Anxiety disorders : assessment and management in general practice

Background: Anxiety is a normal physiological response to a threat. Anxiety disorders occur when this normal physiological response is associated with high levels of autonomic arousal, erroneous cognitions and dysfunctional coping strategies. Anxiety disorders are highly prevalent and present commonly to general practice. Anxiety disorders are often comorbid with other psychiatric and medical disorders and may be associated with significant morbidity.

Objective: This article describes the diagnosis, assessment and management of anxiety disorders in the general practice setting.

Discussion: Assessment in patients presenting with anxiety symptoms involves excluding a medical cause, identifying features of specific anxiety disorders as well as other coexisting psychiatric disorders, and assessing the degree of distress. Management options include psychoeducation, psychological treatments (particularly cognitive behaviour therapy) and pharmacological treatments. Patients with a diagnosis of an anxiety disorder can access Medicare funded psychological care under a number of Australian government initiatives. Selective serotonin reuptake inhibitors and serotonin norepinephrine reuptake inhibitors are the first line pharmacological agents used to treat anxiety disorders. Regular review is vital to monitor for clinical improvement and more complex presentations may require specialist psychological or psychiatric referral.

Undergraduate nursing students' performance in recognising and responding to sudden patient deterioration in high psychological fidelity simulated environments: an Australian multi-centre study

Objectives
This paper reports the quantitative findings of the first phase of a larger program of ongoing research: Feedback Incorporating Review and Simulation Techniques to Act on Clinical Trends (FIRST2ACTTM). It specifically aims to identify the characteristics that may predict primary outcome measures of clinical performance, teamwork and situation awareness in the management of deteriorating patients.

Design
Mixed-method multi-centre study.

Setting
High fidelity simulated acute clinical environment in three Australian universities.

Participants
A convenience sample of 97 final year nursing students enrolled in an undergraduate Bachelor of Nursing or combined Bachelor of Nursing degree were included in the study.

Method
In groups of three, participants proceeded through three phases: (i) pre-briefing and completion of a multi-choice question test, (ii) three video-recorded simulated clinical scenarios where actors substituted real patients with deteriorating conditions, and (iii) post-scenario debriefing. Clinical performance, teamwork and situation awareness were evaluated, using a validated standard checklist (OSCE), Team Emergency Assessment Measure (TEAM) score sheet and Situation Awareness Global Assessment Technique (SAGAT). A Modified Angoff technique was used to establish cut points for clinical performance.

Results
Student teams engaged in 97 simulation experiences across the three scenarios and achieved a level of clinical performance consistent with the experts' identified pass level point in only 9 (1%) of the simulation experiences. Knowledge was significantly associated with overall teamwork (p = .034), overall situation awareness (p = .05) and clinical performance in two of the three scenarios (p = .032 cardiac and p = .006 shock). Situation awareness scores of scenario team leaders were low overall, with an average total score of 41%.

Conclusions
Final year undergraduate nursing students may have difficulty recognising and responding appropriately to patient deterioration. Improving pre-requisite knowledge, rehearsal of first response and team management strategies need to be a key component of undergraduate nursing students' education and ought to specifically address clinical performance, teamwork and situation awareness.

Assessment of performance properties of wetsuits

Wetsuits are an integral part of surfing especially in the southern regions of Australia. There is currently little information about mechanical, comfort and thermal properties of wetsuits. There is a demand from wetsuit manufacturers to better understand the neoprene properties and wetsuit performance. The performance characteristics of eight topselling wetsuits, from both high end and low end of the market, were examined. These characteristics include thickness, elasticity, bursting strength, hydrophobicity, thermal conductivity and seal strength. Tensile assessment revealed that neoprene foam was strong and its stretch recovery was well beyond 1.6 times of the original length. Neoprene was found to be hydrophobic with very low surface energy. High-end wetsuits with higher thickness showed slightly higher thermal resistance than low-end wetsuits, indicating that both thickness and bulk density of neoprene influenced thermal properties. High-end wetsuits with fluid seal were stronger than low-end wetsuits with stitched seal.

A hazardous substance exposure prevention rating method for intervention needs assessment and effectiveness evaluation: the small business exposure index

Aims This paper describes the refinement and adaptation to small business of a previously developed method for systematically prioritizing needs for intervention on hazardous substance exposures in manufacturing worksites, and evaluating intervention effectiveness. Methods We developed a checklist containing six unique sets of yes/no variables organized in a 2 × 3 matrix of exposure potential versus exposure protection at three levels corresponding to a simplified hierarchy of controls: materials, processes, and human interface. Each of the six sets of indicator variables was reduced to a high/moderate/low rating. Ratings from the matrix were then combined to generate an exposure prevention 'Small Business Exposure Index' (SBEI) Summary score for each area. Reflecting the hierarchy of controls, material factors were weighted highest, followed by process, and then human interface. The checklist administered by an industrial hygienist during walk-through inspection (N = 149 manufacturing processes/areas in 25 small to medium-sized manufacturing worksites). One area or process per manufacturing department was assessed and rated. A second hygienist independently assessed 36 areas to evaluate inter-rater reliability. Results The SBEI Summary scores indicated that exposures were well controlled in the majority of areas assessed (58% with rating of 1 or 2 on a 6-point scale), that there was some room for improvement in roughly one-third of areas (31% of areas rated 3 or 4), and that roughly 10% of the areas assessed were urgently in need of intervention (rated as 5 or 6). Inter-rater reliability of EP ratings was good to excellent (e.g., for SBEI Summary scores, weighted kappa = 0.73, 95% CI 0.52–0.93). Conclusion The SBEI exposure prevention rating method is suitable for use in small/medium enterprises, has good discriminatory power and reliability, offers an inexpensive method for intervention needs assessment and effectiveness evaluation, and complements quantitative exposure assessment with an upstream prevention focus.

Machinability assessment of Ti-6Al-4V for aerospace applications

Titanium alloy Ti-6Al-4V is the most commonly used titanium alloy in the aerospace and biomedical industries due to its superior material properties. An experimental investigation has been carried out to evaluate the machinability of high performance aerospace alloys (Ti-6Al-4V) to determine their in service performance characteristics based on different machining strategies. Nearly 80-90% of the titanium used in airframes is Ti-6Al-4V. The experimental design consist of face milling Ti-6Al-4V at 12 different combinations of cutting parameters consisting of Depth Of Cut (DoC)- 1, 2 and 3 mm; speeds- 60 and 100 m/min; coolant on/off and at constant feed rate of 0.04mm/tooth. Post machining analysis consists of cutting force measurement, surface texture analysis and metallographic analysis. The future work consists of in-depth investigation into the phase transformational reactions during machining.

A preliminary study on machinability assessment of nanobainite steel

The demand for high strength materials and improvements in heat treatment techniques has given rise to this new form of high strength steel known as nanobainite steel. The production of nanobainite steel involves slow isothermal holding of austenitic steel around 200oC for 10 days, in order to obtain a carbon enriched austenite and cooling to room temperature using austempering. The microstructure of nanobainite steel is dual phase consisting of alternate layers of bainitic ferrite and austenite. The experimental design consists of face milling under 12 combination of Depth of Cut (DoC)-1, 2 and 3mm; cutting speed-100 and 150m/min; constant feed- 0.15mm/rev and coolant on/off. The machinability of the material is assessed by means of analysis such as metallography and cutting force analysis. The results obtained are used to assess the most favorable condition to machine this new variety of steel. Future work involves study on phase transformation by quantifying the microstructural phase before and after milling using XRD.

Modification of the National Inpatient Medication Chart improves venous thromboembolism prophylaxis rates in high-risk medical patients

Background : Venous thromboembolism (VTE) is a significant contributor to morbidity and mortality in Australia. While there is well-established evidence for the use of VTE prophylaxis in hospital inpatients, adherence to such guidelines is poor. Aim : The aim of the present study is to assess the impact of education and system change on improving rates of VTE prophylaxis in hospital inpatients. Methods : We performed four consecutive audits of inpatient medical records of a regional hospital service over 2 years. The audits aimed to test the impact of serial interventions at increasing the appropriate use of VTE prophylaxis (based on risk assessment). The interventions were (i) staff education and (ii) a process change that mandated a prophylaxis decision by modifying the National Inpatient Medication Chart with ‘VTE avoidance’ preprinted in the first medication box. Results : Our results from the baseline study showed that of the 236 medical inpatients reviewed, 80% were at high risk of VTE. Of this high-risk cohort, 34.9% (confidence interval (CI) 28–42%) had appropriate prophylaxis decisions. Post the education intervention, 43.2% (CI 37–49%) of the high-risk cohort received appropriate VTE prophylaxis, an improvement of 8.3% (CI −1% to 18%) from baseline. With the subsequent introduction of a process change, 82.1% (CI 66–92%) of the high-risk cohort received appropriate prophylaxis, an improvement of 47.2% and 38.8% (CI 24–54%) when compared with baseline and education respectively. Retention rates at 11 months postsystem change were 73% (CI 55–86%). Conclusions : This study therefore concluded that while education has an impact on rates of appropriate VTE prophylaxis, it is system change that has the most marked and sustained effect.

Identification of mental illness in police cells: a comparison of police processes, the brief jail mental health screen and the jail screening assessment tool

The study investigated current police practices employed to identify those with a mental illness in police custody, and to evaluate the predictive utility of the Brief Jail Mental Health Screen (BJMHS) and the Jail Screening Assessment Tool (JSAT). One hundred and fifty detainees were recruited from two police stations in Melbourne, Australia. Measures included the Structured Clinical Interview for DSM-IV-TR, BJMHS and JSAT. Axis-I disorders were compared with police decisions regarding identification of mental illness based on their usual practices. Participants were classified as requiring referral for further mental health evaluation according to the screening tools. Results indicated that current police practices produced high false negatives, with many of those experiencing mental illness not identified. There was no significant difference in performance between BJMHS (AUC =0.722) and JSAT (AUC =0.779) in identifying those with a serious mental illness (p=0.109). However, JSAT performed significantly better at identifying any Axis-I disorder, excluding substance use disorders, as compared with BJMHS (AUC =0.815, vs AUC =0.729; p=0.018). Given the high prevalence of mental illness among detainees, there is a pressing need to introduce standardised screening tools for mental illness in police custody. This can assist the police in managing detainees appropriately and securing mental health services as required.

Development and measurement properties of a putting skill test for high-level golf

Despite a recent increase in the amount of research investigating performance in golf, a comprehensive putting skill test has not been reported in the peer-reviewed literature. In this study, the Golf Australia Putting Test (GAPT) was developed and a series of measurement properties were assessed. Elite (n = 18) and high-level amateur (HLA; n = 22) participants completed six single putts from various areas on six concentric circles (circle radii = 0.9, 1.5, 3.0, 4.6, 6.1 and 7.6 m). Using a scoring system that rewarded participants for holing putts from longer distances, the maximum score from a single round of the test (i.e. 36 putts) was 27 points. After two rounds of the test were completed by all players, a subsample of participants (elite, n = 15; HLA, n = 7) had their putting performance recorded during tournament play for a period of 90 days to assess criterion (predictive) validity of the test. The reliability, sensitivity and discriminative validity of the GAPT were also assessed. Better agreement between Rounds 1 and 2 scores was noted in the elite group, whilst reliability values were similar for both groups. Further, the GAPT scores were shown to predict players from the elite and high-ability groups with a low classification error. An equation for predicting on-course performance from GAPT scores was also developed. Findings from this study indicate that the GAPT is a valid and reliable tool for high-level players and the GAPT may be used for player evaluation in the field.

The contribution of Building Information Modelling (BIM) to Green Building Design and Assessment in Abu Dhabi "ESTIDAMA"

Estidama is a mandatory Green Building code in Abu Dhabi by which the compliance of building design is being assessed. This paper examines the current design and assessment approaches for Green Buildings to identify the reasons that lead to delay defects and it investigates a new approach for improvement. The available literature provides a realistic understanding to the problems and shows the road to some potential solutions. The identified problems were mainly attributed to the manual assessment with too much human interference. The piled documents with limited resources left the assessment system too slow to handle the whole projects within the greater Abu Dhabi engendering high risk of the commitment to review mistakes. Therefore, this paper investigates the potentiality of automating several stages via the use of Building Information Modeling (BIM) into the assessment process. Different experienced participants from all aspects within the construction industry were interviewed to contribute to the research. Also, a close question questionnaire was distributed to examine the current practice in Abu Dhabi to compare it with the initial findings. The findings point out significant requirements to adopt BIM in the assessment process, such as the availability of proper contracts form to shape the relationship between BIM parties and the readiness of the current system. Hence, the authors suggest a new model that integrates BIM capabilities within the system to accelerate the process and reduce human involvement.

An exposure prevention rating method for intervention needs assessment and effectiveness evaluation

This article describes a new method for (1) systematically prioritizing needs for intervention on hazardous substance exposures in manufacturing work sites, and (2) evaluating intervention effectiveness. We developed a checklist containing six unique sets of yes/no variables organized in a 2 × 3 matrix of exposure potential versus protection (two columns) at the levels of materials, processes, and human interface (three rows). The three levels correspond to a simplified hierarchy of controls. Each of the six sets of indicator variables was reduced to a high/moderate/low rating. Ratings from the matrix were then combined to generate a single overall exposure prevention rating for each area. Reflecting the hierarchy of controls, material factors were weighted highest, followed by process, and then human interface. The checklist was filled out by an industrial hygienist while conducting a walk-through inspection (N = 131 manufacturing processes/areas in 17 large work sites). One area or process per manufacturing department was assessed and rated. Based on the resulting Exposure Prevention ratings, we concluded that exposures were well controlled in the majority of areas assessed (64% with rating of 1 or 2 on a 6-point scale), that there is some room for improvement in 26 percent of areas (rating of 3 or 4), and that roughly 10 percent of the areas assessed are urgently in need of intervention (rated as 5 or 6). A second hygienist independently assessed a subset of areas to evaluate inter-rater reliability. The reliability of the overall exposure prevention ratings was excellent (weighted kappa = 0.84). The rating scheme has good discriminatory power and reliability and shows promise as a broadly applicable and inexpensive tool for intervention needs assessment and effectiveness evaluation. Validation studies are needed as a next step. This assessment method complements quantitative exposure assessment with an upstream prevention focus.

Bevacizumab for the treatment of high-grade glioma: an update after phase III trials.

Gliomas are highly vascular and rich in VEGF, which promotes angiogenesis. Bevacizumab is a monoclonal antibody against VEGF, inhibiting angiogenesis by preventing receptor activation. Early Phase II clinical trials using bevacizumab in both newly diagnosed and recurrent high-grade gliomas (HGG) showed promising results, but these have not been confirmed in recent Phase III trials. This review is an update including recently reported Phase II and III study results.

Investigating the predictive ability of gait speed and quadriceps strength for incident falls in community-dwelling older women at high risk of fracture

Gait speed is a recommended geriatric assessment of physical performance, but may not be regularly examined in clinical settings. We aimed to investigate whether quadriceps strength tests demonstrate similar predictive ability for incident falls as gait speed in older women. We investigated 135 female volunteers aged mean±SD 76.7±5.0 years (range 70-92) at high risk of fracture. Participants completed gait speed assessments using the GAITRite Electronic Walkway System, and quadriceps strength assessments using a hand-held dynamometer (HHD). Participants reported incident falls monthly for 3.7±1.2 years. N=99 (73%) participants fell 355 times during the follow-up period (mean fall rate 83 per 100 person years). We observed a reduced odds ratio for multiple falls (0.83, 95% CI 0.70-0.98) and a reduced hazard ratio for time to first fall (0.90, 95% CI 0.83-0.98), according to quadriceps strength. There was also a significantly shorter time to first fall for those with low quadriceps strength (<7.0 kg; lowest tertile) compared with those with normal quadriceps strength (estimated means [95% CI] 1.54 [1.02, 2.06] vs. 2.23 [1.82, 2.64] years; P=0.019), but not for those with low (<1.0 m/s) vs. normal gait speed (P=0.15). Quadriceps strength is a significant predictor of incident falls over three years amongst community-dwelling older women at high risk of fracture. Quadriceps strength tests may be an acceptable alternative to gait speed for geriatric assessments of falls risk.