Improving the communication between care providers of individuals who may require joint replacement surgery (JRS) a framework for referral

Aims & rationale/Objectives : The objective of the project was to specify the information required in referrals to public hospital orthopaedic outpatient departments in order to streamline the care and prioritisation of individuals who may require JRS. It was envisaged that an evidence-based GP-Orthopaedic derived referral system would assist in ensuring that the right person accessed the right care at the right time.

Methods : In collaboration with the RACGP and the Commonwealth Department of Health and Ageing, a national stakeholder working group was convened. A scoping document was prepared with input from key stakeholders. A review of primary research was undertaken as well as a review of relevant guidelines. Information on the implementation and evaluation of similar programs in Australia and overseas also informed the referral specification.

Principal findings : The initial scoping processes with key stakeholders provided clear information on core components of the referral. These were the use of standardised and respected assessment tools to determine the severity of arthritis, fitness for surgery and willingness of affected individuals to undergo surgery.

Discussion : About 20,000 JRS occur each year in public hospitals which emanate from 5 to 10 fold number of referrals. Arthritis and musculoskeletal diseases are a national health priority area reflecting the high burden of disease associated with these conditions. Various initiatives are being undertaken to address the quality of life of affected individuals. This project has revealed areas of potential improvement in the communication between care providers of individuals who may need JRS.

Implications : The project will result in the development of a standard referral form and guidelines to assist referring practitioners to communicate more effectively with the multidisciplinary care team, in particular orthopaedic care providers. The guidelines will be piloted in a large rural setting.

Assessing the validity of impact pathways for child labour and well-being in social life cycle assessment

Background, aim and scope: Assuming that the goal of social life cycle assessment (SLCA) is to assess damage and benefits on its ‘area of protection’ (AoP) as accurately as possible, it follows that the impact pathways, describing the cause effect relationship between indicator and the AoP, should have a consistent theoretical foundation so the inventory results can be associated with a predictable damage or benefit to the AoP. This article uses two concrete examples from the work on SLCA to analyse to what extent this is the case in current practice. One considers whether indicators included in SLCA approaches can validly assess impacts on the well-being of the stakeholder, whereas the other example addresses whether the ‘incidence of child labour’ is a valid measure for impacts on the AoPs.

Materials and methods: The theoretical basis for the impact pathway between the relevant indicators and the AoPs is analysed drawing on research from relevant scientific fields.

Results:   The examples show a lack of valid impact pathways in both examples. The first example shows that depending on the definition of ‘well-being’, the assessment of impacts on well-being of the stakeholder cannot be performed exclusively with the type of indicators which are presently used in SLCA approaches. The second example shows that the mere fact that a child is working tells little about how this may damage or benefit the AoPs, implying that the normally used indicator; ‘incidence of child labour’ lacks validity in relation to predicting damage or benefit on the AoPs of SLCA.

Discussion: New indicators are proposed to mitigate the problem of invalid impact pathways. However, several problems arise relating to difficulties in getting data, the usability of the new indicators in management situations, and, in relation to example one, boundary setting issues.

Conclusions: The article shows that it is possible to assess the validity of the impact pathways in SLCA. It thereby point to the possibility of utilising the same framework that underpins the environmental LCA in this regard. It also shows that in relation to both of the specific examples investigated, the validity of the impact pathways may be improved by adopting other indicators, which does, however, come with a considerable ‘price’.

Recommendations and perspectives: It is argued that there is a need for analysing impact pathways of other impact categories often included in SLCA in order to establish indicators that better reflect actual damage or benefit to the AoPs.

Pathways to sex offending

The research of the thesis aimed to contribute to the theoretical understanding of the various pathways that offenders follow in committing sexual offences. Using grounded theory a theoretical model was generated which described four major pathways to sexual offending. Quantitative analyses revealed that offenders who take different pathways differ significantly in respect of their risk of recidivism, demographic variables, rape myth acceptance and aggression. The portfolio considered the limitations of sex offender treatment programs for treating sex offenders with histories of childhood sexual abuse and presented four case studies.

Sentencing pathways for offenders in Victoria : clinical influences and considerations

This portfolio aims to review aspects of the sentencing of violent offenders under Victoria's criminal justice system. Focuses on a critique of current legislation, the way the rights of special needs offenders are acknowledged and enshrined in law, how these provisions are expressed in practice, and the clinical factors that contribute to, and influence, the dispositions individuals receive.

Professionals' attributions and referral decisions in cases of domestic violence

This thesis is the first national study of workers who have contact with victims and perpetrators of domestic violence. It highlights that the victim and perpetrator's gender, as well as the relevant professional's agency type and experience, all influenced their attitudes to, and service delivery decisions with, domestic violence-related clients. The portfolio utilises four case studies to examine the way that two Victorian sex offender programs attempt to balance risk-need and good lives principles in the assessment and treatment of sex offenders.

Analysis on relationship between extreme pathways and correlated reaction sets

Background: Constraint-based modeling of reconstructed genome-scale metabolic networks has been successfully applied on several microorganisms. In constraint-based modeling, in order to characterize all allowable phenotypes, network-based pathways, such as extreme pathways and elementary flux modes, are defined. However, as the scale of metabolic network rises, the number of extreme pathways and elementary flux modes increases exponentially. Uniform random sampling solves this problem to some extent to study the contents of the available phenotypes. After uniform random sampling, correlated reaction sets can be identified by the dependencies between reactions derived from sample phenotypes. In this paper, we study the relationship between extreme pathways and correlated reaction sets.

Results: Correlated reaction sets are identified for E. coli core, red blood cell and Saccharomyces cerevisiae metabolic networks respectively. All extreme pathways are enumerated for the former two metabolic networks. As for Saccharomyces cerevisiae metabolic network, because of the large scale, we get a set of extreme pathways by sampling the whole extreme pathway space. In most cases, an extreme pathway covers a correlated reaction set in an 'all or none' manner, which means either all reactions in a correlated reaction set or none is used by some extreme pathway. In rare cases, besides the 'all or none' manner, a correlated reaction set may be fully covered by combination of a few extreme pathways with related function, which may bring redundancy and flexibility to improve the survivability of a cell. In a word, extreme pathways show strong complementary relationship on usage of reactions in the same correlated reaction set.

Conclusion: Both extreme pathways and correlated reaction sets are derived from the topology information of metabolic networks. The strong relationship between correlated reaction sets and extreme pathways suggests a possible mechanism: as a controllable unit, an extreme pathway is regulated by its corresponding correlated reaction sets, and a correlated reaction set is further regulated by the organism's regulatory network.

Opening up pathways : engagement in STEM across the primary-secondary school transition

A review of the literature concerning supports and barriers to Science, Technology, Engineering and Mathematics engagement at Primary-Secondary transition. Commissioned by the Australian Department of Education, Employment and Workplace Relations.

A nurse-assisted screening and referral program for depression among survivors of colorectal cancer : feasibility study

Objective: To test the feasibility and acceptability of a telephone-based program to screen survivors of colorectal cancer (CRC) for distress, and to refer distressed patients to their treating health service.

Design, setting and participants: A prospective, multicentre study involving 59 patients with CRC recruited from six public and private health services in Melbourne, Victoria, from 15 June 2008 to 22 September 2009. Patients who had completed adjuvant chemotherapy for CRC were contacted (7–10 days after recruitment [outcall one] and again 4 weeks later [outcall two]) by the Cancer Council Victoria’s helpline nurse, and screened for distress with the Distress and Impact Thermometer (DIT); participants were given tailored information and support and those with distress scores of ≥5, and impact scores of ≥4, were referred for follow-up. Telephone interviews were conducted 4 weeks after outcall two. Participating helpline and health service staff were surveyed on the feasibility and acceptability of the service. Main outcome measure: Anxiety and depression, measured by the Hospital Anxiety and Depression Scale (HADS).

Results: Of the 59 patients (87%) who agreed to participate, 63% were men; their mean age was 59 years (SD, 9.5 years). HADS depression decreased significantly from baseline (mean score, 4.93; SD, 4.22) to follow-up (mean score, 3.84; SD, 4.10; Z = −2.375; P= 0.02). However, there was no significant difference in HADS anxiety between baseline (mean score, 5.29; SD, 4.11) and follow-up (mean score, 4.78; SD, 3.65). Outcall one generated two referrals (4% of participants) and outcall two generated four referrals
(8%); five of these six participants took up the referrals. Satisfaction with the program among participants was high; 82% found outcall one “quite or very helpful” and 79% found outcall two “quite or very helpful”. Helpline and health service staff reported a straightforward process that did not adversely affect workloads.

Conclusion: This model of care carries the potential to meet ongoing psychosocial needs of survivors of CRC.

Disposition pathways and pharmacokinetics of herbal medicines in humans

Pharmacokinetic studies have become an integral part of modern drug development, but these studies are not regulatory needs for herbal remedies. This paper updates our current knowledge on the disposition pathways and pharmacokinetic properties of commonly used herbal medicines in humans. To retrieve relevant data, the authors have searched through computer-based literatures by full text search in Medline (via Pubmed), ScienceDirect, Current Contents Connect (ISI), Cochrance Library, CINAHL (EBSCO), CrossRef Search and Embase (all from inception to May 2010). Many herbal compounds undergo Phase I and/or Phase II metabolism in vivo, with cytochrome P450s (CYPs) and uridine diphosphate glucuronosyltransferases (UGTs) playing a major role. Some herbal ingredients are substrates of P-glycoprotein (P-gp) which is highly expressed in the intestine, liver, brain and kidney. As such, the activities of these drug metabolizing enzymes and drug transporters are determining factors for the in vivo bioavailability, disposition and distribution of herbal remedies. There are increasing pharmacokinetic studies of herbal remedies, but these studies are mainly focused on a small number of herbal remedies including St John's wort, milk thistle, sculcap, curcumin, echinacea, ginseng, ginkgo, and ginger. The pharmacokinetic data of a small number of purified herbal ingredients, including anthocyanins, berberine, catechins, curcumin, lutein and quercetin, are available. For the majority of herbal remedies used in folk medicines, data on their disposition and biological fate in humans are lacking or in paucity. For a herbal medicine, the pharmacological effect is achieved when the bioactive agents or the metabolites reach and sustain proper levels at their sites of action. Both the dose levels and fates of active components in the body govern their target-site concentrations after administration of an herbal remedy. In this regard, a safe and optimal use of herbal medicines requires a full understanding of their pharmacokinetic profiles. To optimize the use of herbal remedies, further clinical studies to explore their biological fate including the disposition pathways and kinetics in the human body are certainly needed.

An evaluation of a mental health screening and referral pathway for community nursing care : nurses' and general practitioners' perspectives

Aims and objectives. To evaluate a feasible, best practice mental health screening and referral clinical pathway for generalist community nursing care of war veterans and war widow(er)s in Australia.
Background. War veterans commonly experience mental health difficulties and do not always receive required treatment, as can also occur for war widow(er)s. Whenever opportunity arises, such as during community nursing care, it is vital to identify mental health problems in a health promotion framework.
Design. A clinical pathway was developed by literature review and consultation and then trialled and evaluated using mixed methods – quantitative and qualitative.
Methods. Community nurses who trialled the pathway completed an evaluation survey and attended focus groups. General practitioners responded to an evaluation survey.
Results. Most nurses found the pathway clear and easy to understand but not always easy to use. They emphasised the need to establish trust and rapport with clients prior to implementing the pathway. It was sometimes difficult to ensure effective referral to general practitioners for clients who screened positive for a mental health problem. When referral was accomplished, general practitioners reported adequate and useful information was provided. Some general practitioners also commented on the difficulty of achieving effective communication between general practitioners and nurses.
Conclusions. Nurses and some general practitioners found the pathway useful for their practice. They offered several suggestions for improvement by simplifying the trialled pathway and accompanying guidelines and strategies to improve communication between nurses and general practitioners. This study adds understanding of how community nurses might productively screen for mental health difficulties.
Relevance to clinical practice. The trialled pathway, which was modified and refined following the study, is an evidence-based
resource for community nurses in Australia and similar contexts to guide practise and maximise holistic care for war veterans and war widow(er)s and possibly other client groups.