Improving the outcomes of foot and ankle surgery. Professional impact of the Australasian College of Podiatric Surgeons' audit tool

Background Surgery is an example of expanded practice scope that enhances podiatry and incorporates inter-professional collaboration. By 2050 demand for foot and ankle procedures is predicted to rise nationally by 61.9%. Performance management of this increase motivated the development of an online audit tool. Developed in collaboration with the Australasian College of Podiatric Surgeons (ACPS), the ACPS audit tool provides real-time data capture and reporting. It is the first audit tool designed in Australia to support and improve the outcomes of foot and ankle surgery. Methods Audit activity in general, orthopaedic, plastic and podiatric surgery was examined using a case study design. Audit participation enablers and barriers were explored. Case study results guided a Delphi survey of international experts experienced or associated with foot and ankle surgery. Delphi survey-derived consensus informed modification of a generic data set from the Royal Australasian College of Surgeons (RACS). Based on the Delphi survey findings the ACPS online audit tool was developed and piloted. Reliability and validity of data entry and usability of this new tool was then assessed with an online survey. Results The case study found surgeon attitudes and behaviours positively impacted audit participation, and also indicated that audit data should be: (1) available in real time, (2) identify practice change, (3) applicable for safety and quality management, and; (4) useful for peer review discussion. The Delphi process established consensus on audit variables to be captured, including the modified RACS generic data set. 382 cases of foot and ankle surgery were captured across 3 months using the new tool. Data entry was found to be valid and reliable. Real-time outcome reporting and practice change identification impacted positively on safety and quality management and assisted peer review discussion. An online survey showed high levels of usability. Conclusions Surgeon contribution to audit tool development resulted in 100% audit participation. The data from the ACPS audit tool supported the ACPS submission to the Medical Services Advisory Committee to list podiatric surgery under Medicare, an outcome noted by the Federal Minister of Health.

Supporting mindful planners in a mindless system: Limitations to the emotional turn in planning practice

Despite widespread acknowledgment within planning scholarship that emotion – both present in knowledge and a form of knowledge – is integral to lived experience and the judgement of planners, it is often sidelined within planning practice. The extent to which mainstream planning has been able or willing to accommodate emotions remains constrained and the emotions of planners and the public remain an unacknowledged but pervasive presence. Antonio Ferreira recently highlighted in this journal the importance of attending to emotions at the level of the individual planner through the concept of mindfulness. We argue this approach must be complemented by an acknowledgement of the structural and institutional limitations of including emotions in planning practice. Drawing from the emotional geographies literature to describe a social-spatial conceptualisation of emotion, we highlight ontological and practical tensions associated with the achievement of the ‘emotional turn’ and advance a more purposeful engagement with emotion in mainstream planning practice.

Unpredictability, invisibility and vulnerability: Unaccompanied asylum-seeking minors’ journeys to Australia

This qualitative study investigated the refugee journey of 17 males who arrived in Australia as unaccompanied asylum-seeking minors between 2009 and 2013, and were granted protection visas. The paper focuses on the four conceptual challenges of refugee journeys, as identified recently by BenEzer and Zetter: temporal characteristics; drivers and destinations; the process/content of the journey; and the characteristics of the wayfarers. The findings indicate that their mental journey has not yet ended and transcends the physical departure-arrival voyage. Although the primary drivers for the refugee journey were protection reasons, their desire to find a “better life” free from violence and exclusion also played an important role. The irregular character of the journey made it highly unpredictable, exposed these minors to extreme levels of vulnerability and the need to remain invisible, prompted short lived friendships with other asylum seekers, and created a pervasive feeling of mistrust towards smugglers and other people they met along the way. The study has highlighted the need for interventions to protect unaccompanied minors during their refugee journey.

Mobility and security: the perceived benefits of citizenship for resettled young people from refugee backgrounds

In recent decades, the meaning and value of formal state citizenship has shifted dramatically. In the same period, scholarship on citizenship has drawn attention to the proliferation of alternative forms of sub-, supra- and transnational citizenship, at times obscuring the ongoing importance of formal state citizenship. For refugees, however, formal state citizenship remains a critical and widely shared goal. Drawing on interviews with 51 young people from refugee backgrounds in Melbourne, Australia, this article explores the intersecting themes of mobility and security that were identified by participants as the most important benefits of acquiring formal state citizenship in the country of resettlement. In contrast to the insecurity of forced migration, formal state citizenship provides a privileged mobility that enables refugee-background youth to maintain and create transnational identities and attachments and to be protected while doing so, while also granting a secure status within the nation state and insurance against further displacement in an uncertain future. In offering these forms of mobility and security, formal state citizenship contributes to a sense of ontological security among refugee-background youth, providing an important foundation for building national and transnational futures.

Evaluation of the Red Light Camera Program and the Owner Onus Legislation

Red light cameras were introduced in Victoria in August 1983, with the intention of reducing the number of accidents that result from motorists disobeying red traffic signals at signalised intersections. Accident data from 46 treated and 46 control sites from 1981 to 1986 were analysed. The analysis indicated that red light camera use resulted in a reduction in the incidence of right angle accidents, and in the number of accident casualties. Legislation was introduced in March 1986 to place the onus for red light camera offences onto the vehicle owner. This legislation was intended to improve Police efficiency and therefore increase the number of red light cameras in operation. Data supplied by the Police indicated that these aims have beneficial road safety effects.

Random Breath Testing Operation and Effectiveness in 1987

• In December 1986 funds were approved to double the intensity of random breath testing (RBT) and provide publicity support for police efforts. These changes were considered necessary to make RBT effective. • RBT methods were changed in the metropolitan area to enable block testing (pulling over a block of traffic rather than one or two cars), deployment of police to cut off escape routes, and testing by traffic patrols in all police subdivisions. Additional operators were trained for country RBT. • A publicity campaign was developed, aimed mainly at male drivers aged 18-50. The campaign consisted of the “cardsharp” television commercials, radio commercials, newspaper articles, posters and pamphlets. • Increased testing and the publicity campaigns were launched on 10 April 1987. • Police tests increased by 92.5% in May – December 1987, compared with the same period in the previous four years. • The detection rate for drinking drivers picked up by police who were cutting off escape routes was comparatively high, indicating that drivers were attempting to avoid RBT, and that this police method was effective at detecting these drivers. • A telephone survey indicated that drivers were aware of the messages of the publicity campaign. • The telephone survey also indicated that the target group had been exposed to high levels of RBT, as planned, and that fear of apprehension was the major factor deterring them from drink driving. • A roadside survey of driver blood alcohol concentrations (BACs) by the University of Adelaide’s Road Accident Research Unit (RARU) showed that, between 10p.m. and 3a.m., the proportion of drivers in Adelaide with a BAC greater than or equal to 0/08 decreased by 42%. • Drivers under 21 were identified as a possible problem area. • Fatalities in the twelve month period commencing May 1987 decreased by 18% in comparison with the previous twelve month period, and by 13% in comparison with the average of the previous two twelve month periods (commencing May 1985 and May 1986). There are indications that this trend is continuing. • It is concluded that the increase in RBT, plus publicity, was successful in achieving its aims of reductions in drink driving and accidents.

Random Breath Testing Operation and Effectiveness in 1985

Random breath testing (RBT) was introduced in South Australia in 1981 with the intention of reducing the incidence of accidents involving alcohol. In April 1985, a Select Committee of the Upper House which had been established to “review the operation of random breath testing in this State and any other associated matters and report accordingly” presented its report. After consideration of this report, the Government introduced extensive amendments to those sections of the Motor Vehicles Act (MVA) and Road Traffic Act (RTA) which deal with RBT and drink driving penalties. The amended section 47da of the RTA requires that: “(5) The Minister shall cause a report to be prepared within three months after the end of each calendar year on the operation and effectiveness of this section and related sections during that calendar year. (6) The Minister shall, within 12 sitting days after receipt of a report under subsection (5), cause copies of the report to be laid before each House of Parliament.” This is the first such report. Whilst it deals with RBT over a full year, the changed procedures and improved flexibility allowed by the revision to the RTA were only introduced late in 1985 and then only to the extent that the existing resources would allow.

THE DRINKING DRIVER, A guide to the five part series ONE FOR THE ROAD

THE DRINKING DRIVER is a guide for listeners to the Adult Education radio series ONE FOR THE ROAD, a five-part series on drink-driving and Australia’s road toll. ONE FOR THE ROAD was produced by Lee Parker and Julie Levi, with assistance from the Federal Office of Road Safety in Canberra. The five programs, presented by Lee Parker were first broadcast on ABC Radio National in January 1989, and repeated on Radio National and Regional Stations across Australia in April/May 1989. THE DRINKING DRIVER was written by Mark King, Senior Project Officer with the Road Safety Division of the South Australian Department of Transport.

Gudinski, by Stuart Coupe is a wild and fast ride

Review of Stuart Coupe's biography of Australian music legend Michael Gudinski.

Qualitative study of patients' choice between public and private hospital emergency departments

Objective The aim of this study was to gather patients' perceptions regarding their choice between public and private hospital EDs for those who hold private health insurance. The findings of this study will contribute to knowledge regarding patients' decision-making processes and therefore may contribute to the development of evidence based public policies. Methods An in-depth semi-structured guide was used to interview participants at public and private hospital EDs. Questions sought to identify the issues that were considered by the participants to decide to attend that hospital ED, previous ED experience, expectations of ED services and perceived benefits and barriers to accessing services. Interviews were audio recorded, transcribed verbatim and analysed using content and thematic approaches. Results Four core themes emerged: prior good experience with the hospital, perceived quality of care, perceived waiting times and perceived costs that may explain patients' choice. Patients' choice between public and private EDs can be explained by the interaction of these core themes. The principal issues appear to be concern for gap payments at private hospital ED and waiting times at public hospital ED. Conclusions Patients who choose to attend public EDs appear to value financial concern over waiting time; those who choose to attend private EDs appear to value waiting time ahead of financial concerns.

Compression use during an exercise intervention and associated changes in breast cancer-related lymphoedema

Aim This study assessed the association between compression use and changes in lymphoedema observed in women with breast cancer-related lymphoedema who completed a 12 week exercise intervention. Methods This work uses data collected from a 12 week exercise trial, whereby women were randomly allocated into either aerobic-based only (n=21) or resistance-based only (n=20) exercise. Compression use during the trial was at the participant’s discretion. Differences in lymphoedema (measured by L-Dex score and inter-limb circumference difference [%]) and associated symptoms between those who wore, and did not wear compression during the 12 week intervention were assessed. We also explored participants’ reasons surrounding compression during exercise. Results No significant interaction effect between time and compression use for lymphoedema was observed. There was no difference between groups over time in the number or severity of lymphoedema symptoms. Irrespective of compression use, there were trends for reductions in the proportion of women reporting severe symptoms, but lymphoedema status did not change. Individual reasons for the use of compression, or lack thereof, varied markedly. Conclusion Our findings demonstrated an absence of a positive or negative effect from compression use during exercise on lymphoedema. Current and previous findings suggest the clinical recommendation that garments must be worn during exercise is questionable, and its application requires an individualised approach.

Feasibility of a stepped wedge cluster RCT and concurrent observational sub-study to evaluate the effects of modified ward night lighting on inpatient fall rates and sleep quality: A protocol for a pilot trial

Background: Falls among hospitalised patients impose a considerable burden on health systems globally and prevention is a priority. Some patient-level interventions have been effective in reducing falls, but others have not. An alternative and promising approach to reducing inpatient falls is through the modification of the hospital physical environment and the night lighting of hospital wards is a leading candidate for investigation. In this pilot trial, we will determine the feasibility of conducting a main trial to evaluate the effects of modified night lighting on inpatient ward level fall rates. We will test also the feasibility of collecting novel forms of patient level data through a concurrent observational sub-study. Methods/design: A stepped wedge, cluster randomised controlled trial will be conducted in six inpatient wards over 14 months in a metropolitan teaching hospital in Brisbane (Australia). The intervention will consist of supplementary night lighting installed across all patient rooms within study wards. The planned placement of luminaires, configurations and spectral characteristics are based on prior published research and pre-trial testing and modification. We will collect data on rates of falls on study wards (falls per 1000 patient days), the proportion of patients who fall once or more, and average length of stay. We will recruit two patients per ward per month to a concurrent observational sub-study aimed at understanding potential impacts on a range of patient sleep and mobility behaviour. The effect on the environment will be monitored with sensors to detect variation in light levels and night-time room activity. We will also collect data on possible patient-level confounders including demographics, pre-admission sleep quality, reported vision, hearing impairment and functional status. Discussion: This pragmatic pilot trial will assess the feasibility of conducting a main trial to investigate the effects of modified night lighting on inpatient fall rates using several new methods previously untested in the context of environmental modifications and patient safety. Pilot data collected through both parts of the trial will be utilised to inform sample size calculations, trial design and final data collection methods for a subsequent main trial.

Concentrations of phthalates and DINCH metabolites in pooled urine from Queensland, Australia

Dialkyl phthalate esters (phthalates) are ubiquitous chemicals used extensively as plasticizers, solvents and adhesives in a range of industrial and consumer products. 1,2-Cyclohexane dicarboxylic acid, diisononyl ester (DINCH) is a phthalate alternative introduced due to a more favourable toxicological profile, but exposure is largely uncharacterised. The aim of this study was to provide the first assessment of exposure to phthalates and DINCH in the general Australian population. De-identified urine specimens stratified by age and sex were obtained from a community-based pathology laboratory and pooled (n = 24 pools of 100). Concentrations of free and total species were measured using online solid phase extraction isotope dilution high performance liquid chromatography tandem mass spectrometry. Concentrations ranged from 2.4 to 71.9 ng/mL for metabolites of di(2-ethylhexyl)phthalate, and from < 0.5 to 775 ng/mL for all other metabolites. Our data suggest that phthalate metabolites concentrations in Australia were at least two times higher than in the United States and Germany; and may be related to legislative differences among countries. DINCH metabolite concentrations were comparatively low and consistent with the limited data available. Ongoing biomonitoring among the general Australian population may help assess temporal trends in exposure and assess the effectiveness of actions aimed at reducing exposures.

Use of pooled samples to assess human exposure to parabens, benzophenone-3 and triclosan in Queensland, Australia

Parabens, benzophenone-3 and triclosan are common ingredients used as preservatives, ultraviolet radiation filters and antimicrobial agents, respectively. Human exposure occurs through consumption of processed food and use of cosmetics and consumer products. The aim of this study was to provide a preliminary characterisation of exposure to selected personal care product chemicals in the general Australian population. De-identified urine specimens stratified by age and sex were obtained from a community-based pathology laboratory and pooled (n= 24 pools of 100). Concentrations of free and total (sum of free plus conjugated) species of methyl, ethyl, propyl and butyl paraben, benzophenone-3 and triclosan were quantified using isotope dilution tandem mass spectrometry; with geometric means 232, 33.5, 60.6, 4.32, 61.5 and 87.7. ng/mL, respectively. Age was inversely associated with paraben concentration, and females had concentrations approximately two times higher than males. Total paraben and benzophenone-3 concentrations are significantly higher than reported worldwide, and the average triclosan concentration was more than one order of magnitude higher than in many other populations. This study provides the first data on exposure of the general Australian population to a range of common personal care product chemical ingredients, which appears to be prevalent and warrants further investigation.

Elevated levels of PFOS and PFHxS in firefighters exposed to aqueous film forming foam (AFFF)

Exposure to aqueous film forming foam (AFFF) was evaluated in 149 firefighters working at AFFF training facilities in Australia by analysis of PFOS and related compounds in serum. A questionnaire was designed to capture information about basic demographic factors, lifestyle factors and potential occupational exposure (such as work history and self-reported skin contact with foam). The results showed that a number of factors were associated with PFAA serum concentrations. Blood donation was found to be linked to low PFAA levels, and the concentrations of PFOS and PFHxS were found to be positively associated with years of jobs with AFFF contact. The highest levels of PFOS and PFHxS were one order of magnitude higher compared to the general population in Australia and Canada. Study participants who had worked ten years or less had levels of PFOS that were similar to or only slightly above those of the general population. This coincides with the phase out of 3M AFFF from all training facilities in 2003, and suggests that the exposures to PFOS and PFHxS in AFFF have declined in recent years. Self-reporting of skin contact and frequency of contact were used as an index of exposure. Using this index, there was no relationship between PFOS levels and skin exposure. This index of exposure is limited as it relies on self-report and it only considers skin exposure to AFFF, and does not capture other routes of potential exposure. Possible associations between serum PFAA concentrations and five biochemical outcomes were assessed. The outcomes were serum cholesterol, triglycerides, high-density lipoproteins, low density lipoproteins, and uric acid. No statistical associations between any of these endpoints and serum PFAA concentrations were observed.