What do emergency physicians think of law?

What do emergency physicians think of law? Do they know the law? What role does it have in the practice of emergency medicine? Emergency physicians in New South Wales, Victoria and Queensland are being asked about these issues in a study by the Queensland University of Technology, Brisbane, Australia, titled ‘Withholding and withdrawing life-sustaining treatment from adults who lack capacity: The role of law in medical practice’. The study aims to examine the role that law plays in decisions to withhold or withdraw life-sustaining treatment from adults who lack capacity.

Growth-hormone-stimulated dentinogenesis in Lewis dwarf rat molars

In dentinogenesis, certain growth factors, matrix proteoglycans, and proteins are directly or indirectly dependent on growth hormone. The hypothesis that growth hormone up-regulates the expression of enzymes, sialoproteins, and other extracellular matrix proteins implicated in the formation and mineralization of tooth and bone matrices was tested by the treatment of Lewis dwarf rats with growth hormone over 5 days. The molar teeth were processed for immunohistochemical demonstration of bone-alkaline phosphatase, bone morphogenetic proteins-2 and -4, osteocalcin, osteopontin, bone sialoprotein, and E11 protein. Odontoblasts responded to growth hormone by more cells expressing bone morphogenetic protein, alkaline phosphatase, osteocalcin, and osteopontin. No changes were found in bone sialoprotein or E11 protein expression. Thus, growth hormone may stimulate odontoblasts to express several growth factors and matrix proteins associated with dentin matrix biosynthesis in mature rat molars.

A home-based progressive resistance exercise programme for patients with venous leg ulcers : a feasibility study

This study aimed to assess the feasibility of a home-based exercise program and examine the effects on the healing rates of venous leg ulcers. A 12 –week randomised controlled trial was conducted investigating the effects of an exercise intervention compared to a usual care group. Participants in both groups (n = 13) had active venous ulceration and were treated in a metropolitan hospital outpatients clinic in Australia. Data were collected on recruitment from medical records, clinical assessment and questionnaires. Follow-up data on progress in healing and treatments were collected fortnightly for 12 weeks. Calf muscle pump function data were collected at baseline and 12 weeks from recruitment. Range of ankle motion data were collected at baseline, 6 and 12 weeks from recruitment. This pilot study indicated that the intervention was feasible. Clinical significance was observed in the intervention group with a 32% greater decrease in ulcer size (p=0.34) than the control group, and a 10% (p=0.74) improvement in the number of participants healed in the intervention group compared to the control group. Significant differences between groups over time were observed in calf muscle pump function parameters; (ejection fraction [p = 0.05]; residual volume fraction [p = 0.04]) and range of ankle motion (p = 0.01). This pilot study is one of the first studies to examine and measure clinical healing rates for participants involved in a home-based progressive resistance exercise program. Further research is warranted with a larger multi-site study.

Elevated uric acid correlates with wound severity

Chronic venous leg ulcers are a major health issue and represent an often overlooked area of biomedical research. Nevertheless, it is becoming increasingly evident that new approaches to enhance healing outcomes may arise through better understanding the processes involved in the formation of chronic wounds. We have for the first time shown that the terminal purine catabolite uric acid (UA) is elevated in wound fluid (WF) from chronic venous leg ulcers with relative concentrations correlating with wound chronicity. We have also shown a corresponding depletion in UA precursors, including adenosine, with increased wound severity. Further, we have shown that xanthine oxidase, the only enzyme in humans that catalyses the production of UA in conjunction with a burst of free radicals, is active in chronic WF. Taken together, this provides compelling evidence that xanthine oxidase may play a critical role in the formation of chronic wounds by prolonging the inflammatory process.

Language and utilisation of emergency care in Queensland

Objective: To compare access and utilisation of EDs in Queensland public hospitals between people who speak only English at home and those who speak another language at home. Methods: A retrospective analysis of a Queensland statewide hospital ED dataset (ED Information System) from 1 January 2008 to 31 December 2010 was conducted. Access to ED care was measured by the proportion of the state’s population attending EDs. Logistic regression analyses were performed to determine the relationships between ambulance use and language, and between hospital admission and language, both after adjusting for age, sex and triage category. Results: The ED utilisation rate was highest in English only speakers (290 per 1000 population), followed by Arabic speakers (105), and lowest among German speakers (30). Compared with English speakers, there were lower rates of ambulance use in Chinese (odds ratio 0.50, 95% confidence interval, 0.47–0.54), Vietnamese (0.87, 0.79–0.95), Arabic (0.87, 0.78–0.97), Spanish (0.56, 0.50–0.62), Italian (0.88, 0.80–0.96), Hindi (0.61, 0.53–0.70) and German (0.87, 0.79–0.90) speakers. Compared with English speakers, German speakers had higher admission rates (odds ratio 1.17, 95% confidence interval, 1.02–1.34), whereas there were lower admission rates in Chinese (0.90, 0.86–0.99), Arabic (0.76, 0.67–0.85) and Spanish (0.83, 0.75–0.93) speakers. Conclusion: This study showed that there was a significant association between lower utilisation of emergency care and speaking languages other than English at home. Further researches are needed using in-depth methodology to investigate if there are language barriers in accessing emergency care in Queensland.

Wound Management Innovation Cooperative Research Centre - a new model for inter-disciplinary wound research

Wound research is a complex multidimensional activity most effectively conducted by inter-disciplinary teams that connect studies in basic wound biology, devices and biomaterials with clinical practice. These complexities have been recognised in a new initiative through the establishment of an inter-disciplinary wound research centre in Australia; the Wound Management Innovation Cooperative Research Centre (WMI CRC). The centre is funded by the Australian Government's Cooperative Research Centre Program and a consortium of 22 participants and has a resource of US$108 million over 8 years...

Review article : paramedic education opportunities and challenges in Australia

Paramedic education has been undergoing major development in Australia in the past 20 years, with many different educational programmes being developed across all Australian jurisdictions. This paper aims to review the current paramedic education programmes in Australia to identify the similarities and differences between the programmes, and the strengths and challenges in these programmes. A literature search was performed using six scientific databases to identify any systematic reviews, literature reviews or relevant articles on the topic. Additional searches included journal articles and text references from 1995 to 2011. The search was conducted during December 2010 and November 2011. Included in this review are a total of 28 articles, which are focused around five major issues in paramedic education: (i) principle on paramedic programmes and the involvement of industry partners; (ii) clinical placements; (iii) contemporary methods of education; (iv) needs for specific programmes within paramedic education; and (v) articles related to the accreditation process for paramedic programmes. Paramedic programmes across Australian universities vary with many different practices, especially relating to clinical placements in the field. The further advances of the paramedic education programmes should aim to respond to population change and industry development, which would enhance the paramedic profession across Australia.

Intern underperformance is detected more frequently in emergency medicine rotations

Objective: To determine the frequency and nature of intern underperformance as documented on in-training assessment forms. Methods: A retrospective review of intern assessment forms from a 2 year period (2009–2010) was conducted at a tertiary referral hospital in Brisbane, Queensland. The frequency of interns assessed as ‘requiring substantial assistance’ and/or ‘requires further development’ on mid- or end-of-term assessment forms was determined. Forms were analysed by the clinical rotation, time of year and domain(s) of clinical practice in which underperformance was documented. Results: During 2009 and 2010 the overall documented incidence of intern underperformance was 2.4% (95% CI 1.5–3.9%). Clinical rotation in emergency medicine detected significantly more underperformance compared with other rotations (P < 0.01). Interns predominantly had difficulty with ‘clinical judgment and decision-making skills’, ‘time management skills’ and ‘teamwork and colleagues’ (62.5%, 55% and 32.5% of underperforming assessments, respectively). Time of the year did not affect frequency of underperformance. A proportion of 13.4% (95% CI 9.2–19.0%) of interns working at the institution over the study period received at least one assessment in which underperformance was documented. Seventy-six per cent of those interns who had underperformance identified by mid-term assessment successfully completed the term following remediation. Conclusion: The prevalence of underperformance among interns is low, although higher than previously suggested. Emergency medicine detects relatively more interns in difficulty than other rotations.

Dosimetric effects of a high-density spinal implant

In this study, a treatment plan for a spinal lesion, with all beams transmitted though a titanium vertebral reconstruction implant, was used to investigate the potential effect of a high-density implant on a three-dimensional dose distribution for a radiotherapy treatment. The BEAMnrc/DOSXYZnrc and MCDTK Monte Carlo codes were used to simulate the treatment using both a simplified, recltilinear model and a detailed model incorporating the full complexity of the patient anatomy and treatment plan. The resulting Monte Carlo dose distributions showed that the commercial treatment planning system failed to accurately predict both the depletion of dose downstream of the implant and the increase in scattered dose adjacent to the implant. Overall, the dosimetric effect of the implant was underestimated by the commercial treatment planning system and overestimated by the simplified Monte Carlo model. The value of performing detailed Monte Carlo calculations, using the full patient and treatment geometry, was demonstrated.

Measurement of a PAGAT gel dosimeter by ultrasound computed tomography

In this work we used a 3D quantitative CT ultrasound imaging system to characterise polymer gel dosimeters. The system comprised of two identical 5 MHz 128 element phased-array ultrasound transducers co-axially aligned and submerged in water as a coupling agent. Rotational and translational movement of the gel dosimeter sample between the transducers were performed using a robotic arm. Ultrasound signals were generated and received using an Olympus Omniscan unit. Dose sensitivity of attenuation and time of flight ultrasonic parameters were assessed using this system.

Quantitative evaluation of polymer gel dosimeters by broadband ultrasound attenuation

Ultrasound has been examined previously as an alternative readout method for irradiated polymer gel dosimeters, with authors reporting varying dose response to ultrasound transmission measurements. In this current work we extend previous work to measure the broadband ultrasound attenuation (BUA) response of irradiated PAGAT gel dosimeters, using a novel ultrasound computed tomography system.

Reconstructing 3D x-ray CT images of polymer gel dosimeters using the zero-scan method

In this study x-ray CT has been used to produce a 3D image of an irradiated PAGAT gel sample, with noise-reduction achieved using the ‘zero-scan’ method. The gel was repeatedly CT scanned and a linear fit to the varying Hounsfield unit of each pixel in the 3D volume was evaluated across the repeated scans, allowing a zero-scan extrapolation of the image to be obtained. To minimise heating of the CT scanner’s x-ray tube, this study used a large slice thickness (1 cm), to provide image slices across the irradiated region of the gel, and a relatively small number of CT scans (63), to extrapolate the zero-scan image. The resulting set of transverse images shows reduced noise compared to images from the initial CT scan of the gel, without being degraded by the additional radiation dose delivered to the gel during the repeated scanning. The full, 3D image of the gel has a low spatial resolution in the longitudinal direction, due to the selected scan parameters. Nonetheless, important features of the dose distribution are apparent in the 3D x-ray CT scan of the gel. The results of this study demonstrate that the zero-scan extrapolation method can be applied to the reconstruction of multiple x-ray CT slices, to provide useful 2D and 3D images of irradiated dosimetry gels.

Atomic hydrogen diffusion in novel magnesium nanostructures : the impact of incorporated subsurface carbon atoms

Ab initio Density Functional Theory (DFT) calculations are performed to study the diffusion of atomic hydrogen on a Mg(0001) surface and their migration into the subsurface layers. A carbon atom located initially on a Mg(0001) surface can migrate into the sub-surface layer and occupy a fcc site, with charge transfer to the C atom from neighboring Mg atoms. The cluster of postively charged Mg atoms surrounding a sub-surface C is then shown to facilitate the dissociative chemisorption of molecular hydrogen on the Mg(0001) surface, and the surface migration and subsequent diffusion into the subsurface of atomic hydrogen. This helps rationalize the experimentally-observed improvement in absorption kinetics of H2 when graphite or single walled carbon nanotubes (SWCNT) are introduced into the Mg powder during ball milling.

Private hospital emergency departments in Australia : challenges and opportunities

BACKGROUND: Public hospital EDs in Australia have become increasingly congested because of increasing demand and access block. Six per cent of ED patients attend private hospital EDs whereas 45% of the population hold private health insurance. OBJECTIVES: This study describes the patients attending a small selection of four private hospital EDs in Queensland and Victoria, and tests the feasibility of a private ED database. METHODS: De-identified routinely collected patient data were provided by the four participating private hospital and amalgamated into a single data set. RESULT: The mean age of private ED patients was 52 years. Males outnumbered females in all age groups except > 80 years. Attendance was higher on weekends and Mondays, and between 08.00 and 20.00 h. There were 6.6% of the patients triaged as categories 1 and 2, and 60% were categories 4 or 5. There were 36.4% that required hospital admission. Also, 96% of the patients had some kind of insurance. Furthermore, 72% were self-referred and 12% were referred by private medical practitioners. Approximately 25% arrived by ambulance. There were 69% that completed their ED treatment within 4 h. CONCLUSION: This study is the first public description of patients attending private EDs in Australia. Private EDs have a significant role to play in acute medical care and in providing access to private hospitals which could alleviate pressure on public EDs. This study demonstrates the need for consolidated data based on a consistent data set and data dictionary to enable system-wide analysis, benchmarking and evaluation

Pragmatism and precision : psychology in the service of civil litigation

While forensic psychology is commonly associated with the criminal and family law domains, its ambit to offer skills and knowledge at the legal interface also makes it particularly suited to the civil law domain. At this time, civil law is arguably the least represented legislative area in terms of psychological research and professional commentary. However, it is also a broad area, with its very breadth providing scope for research consideration, as urged by Greene. The purposes of this article are (1) to review the broad role of the psychologist in the conduct of civil litigation matters in Australia, (2) to assist the novice to the area by indicating a non-exhaustive list of potentially ambiguous terms and concepts common to the conduct of professional practice, and; (3) to highlight, as an example, one area of practice not only where legal direction demands professional pragmatism but also where opportunity arises for psychological research to vitally address a major social issue.