.8% were using a mobile phone while driving. This study provides the first scientific evidence to substantiate public concerns regarding the safety of MRs. It demonstrates that about a quarter of MRDs are underage,almost half of MRs are overloaded and more than half disobey traffic signals. This research could inform authorities to manage MR related transport and road safety issues.

The ATHEROMA (Atorvastatin Therapy: Effects on Reduction of Macrophage Activity) Study. Evaluation using ultrasmall superparamagnetic iron oxide-enhanced magnetic resonance imaging in carotid disease

Objectives: The aim of this study was to evaluate the effects of low-dose (10 mg) and high-dose (80 mg) atorvastatin on carotid plaque inflammation as determined by ultrasmall superparamagnetic iron oxide (USPIO)-enhanced carotid magnetic resonance imaging (MRI). The hypothesis was that treatment with 80 mg atorvastatin would demonstrate quantifiable changes in USPIO-enhanced MRI-defined inflammation within the first 3 months of therapy. Background: Preliminary studies indicate that USPIO-enhanced MRI can identify macrophage infiltration in human carotid atheroma in vivo and hence may be a surrogate marker of plaque inflammation. Methods: Forty-seven patients with carotid stenosis >40% on duplex ultrasonography and who demonstrated intraplaque accumulation of USPIO on MRI at baseline were randomly assigned in a balanced, double-blind manner to either 10 or 80 mg atorvastatin daily for 12 weeks. Baseline statin therapy was equivalent to 10 mg of atorvastatin or less. The primary end point was change from baseline in signal intensity (ΔSI) on USPIO-enhanced MRI in carotid plaque at 6 and 12 weeks. Results: Twenty patients completed 12 weeks of treatment in each group. A significant reduction from baseline in USPIO-defined inflammation was observed in the 80-mg group at both 6 weeks (ΔSI 0.13; p = 0.0003) and at 12 weeks (ΔSI 0.20; p < 0.0001). No difference was observed with the low-dose regimen. The 80-mg atorvastatin dose significantly reduced total cholesterol by 15% (p = 0.0003) and low-density lipoprotein cholesterol by 29% (p = 0.0001) at 12 weeks. Conclusions: Aggressive lipid-lowering therapy over a 3-month period is associated with significant reduction in USPIO-defined inflammation. USPIO-enhanced MRI methodology may be a useful imaging biomarker for the screening and assessment of therapeutic response to "anti-inflammatory" interventions in patients with atherosclerotic lesions. (Effects of Atorvastatin on Macrophage Activity and Plaque Inflammation Using Magnetic Resonance Imaging [ATHEROMA]; NCT00368589).

Conceptualising the challenge of integrating digital technologies in pedagogy

The integration of digital technologies in pedagogy is positioned as an important change in education, but widespread innovative use of digital technologies is yet to be truly realised. The gap between the potential and the reality of digital technology integration is commonly attributed to a range of challenging extrinsic and intrinsic influences. Activity Theory (Engeström, 2009) is used to analyse challenges created by extrinsic influences (Nielsen, Miller, & Hoban, 2012); a complementary theory is needed to conceptualise intrinsic influences. System 1 and System 2 thinking theory (Kahneman, 2011) will be advanced as a conceptual framework for understanding conscious and unconscious aspects of teacher practice, particularly the interaction between innovation and teacher routine, attitudes and beliefs. Transformative Learning Theory (Mezirow, 2009) will be positioned to comprehend the nexus of extrinsic and intrinsic influences. This paper will propose how, when faced with extrinsic and intrinsic influences on innovative practice, educators can use these theories to conceptualise the challenge of integrating digital technologies in pedagogy.

Developing a new index for comparing road safety maturity: Case study of the ASEAN community

As part of the development of the ASEAN Regional Road Safety Strategy, a new index for measuring road safety maturity (RSM) was constructed from numerical weightings given to measurable factors presented for each of the pillars that guide national road safety plans and activities in WHO Global Road Safety Report 2013: road safety management, safer road and mobility, safer vehicles, safer road users and post-crash response. The index is based on both a content analysis approach and a binary methodology (report/no report) including measures which have been considered pertinent and not redundant. For instance, the use of random breath testing and/or police checkpoints in the national drink driving law are combined in the enforcement index. The value of the index per pillar ranges from 0 to 100%, taking into account whether there is total, partial or non-implementation of certain actions. In addition, when possible, the self-rated level of enforcement is included. The overall ratings for the I 0 ASEAN countries and the scores for each of the pillars are presented in the paper. The extent to which the RSM index is a valid indicator of road safety performance is also discussed.

Use of electronic portal imaging devices for electron treatment verification

This study aims to help broaden the use of electronic portal imaging devices (EPIDs) for pre-treatment patient positioning verification, from photon-beam radiotherapy to photon- and electron-beam radiotherapy, by proposing and testing a method for acquiring clinicallyuseful EPID images of patient anatomy using electron beams, with a view to enabling and encouraging further research in this area. EPID images used in this study were acquired using all available beams from a linac configured to deliver electron beams with nominal energies of 6, 9, 12, 16 and 20 MeV, as well as photon beams with nominal energies of 6 and 10 MV. A widely-available heterogeneous, approximately-humanoid, thorax phantom was used, to provide an indication of the contrast and noise produced when imaging different types of tissue with comparatively realistic thicknesses. The acquired images were automatically calibrated, corrected for the effects of variations in the sensitivity of individual photodiodes, using a flood field image. For electron beam imaging, flood field EPID calibration images were acquired with and without the placement of blocks of water-equivalent plastic (with thicknesses approximately equal to the practical range of electrons in the plastic) placed upstream of the EPID, to filter out the primary electron beam, leaving only the bremsstrahlung photon signal. While the electron beam images acquired using a standard (unfiltered) flood field calibration were observed to be noisy and difficult to interpret, the electron beam images acquired using the filtered flood field calibration showed tissues and bony anatomy with levels of contrast and noise that were similar to the contrast and noise levels seen in the clinically acceptable photon beam EPID images. The best electron beam imaging results (highest contrast, signal-to-noise and contrast-to-noise ratios) were achieved when the images were acquired using the higher energy electron beams (16 and 20 MeV) when the EPID was calibrated using an intermediate (12 MeV) electron beam energy. These results demonstrate the feasibility of acquiring clinically-useful EPID images of patient anatomy using electron beams and suggest important avenues for future investigation, thus enabling and encouraging further research in this area. There is manifest potential for the EPID imaging method proposed in this work to lead to the clinical use of electron beam imaging for geometric verification of electron treatments in the future.