Seclusion use with children and adolescents: an Australian experience

Objective: To summarize the current state of knowledge on the use of seclusion and restraint with children and adolescents and to report the findings of an exploratory study to identify factors that place a child or adolescent at increased risk of seclusion during their admission. Method: Literature searches were undertaken on MEDLINE, CINAHL and PsycINFO databases. Articles were identified that focused specifically on seclusion and restraint use with children and adolescents or contained material significant to this population. The study reports findings from a retrospective review of patient charts, seclusion registers and staffing from an Australian acute inpatient facility. Results: The data available in regard to seclusion use in this population is limited and flawed. Further research is needed on the use and outcomes of seclusion and restraint and on alternative measures in the containment of dangerousness. Both the literature and this study find that patients with certain factors are at increased risk of being secluded during an inpatient stay. These factors include being male, diagnoses of disruptive behaviour disorder and a previous history of physical abuse. Staffing factors did not show a relationship to the use of seclusion. Conclusions: There are patient factors that predict increased risk of seclusion; these factors and their interrelationships require further elucidation. Further research is also needed on the outcomes, both positive and negative, of seclusion use and of alternatives to seclusion.

Health-related quality of life in Australian children with asthma: lessons for the cross-cultural use of quality of life instruments

The development of Australian forms of the Childhood Asthma Questionnaires (CAQs) is reported. Focus group methods and psychometric analyses were used to establish the conceptual, semantic and technical equivalence of these forms with the UK versions. Both versions also provide for data collection from non-asthmatic youngsters. The internal consistency was found to be acceptable (Cronbach's alpha 0.52-0.90) and the health-related quality of life (HRQoL) scores were found to vary with asthma severity (p < 0.05). Comparison with the UK data revealed that the non-asthmatic scores were higher for Australian than British children (p < 0.001) but that the scores for children with asthma did not differ between the two countries. It was only In the Australian sample that the group with asthma reported impaired HRQoL when compared to their healthy peers. These findings were interpreted in the context of cultural expectations of life quality and conclusions are presented regarding the importance of the gap between experience and expectations. The difficulties raised by the developmental and cultural issues inherent in paediatric HRQoL research were discussed. Qual. Life Res. 7:409-419 (C) 1998 Kluwer Academic Publishers

The effects of adolescent cannabis use: How should the empirical evidence inform drug policy for young people? : Meeting abstract

Ethics as a subject is now consistently taught in medical schools within Australia. The theoretical Ethical models used, and the associated clinical discussions, vary between schools. Registrars have further theoretical Ethics teaching within Psychiatry Fellowship Training, and ongoing clinical work that is likely to provide exposure to complex and frequent Ethical dilemmas. As Psychiatry Trainees approach subspecialty training in Child and Adolescent Psychiatry they therefore have a rich experience of both theoretical Ethics teaching and clinical exposure to Ethical issues. In this symposium, the difficulties Child and Adolescent Psychiatry Trainees may have in the integration of multiple theoretical Ethical models are discussed. It is suggested that these difficulties make Ethics Teaching for Child and Adolescent Psychiatry Trainees particularly challenging. This is important given the complex Ethical issues often present when working with Children and their Families. The three main Ethical models of Deontology, Virtue Ethics and Consequentialism are described and their usefulness for the Child and Adolescent Psychiatrist examined. Limitations of these models, and “Four Principles” approaches (such as that of Beauchamp and Childress), for Child and Adolescent Psychiatry, are also considered. Clinical cases are included for discussion. Finally, the ways in which these models may be used to enhance Child and Adolescent Psychiatry Training, and subsequent clinical practice as a Child and Adolescent Psychiatrist, are discussed. The integration of different theoretical Ethical models is considered, with implications identified for clinical practice.

Early Australian experience with infliximab, a chimeric antibody against tumour necrosis factor-alpha, in the treatment of Crohn's disease: is its efficacy augmented by steroid-sparing immunosuppressive therapy?

Background: Tumour necrosis factor-alpha (TNF-alpha) plays an important role in the pathology of Crohn's disease. Infliximab, a chimeric antibody against TNF-alpha, has been shown in controlled clinical trials to be effective in two-thirds of patients with refractory or fistulating Crohn's disease. The factors that determine a clinical response in some patients but not others are unknown. Aims: To document the early Australian experience with infliximab treatment for Crohn's disease and to identify factors that may determine a beneficial clinical response. Methods: Gastroenterologists known to have used infliximab for Crohn's disease according to a compassionate use protocol were asked to complete a spreadsheet that included demographic information, Crohn's disease site, severity, other medical or surgical treatments and a global clinical assessment of Crohn's disease outcome, judged by participating physicians as complete and sustained (remission for the duration of the study), complete but unsustained (remission at 4 weeks but not for the whole study) or partial clinical improvement (sustained or unsustained). Results: Fifty-seven patients were able to be evaluated, with a median follow-up time of 16.4 (4-70) weeks, including 23 patients with fistulae. There were 21 adverse events, including four serious events. Fifty-one patients (89%) had a positive clinical response for a median duration (range) of 11 (2-70) weeks. Thirty patients (52%) had a remission at 4 weeks, 10 of whom had remission for longer than 12 weeks. Forty-two per cent of fistulae closed. Sustained remission (P = 0.065), remission at 4 weeks (P = 0.033) and a positive clinical response of any sort (P = 0.004) were more likely in patients on immunosuppressive therapy, despite there being more smelters in this group. Conclusion: This review of the first Australian experience with infliximab corroborates the reported speed and efficacy of this treatment for Crohn's disease. The excellent response appears enhanced by the concomitant use of conventional steroid-sparing immunosuppressive therapy.

Evaluation of cyclooxygenase 2 inhibitor use in patients admitted to a large teaching hospital

Background: The heavy usage of coxibs in Australia far outstrips the predicted usage that was based on the treatment of patients with risk factors for upper gastro-intestinal adverse events from conventional anti--inflammatory agents. This raises questions regarding the appropriateness of prescribing. Aims: To determine: (i) the relationship between prescriptions for cyclooxygenase 2 (COX-2) inhibitors and objective evidence of inflammatory arthritis, (ii) prior experience with paracetamol and/or conventional non-steroidal anti-inflammatory drugs (NSAIDs), and (iii) contraindications to the use of NSAIDs. Methods: Drug utilization evaluation and rheumato-logical assessment was conducted on 70 consecutive patients admitted on COX-2 inhibitors to a 480-bed metropolitan hospital. The main outcome measures were: the indication for COX-2 inhibitor; objective -evidence of inflammatory arthritis; previous trial of -paracetamol or conventional NSAIDs; and patient -satisfaction. Results: Only 11 patients (16%) had symptoms or signs of an inflammatory arthropathy, and met Pharmaceut-ical Benefits Schedule criteria for prescribing a COX-2 inhibitor. Fifty-nine patients (84%) had chronic osteo-arthritis, degenerative spinal disease, injury or malignancy, without overt active inflammation. Fourteen patients (20%) had trialled regular paracetamol prior to using any NSAID treatment. Conventional NSAIDs had been previously used by 51 patients (73%). Eleven patients (16%) reported previous adverse gastrointestinal effects from conventional NSAIDs. On the basis of significant renal impairment (creatinine clearance 5/10). Conclusions: Drug utilization data indicate that COX-2 inhibitors are frequently used first line for degenerative osteoarthritis in the absence of overt inflammation, without prior adequate trial of paracetamol and with disregard for the cautions and contraindications of these agents. These findings may explain the unprecedented Pharmaceutical Benefits Schedule expenditure on COX-2 inhibitors in Australia.

Prediction of mortality in patients without angina: Use of an exercise score and exercise echocardiography

Background Exercise testing has limited efficacy for identifying coronary artery disease (CAD) in the absence of anginal. symptoms. Exercise echocardiography is more accurate than standard exercise testing, but its efficacy in this situation has not been defined. We sought to identify whether the Duke treadmill. score or exercise echocardiography (ExE) could be used to identify risk in patients without anginal symptoms. Methods We studied 1859 patients without typical or atypical angina, heart failure, or a history or ECG evidence of infarction or CAD, who were referred for ExE, of whom 1832 (age 51 15 years, 944 men) were followed for up to 10 years. The presence and extent of ischaemia and scar were interpreted by expert reviewers at the time of the original study. Results Exercise provoked significant (>0.1 mV) ST segment depression in 215 patients (12%), and wall motion abnormalities in 137 (8%). Seventy-eight patients (4%) died before revascularization, only 17 from known cardiac causes. The independent predictors of death were age (RR 1.1, p

A review of the first year's experience with an automatic message-routing system for low-cost telemedicine

The Swinfen Charitable Trust has used email for some years as a low-cost telemedicine medium to provide consultant support for doctors in developing countries. A scalable, automatic message-routing system was constructed which automates many of the tasks involved in message handling. During the first 12 months of its use, 1510 messages were processed automatically. There were 128 referrals from 18 hospitals in nine countries. Of these 128 queries, 89 (70%) were replied to within 72 h; the median delay was 1.1 day. The 39 unanswered queries were sent to backup specialists for reply and 36 of them (92%) were replied to within 72 h. In the remaining three cases, a second-line (backup) specialist was required. The referrals were handled by 54 volunteer specialists from a panel of over 70. Two system operators, located 10 time zones apart, managed the system. The median time from receipt of a new referral to its allocation to a specialist was 0.2 days (interquartile range, IQR, 0.1-0.8). The median interval between receipt of a new referral and first reply was 2.6 days (IQR 0.8-5.9). Automatic message handling solves many of the problems of manual email telemedicine systems and represents a potentially scalable way of doing low-cost telemedicine in the developing world.

Knowledge beliefs and attitudes of squash venue operators relating to use of protective eyewear

Sports venues are in a position to potentially influence the safety practices of their patrons. This study examined the knowledge, beliefs and attitudes of venue operators that could influence the use of protective eyewear by squash players. A 50% random sample of all private and public squash venues affiliated with the Victorian Squash Federation in metropolitan Melbourne was selected. Face-to-face interviews were conducted with 15 squash venue operators during August 2001. Interviews were transcribed and content and thematic analyses were performed. The content of the interviews covered five topics: (1) overall injury risk perception, (2) eye injury occurrence, (3) knowledge, behaviors, attitudes and beliefs associated with protective eyewear, (4) compulsory protective eyewear and (5) availability of protective eyewear at venues. Venue operators were mainly concerned with the severe nature of eye injuries, rather than the relatively low incidence of these injuries. Some venue operators believed that players should wear any eyewear, rather than none at all, and believed that more players should use protective eyewear. Generally, they did not believe that players with higher levels of experience and expertise needed to wear protective eyewear when playing. Only six venues had at least one type of eyewear available for players to hire or borrow or to purchase. Operators expressed a desire to be informed about correct protective eyewear. Appropriate protective eyewear is not readily available at squash venues. Better-informed venue operators may be more likely to provide suitable protective eyewear.

Rehabilitation after total knee replacement via low-bandwidth telemedicine: the patient and therapist experience

After a total knee replacement, inadequate rehabilitation is associated with poor physical outcomes and a reduced longevity of the knee prosthesis. We have developed a low-bandwidth telemedicine system to enable rehabilitation services to be delivered directly to the home of patients in rural and remote areas. We have examined the experience of clinical physiotherapists and of 31 participants who received treatment via the system. High levels of satisfaction were reported by participants (mean responses >7 on a 10 cm visual analogue scale). The service was found to be effective, safe and easy to use, and it integrated well into current clinical practice. The study demonstrates the potential for delivering physiotherapy services via low-bandwidth Internet connections.

How do practitioners use conceptual modeling in practice?

Much research has been devoted over the years to investigating and advancing the techniques and tools used by analysts when they model. As opposed to what academics, software providers and their resellers promote as should be happening, the aim of this research was to determine whether practitioners still embraced conceptual modeling seriously. In addition, what are the most popular techniques and tools used for conceptual modeling? What are the major purposes for which conceptual modeling is used? The study found that the top six most frequently used modeling techniques and methods were ER diagramming, data flow diagramming, systems flowcharting, workflow modeling, UML, and structured charts. Modeling technique use was found to decrease significantly from smaller to medium-sized organizations, but then to increase significantly in larger organizations (proxying for large, complex projects). Technique use was also found to significantly follow an inverted U-shaped curve, contrary to some prior explanations. Additionally, an important contribution of this study was the identification of the factors that uniquely influence the decision of analysts to continue to use modeling, viz., communication (using diagrams) to/from stakeholders, internal knowledge (lack of) of techniques, user expectations management, understanding models' integration into the business, and tool/software deficiencies. The highest ranked purposes for which modeling was undertaken were database design and management, business process documentation, business process improvement, and software development. (c) 2005 Elsevier B.V. All rights reserved.