Detection of right-to-left Atrial communication using agitated saline contrast imaging : experience with 1162 patients and recommendations for echocardiography

Background: Right-to-left shunting via a patent foramen ovale (PFO) has a recognized association with embolic events in younger patients. The use of agitated saline contrast imaging (ASCi) for detecting atrial shunting is well documented, however optimal technique is not well described. The purpose of this study is to assess the efficacy and safety of ASCi via TTE for assessment of right-to-left atrial communication in a large cohort of patients. Method: A retrospective review was undertaken of 1162 consecutive transthoracic (TTE) ASCi studies, of which 195 had also undergone clinically indicated transesophageal (TEE) echo. ASCi shunt results were compared with color flow imaging (CFI) and the role of provocative maneuvers (PM) assessed. Results: 403 TTE studies (35%) had paradoxical shunting seen during ASCi. Of these, 48% were positive with PM only. There was strong agreement between TTE ASCi and reported TEE findings (99% sensitivity, 85% specificity), with six false positive and two false negative results. In hindsight, the latter were likely due to suboptimal right atrial opacification, and the former due to transpulmonary shunting. TTE CFI was found to be insensitive (22%) for the detection of a PFO compared with TTE ASCi. Conclusions: TTE ASCi is minimally invasive and highly accurate for the detection of right-to-left atrial communication when PM are used. TTE CFI was found to be insensitive for PFO screening. It is recommended that TTE ASCi should be considered the initial diagnostic tool for the detection of PFO in clinical practice. A dedicated protocol should be followed to ensure adequate agitated saline contrast delivery and performance of provocative maneuvers.

Food consumption of Sri Lankan adults : an appraisal of serving characteristics

Objective The main aim of the present study was to identify food consumption in Sri Lankan adults based on serving characteristics. Design Cross-sectional study. Fruits, vegetables, starch, meat, pulses, dairy products and added sugars in the diet were assessed with portion sizes estimated using standard methods. Setting Twelve randomly selected clusters from the Sri Lanka Diabetes and Cardiovascular Study. Subjects Six hundred non-institutionalized adults. Results The daily intake of fruit (0·43), vegetable (1·73) and dairy (0·39) portions were well below national recommendations. Only 3·5 % of adults consumed the recommended 5 portions of fruits and vegetables/d; over a third of the population consumed no dairy products and fewer than 1 % of adults consumed 2 portions/d. In contrast, Sri Lankan adults consumed over 14 portions of starch and 3·5 portions of added sugars daily. Almost 70 % of those studied exceeded the upper limit of the recommendations for starch intake. The total daily number of meat and pulse portions was 2·78. Conclusions Dietary guidelines emphasize the importance of a balanced and varied diet; however, a substantial proportion of the Sri Lankan population studied failed to achieve such a recommendation. Nutrition-related diseases in the country may be closely correlated with unhealthy eating habits.

Diet-induced obesity : when does consumption become overconsumption?

Overconsumption is commonly implicated in the aetiology of obesity; however there is a lack of consensus on a definition and the most appropriate methodology for assessing it. The aim of this communication is to highlight the need for theoretical consensus on the assessment of overconsumption, which may lead to improved methodological standards in obesity research. In laboratory studies, overconsumption is most frequently inferred from the comparison of food intake within or between individuals against a single control. Measurement often relies on a single eating episode with limited consideration of preceding or subsequent intake. An alternative approach is to consider food intake in the context of energy requirements, within an energy balance framework. One such marker of chronic overconsumption is body weight. There is a need for agreement on the definition and measurement of overconsumption, so that its role in weight gain and obesity can be more precisely delineated.

International students using online information resources to learn : complex experience and learning needs

This paper reports the findings of a qualitative study which investigated 25 international students’ use of online information resources for study purposes at two Australian universities. Using an expanded critical incident approach, the study viewed international students through an information literacy lens, as information-using learners. The findings are presented in two complementary parts: as a word picture that describes their whole experience of using online information resources to learn; and as a tabulated set of critical findings that summarises their associated information literacy learning needs. The word picture shows international students’ resource use as a complex interplay of eight inter-related elements: students; information-learning environment; interactions (with online resources); strengths-challenges; learning-help; affective responses; reflective responses; cultural-linguistic dimensions. In using online resources, the international students experience an array of strengths and challenges, and an apparent information literacy imbalance between their more developed information skills and less developed critical information use. The critical findings about information literacy needs provide a framework for developing an inclusive informed learning approach that responds to international students’ complex information using experiences and needs. While the study is situated in Australia, the findings are of potential interest to educators, information professionals and researchers worldwide who seek to support learning in culturally diverse higher education contexts.

Smoking status as a moderator of the association between food insecurity and decreased fruit and vegetable consumption

Food insecurity is the inadequate access to, or availability of, sufficient amounts of nutritious, culturally-appropriate and safe foods, or the inability to acquire such foods by socially acceptable means. Food insecurity has been shown to be associated with poor dietary intakes and poor health status. Recently, evidence has emerged suggesting increased rates of food insecurity among those with substance abuse problems, including those who smoke. This cross-sectional study investigates the potential moderating effect of smoking on the association between food insecurity and fruit and vegetable intakes among the Australian population, using regression analyses. Participants were adults 18 years and older participating in the 2004/05 National Health Survey (n = 19,500). Those from food insecure households were up to two-times more likely to report inadequate fruit and vegetable intakes compared to those who were food secure. Those who smoked were nearly six times more likely to report being food insecure, and up to three-times more likely to report inadequate fruit and vegetable intakes, compared to their non-smoking counterparts. Further analyses revealed a marked decline in the strength of the association between food insecurity and fruit consumption with the addition of smoking status into a regression model. These findings have important implications for the development of policy and interventions to address food insecurity, suggesting that those from food insecure households are less likely to comply with national dietary recommendations, and that this may in part be moderated by smoking status.

Experience of overseas-trained health professionals in rural and remote areas of destination countries: A literature review

This study aimed to review and synthesise existing literature that investigated the experience of overseastrained health professionals (OTHPs) in rural and remote areas of destination countries. A systematic literature review was conducted using electronic databases and manual search of studies published from January 2004 to February 2011. Data were analysed from the final 17 original report articles that met the inclusion criteria. The reviewed research studies were conducted in Australia, Canada, New Zealand, the UK and the USA. Overseas-trained medical practitioners were the most frequently researched (n = 14); two studies involved nurses and one study included several health professionals. Three main themes emerged from the review and these were: (i) expectations; (ii) cultural diversity; and (iii) orientation and integration to rural and remote health work environment. The OTHPs were expected to possess the appropriate professional and cultural skills while they themselves expected recognition of their previous experiences and adequate organisational orientation and support. A welcoming and accepting community coupled with a relaxed rural lifestyle and the joy of continued patient care resulted in successful integration and contributed to increased staff retention rates. Recognition of expectations and cultural diversity by all parties and comprehensive orientation with sufficient organisational support are important elements in the integration of OTHPs and subsequent delivery of quality health care to people living in rural and remote areas.

Pregnancy as public property: The experience of couples following diagnosis of a foetal anomaly

Background: Pregnant women find themselves subject to comments and questions from people in public areas. Normally, becoming ‘public property’ is considered friendly and is relatively easy for pregnant women to deal with. However, following diagnosis of a fetal anomaly, the experience of being public property can exacerbate the emotional turmoil experienced by couples. Original research question: What is the experience of couples who continue pregnancy following the diagnosis of a fetal anomaly? Method: The study used an interpretive design informed by Merleau-Ponty and this paper reports on a subset of findings. Thirty-one interviews with pregnant women and their partners were undertaken following the diagnosis of a serious or lethal fetal anomaly. Women were between 25 and 38 weeks gestation at the time of their first interview. The non-directive interviews were audiotaped, transcribed verbatim and the transcripts were thematically analysed. Findings: A prominent theme that emerged during data analysis was that pregnancy is embodied therefore physically evident and ‘public’. Women found it difficult to deal with being public property when the fetus had a serious or lethal anomaly. Some women avoided social situations; others did not disclose the fetal condition but gave minimal or avoidant answers to minimise distress to themselves and others. The male participants were not visibly pregnant and they could continue life in public without being subject to the public’s gaze, but they were very aware and concerned about its impact on their partner. Conclusion: The public tend to assume that pregnancy is normal and will produce a healthy baby. This becomes problematic for women who have a fetus with an anomaly. Women use strategies to help them cope with becoming public property during pregnancy. Midwives can play an important role in reducing the negative consequences of a woman becoming public property following the diagnosis of a fetal anomaly.

A virtual environment to simulate the experience of psychosis

Psychosis is a mental disorder that affects 1-2% of the population at some point in their lives. One of the main causes of psychosis is the mental illness schizophrenia. Sufferers of this illness often have terrifying symptoms such as hallucinations, delusions, and thought disorder. This project aims to develop a virtual environment to simulate the experience of psychosis, focusing on re-creating auditory and visual hallucinations. A model of a psychiatric ward was created and the psychosis simulation software was written to re-create the auditory and visual hallucinations of one particular patient. The patient was very impressed with the simulation, and commented that it effectively re-created the same emotions that she experienced on a day-to-day basis during her psychotic episodes. It is hoped that this work will result in a useful educational tool about schizophrenia, leading to improved training of clinicians, and fostering improved understanding and empathy toward sufferers of schizophrenia in the community, ultimately improving the quality of life and chances of recovery of patients.

The development of a virtual reality environment to model the experience of schizophrenia

Virtual Reality (VR) techniques are increasingly being used for education about and in the treatment of certain types of mental illness. Research indicates that VR is delivering on its promised potential to provide enhanced training and treatment outcomes through incorporation of this high-end technology. Schizophrenia is a mental disorder affecting 1-2% of the population, and it is estimated 12-16% of hospital beds in Australia are occupied by patients with psychosis. Tragically, there is also an increased risk of suicide associated with this diagnosis. A significant research project being undertaken across the University of Queensland faculties of Health Sciences and EPSA (Engineering, Physical Sciences and Architecture) has constructed a number of virtual environments that reproduce the phenomena experienced by patients who have psychosis. Symptoms of psychosis include delusions, hallucinations and thought disorder. The VR environment will allow behavioral, exposure therapies to be conducted with exactly controlled exposure stimuli and an expected reduction in risk of harm. This paper reports on the current work of the project, previous stages of software development and the final goal to introduce VR to medical consulting rooms.

The effect of alcohol and drug consumption on academic performance : a treatment effect evaluation

It is often argued that consumption of alcohol, tobacco and drugs is detrimental to the cognitive abilities of teenagers. In order to disentangle a possible causal effect of these substances use from a self-selection bias, we control for pupils previous performance and for their previous rate of progression applying a DiDiD strategy. Using the NELS 1988 panel dataset, we find that the effects of alcohol and tobacco on test scores disappear once the selection bias is controlled for (this does not preclude long term detrimental effects). However, we find reliable evidence that heavy use of drugs (marijuana and cocaine) has direct detrimental effects on educational achievements. Hence, our results may have significant policy implications.

Psychosocial experience of cancer : surpassing mere survival and recognising the potential for posttraumatic growth as well as distress.

The publication of the fourth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV; American Psychiatric Association, 1994) introduced the notion that a life-threatening illness can be a stressor and catalyst for Posttraumatic Stress Disorder (PTSD). Since then a solid body of research has been established investigating the post-diagnosis experience of cancer. These studies have identified a number of short and long-term life changes resulting from a diagnosis of cancer and associated treatments. In this chapter, we discuss the psychosocial response to the cancer experience and the potential for cancer-related distress. Cancer can represent a life-threatening diagnosis that may be associated with aggressive treatments and result in physical and psychological changes. The potential for future trauma through the lasting effects of the disease and treatment, and the possibility of recurrence, can be a source of continued psychological distress. In addition to the documented adverse repercussions of cancer, we also outline the recent shift that has occurred in the psycho-oncology literature regarding positive life change or posttraumatic growth that is commonly reported after a diagnosis of cancer. Adopting a salutogenic framework acknowledges that the cancer experience is a dynamic psychosocial process with both negative and positive repercussions. Next, we describe the situational and individual factors that are associated with posttraumatic growth and the types of positive life change that are prevalent in this context. Finally, we discuss the implications of this research in a therapeutic context and the directions of future posttraumatic growth research with cancer survivors. This chapter will present both quantitative and qualitative research that indicates the potential for personal growth from adversity rather than just mere survival and return to pre-diagnosis functioning. It is important to emphasise however, that the presence of growth and prevalence of resilience does not negate the extremely distressing nature of a cancer diagnosis for the patient and their families and the suffering that can accompany treatment regimes. Indeed, it will be explained that for growth to occur, the experience must be one that quite literally shatters previously held schemas in order to act as a catalyst for change.

Management of delirium in medicine : experience of a close observation unit

Objective(s): A new model of care for the management of patients with delirium was developed and evaluated. Method: A 4-bedded Close Observation Unit (COU) was introduced. The model comprised an education strategy for assistants in nursing (AIN), environmental adaptations and AIN to patient ratio of 1:4. Outcomes in all patients with delirium before and after introduction of the new model of care were compared. Results: 105 patients were admitted to COU, of whom 100 (95%) were diagnosed with delirium. In-hospital mortality improved after introduction of the unit (15% versus 5%; p=0.002) without significant change in length of stay, discharge destination or falls frequency. Conclusion: A dedicated unit for delirium management within medicine achieved a reduction in mortality.