Achieving better in-hospital and after-hospital care of patients with acute cardiac disease

In patients hospitalised with acute coronary syndromes (ACS) and congestive heart failure (CHF), evidence suggests opportunities for improving in-hospital and after hospital care, patient self-care, and hospital-community integration. A multidisciplinary quality improvement program was designed and instigated in Brisbane in October 2000 involving 250 clinicians at three teaching hospitals, 1080 general practitioners (GPs) from five Divisions of General Practice, 1594 patients with ACS and 904 patients with CHF. Quality improvement interventions were implemented over 17 months after a 6-month baseline period and included: clinical decision support (clinical practice guidelines, reminders, checklists, clinical pathways); educational interventions (seminars, academic detailing); regular performance feedback; patient self-management strategies; and hospital-community integration (discharge referral summaries; community pharmacist liaison; patient prompts to attend GPs). Using a before-after study design to assess program impact, significantly more program patients compared with historical controls received: ACS: Angiotensin-converting enzyme (ACE) inhibitors and lipid-lowering agents at discharge, aspirin and beta-blockers at 3 months after discharge, inpatient cardiac counselling, and referral to outpatient cardiac rehabilitation. CHF. Assessment for reversible precipitants, use of prophylaxis for deep-venous thrombosis, beta-blockers at discharge, ACE inhibitors at 6 months after discharge, imaging of left ventricular function, and optimal management of blood pressure levels. Risk-adjusted mortality rates at 6 and 12 months decreased, respectively, from 9.8% to 7.4% (P=0.06) and from 13.4% to 10.1% (P= 0.06) for patients with ACS and from 22.8% to 15.2% (P < 0.001) and from 32.8% to 22.4% (P= 0.005) for patients with CHF. Quality improvement programs that feature multifaceted interventions across the continuum of care can change clinical culture, optimise care and improve clinical outcomes.

A longitudinal study of employee adaptation to organizational change: The role of change-related information and change-related self-efficacy

This study examined the role of information, efficacy, and 3 stressors in predicting adjustment to organizational change. Participants were 589 government employees undergoing an 18-month process of regionalization. To examine if the predictor variables had long-term effects on adjustment, the authors assessed psychological well-being, client engagement, and job satisfaction again at a 2-year follow-up. At Time 1, there was evidence to suggest that information was indirectly related to psychological well-being, client engagement, and job satisfaction, via its positive relationship to efficacy. There also was evidence to suggest that efficacy was related to reduced stress appraisals, thereby heightening client engagement. Last, there was consistent support for the stress-buffering role of Time I self-efficacy in the prediction of Time 2 job satisfaction.

Multidisciplinary strategies for the management of heart failure patients at high risk for admission - A systematic review of randomized trials

OBJECTIVES The aim of this study was to determine whether multidisciplinary strategies improve outcomes for heart failure (HF) patients. BACKGROUND Because the prognosis of HF remains poor despite pharmacotherapy, there is increasing interest in alternative models of care delivery for these patients. METHODS Randomized trials of multidisciplinary management programs in HF were identified by searching electronic databases and bibliographies and via contact with experts. RESULTS Twenty-nine trials (5,039 patients) were identified but were not pooled, because of considerable heterogeneity. A priori, we divided the interventions into homogeneous groups that were suitable for pooling. Strategies that incorporated follow-up by a specialized multidisciplinary team (either in a clinic or a non-clinic setting) reduced mortality (risk ratio [RR] 0.75, 95% confidence interval [CI] 0.59 to 0.96), HF hospitalizations (RR 0.74, 95% CI 0.63 to 0.87), and all-cause hospitalizations (RR 0.81, 95% CI 0.71 to 0.92). Programs that focused on enhancing patient self-care activities reduced HF hospitalizations (RR 0.66, 95% CI 0.52 to 0.83) and all-cause hospitalizations (RR 0.73, 95% CI 0.57 to 0.93) but had no effect on mortality (RR 1.14, 95% CI 0.67 to 1.94). Strategies that employed telephone contact and advised patients to attend their primary care physician in the event of deterioration reduced HF hospitalizations (RR 0.75, 95% CI 0.57 to 0.99) but not mortality (RR 0.91, 95% CI 0.67 to 1.29) or all-cause hospitalizations (RR 0.98, 95% CI 0.80 to 1.20). In 15 of 18 trials that evaluated cost, multidisciplinary strategies were cost-saving. CONCLUSIONS Multidisciplinary strategies for the management of patients with HF reduce HF hospitalizations. Those programs that involve specialized follow-up by a multidisciplinary team also reduce mortality and all-cause hospitalizations. (C) 2004 by the American College of Cardiology Foundation.

Parenting and adolescent self-regulation

This study examined the relationship between adolescents' academic and non-academic self-regulation (SR), authoritative parenting (as demonstrated by high levels of Involvement, Strictness, and Autonomy Granting), and parent self-efficacy in four areas. Participants were 214 Australian high school students and their parents. There was a moderate correlation (r = 0.63) between academic and non-academic SR. Adolescents and their parents differed significantly in their perceptions of parenting behaviours, with parents rating themselves higher than their children on Involvement, Autonomy Granting, and Strictness behaviours. A model of the relationships between the constructs was developed showing a strong path from parent self-efficacy to both academic and non-academic SR via high parental Involvement (as perceived by adolescents). Strict parenting and the granting by parents of psychological autonomy to their adolescent children did not appear to be important in the development of young people's self-regulatory behaviours. (C) 2004 The Association for Professionals in Services for Adolescents. Published by Elsevier Ltd. All rights reserved.

Group A streptococcal vaccine delivery by immunization with a self-adjuvanting M protein-based lipid core peptide construct

Background & objectives: To develop a broad strain coverage GAS vaccine, several strategies have been investigated which included multi-epitope approaches as well as targeting the M protein conserved C-region. These approaches, however, have relied on the use of adjuvants that are toxic for human application. The development of safe and effective adjuvants for human use is a key issue in the development of effective vaccines. In this study, we investigated the lipid polylysine core peptide (LCP) system as a self-adjuvanting GAS vaccine delivery approach. Methods: An LCP-GAS construct was synthesised incorporating multiple copies of a protective peptide epitope (J8) from the conserved carboxy terminal C-repeat region of the M protein. B10.BR mice were immunized parenterally with the LCP-J8 construct, with or without conventional adjuvant, prior to the assessment of immunogenicity and the induction of serum opsonic antibodies. Results: Our data demonstrated immunogenicity of LCP-J8 when coadministered in complete Freund's adjuvant (CFA), or administered in the absence of conventional adjuvant. In both cases, immunization led to the induction of high-titre J8 peptide-specific serum IgG antibody responses, and the induction of heterologous opsonic antibodies that did not cross-react with human heart tissue proteins. Interpretation & conclusion: These data indicated the potential of a novel self-adjuvanting LCP vaccine delivery system incorporating a synthetic GAS M protein C-region peptide immunogen in the induction of broadly protective immune responses, and pointed to the potential application of this system in human vaccine development against infectious diseases.

A cognitive model of binge drinking: The influence of alcohol expectancies and drinking refusal self-efficacy

While binge drinking-episodic or irregular consumption of excessive amounts of alcohol-is recognised as a serious problem affecting our youth, to date there has been a lack of psychological theory and thus theoretically driven research into this problem. The current paper develops a cognitive model using the key constructs of alcohol expectancies (AEs) and drinking refusal self-efficacy (DRSE) to explain the acquisition and maintenance of binge drinking. It is suggested that the four combinations of the AE and DRSE can explain the four drinking styles. These are normal/social drinkers, binge drinkers, regular heavy drinkers, and problem drinkers or alcoholics. Since AE and DRSE are cognitive constructs and therefore modifiable, the cognitive model can thus facilitate the design of intervention and-prevention strategies for binge drinking. (C) 2003 Elsevier Ltd. All rights reserved.

Perceptions of self and group in the context of a threatened national identity: A field study

Previous research indicates that people who are highly identified with their groups tend to remain committed to them under threat. This study examines the generalizability, of this effect to (a) a real-life context involving the perception that others view the ingroup (Australians) as intolerant of minorities and (b) various dimensions of social identification. The sample comprised 213 respondents to a random mail survey. Perceived threat was inversely related to self-stereotyping (i.e. perceptions of self-ingroup similarity), but only for individuals with weak subjective ties to other group members. Threat perceptions were also predictive of enhanced judgments of within-group variability on threat-relevant dimensions, particularly for individuals with weaker ingroup ties. Various strategies for coping with a threatened social identity are linked to different facets of social identification.

The development of self-awareness and relationship to emotional functioning during early community reintegration after traumatic brain injury

Impaired self-awareness may affect clients' emotional status, engagement in rehabilitation and community reintegration following traumatic brain injury (TBI). The study aimed to investigate the relationship between self-awareness, emotional distress and community integration in adults with TBI during the transition from hospital to the community. Thirty-four rehabilitation clients with TBI were assessed in the week before and 2 months after discharge home. Measures of self-awareness and emotional functioning were administered predischarge and repeated at follow-up along with a measure of community integration. Nonparametric tests were used to compare levels of self-awareness and emotional distress pre- and postdischarge, their interrelationships and association with community integration. Self-awareness significantly increased following discharge, and a trend towards increased depression was found. There were no consistent relationships found between level of self-awareness, emotional functioning, and community integration. The development of self-awareness in the immediate postdischarge phase suggests this is an important time for clinical interventions targeting compensation strategies and adjustment to disability.

Enlisting the influence of others: Alternative strategies for persuasive media campaigns

This study investigated an Australian antidrug campaign that targeted adolescents directly and indirectly via recruiting parents into drug prevention. Eighty-six parent-child dyads completed surveys measuring campaign evaluations, discussions about drugs, and beliefs about risks to self (own child) and to the average young Australian. Adolescents were optimistic about risks, and media impact was evident only in perceptions of risk to others. Parents were less optimistic, and perceptions of campaign quality predicted perceived risk to own child and discussion about drugs. However, this was moderated by negative affect associated with the campaign. There was some evidence that discussions influenced adolescents' perceptions of personal risk. This demonstrates the importance of individual responses and communication processes in determining the impact of persuasive media messages.

Operation of polymer electrolyte membrane fuel cells with dry feeds: Design and operating strategies

The operation of polymer electrolyte membrane fuel cells (PEMFCs) with dry feeds has been examined with different fuel cell flow channel designs as functions of pressure, temperature and flow rate. Auto-humidified (or self-humidifying) PEMFC operation is improved at higher pressures and low gas velocities where axial dispersion enhances back-mixing of the product water with the dry feed. We demonstrate auto-humidified operation of the channel-less, self-draining fuel cell, based on a stirred tank reactor; data is presented showing auto-humidified operation from 25 to 115 degrees C at 1 and 3 atm. Design and operating requirements are derived for the auto-humidified operation of the channel-less, self-draining fuel cell. The auto-humidified self-draining fuel cell outperforms a fully humidified serpentine flow channel fuel cell at high current densities. The new design offers substantial benefits for simplicity of operation and control including: the ability to self-drain reducing flooding, the ability to uniformly disperse water removing current gradients and the ability to operate on dry feeds eliminating the need for humidifiers. Additionally, the design lends itself well to a modular design concept. (c) 2005 Elsevier B.V. All rights reserved.