Guideline-discordant care in acute myocardial infarction: predictors and outcomes

Objectives: To determine (i) factors which predict whether patients hospitalised with acute myocardial infarction (AMI) receive care discordant with recommendations of clinical practice guidelines; and (ii) whether such discordant care results in worse outcomes compared with receiving guideline-concordant care. Design: Retrospective cohort study. Setting: Two community general hospitals. Participants: 607 consecutive patients admitted with AMI between July 1997 and December 2000. Main outcome measures: Clinical predictors of discordant care; crude and risk-adjusted rates of inhospital mortality and reinfarction, and mean length of hospital stay. Results: At least one treatment recommendation for AMI was applicable for 602 of the 607 patients. Of these patients, 411(68%) received concordant care, and 191 (32%) discordant care. Positive predictors at presentation of discordant care were age > 65 years (odds ratio [OR], 2.5; 95% Cl, 1.7-3.6), silent infarction (OR, 2.7; 95% Cl, 1.6-4.6), anterior infarction (OR, 2.5; 95% Cl, 1.7-3.8), a history of heart failure (OR, 6.3; 95% Cl, 3.7-10.7), chronic atrial fibrillation (OR, 3.2; 95% Cl, 1.5-6.4); and heart rate greater than or equal to 100 beats/min (OR, 2.1; 95% Cl, 1.4-3.1). Death occurred in 12.0% (23/191) of discordant-care patients versus 4.6% (19/411) of concordant-care patients (adjusted OR, 2.42; 95% Cl, 1.22-4.82). Mortality was inversely related to the level of guideline concordance (P = 0.03). Reinfarction rates also tended to be higher in the discordant-care group (4.2% v 1.7%; adjusted OR, 2.5; 95% Cl, 0.90-7.1). Conclusions: Certain clinical features at presentation predict a higher likelihood of guideline-discordant care in patients presenting with AMI Such care appears to increase the risk of inhospital death.

Quality of care of patients hospitalized with acute coronary syndromes

Background: Measurement and improvement of quality of care is a priority issue in health care. Patients hospitalized with acute coronary syndromes (ACS) constitute a high-risk population whose care, if shown to be suboptimal on the basis of available research evidence, may benefit from quality improvement interventions. Aim: To evaluate the quality of in-hospital care for patients with ACS, using explicit quality indicators. Methods: Retrospective case note review was undertaken of 397 patients admitted to three teaching hospitals in Brisbane, Queensland, Australia, between 1 October 2000 and 17 April 2001. The main out-come measures were 12 process-of-care quality indicators, calculated as either: (i) the proportion of all patients who received specific interventions or (ii) the proportion of ideal patients who received -specific interventions (i.e. patients with clear indi-cations and lacking contraindications). Results: Quality indicators with values above 80% included: (i) patient selection for thrombolysis (100%) and discharge prescription of beta-blockers (84%), (ii) antiplatelet agents (94%) and (iii) lipid-lowering agents (82%). Indicators with values between 50% and 80% included: (i) timely per-formance of electrocardiogram (ECG) on admission (61%), (ii) early coronary angiography (75%), (iii) measurement of serum lipids (71%) and (iv) discharge prescription of angiotensin-converting-enzyme (ACE) inhibitors (73%). Indicators with values <50% included: (i) timely administration of thrombolysis (35%), (ii) non-invasive risk assessment (23%) and (ii) formal in-hospital and post-hospital cardiac rehabilitation (47% and 7%, respectively). Conclusion: There were delays in performing ECG and administering thrombolysis to patients who presented to emergency departments with ACS. Improvement is warranted in use of non-invasive procedures for identifying high-risk patients who may benefit from coronary revascularization as well as use of serum lipid measurements, ACE inhibitors and cardiac rehabilitation.

Geographic variation of natural products of tropical nudibranch Asteronotus cespitosus

Extracts of the dorid nudibranch Asteronotus cespitosus from two geographically separate regions of Australia and from the Philippines were compared using thin-layer, high-performance liquid and gas chromatography and H-1 NMR analysis. Halogenated metabolites were detected in all mollusk specimens. The major component detected in digestive tissue of specimens from the Great Barrier Reef in northeastern Australia was 4,6-dibromo2-(2',4'-dibromophenoxy)phenol (1), with minor amounts of 3,5-dibromo-2(3',5'-dibromo-20-methoxyphenoxy)phenol (2). In a specimen collected from northwestern Australia, only 3,5-dibromo-2-(3',5'-dibromo-2'-methoxyphenoxy)phenol was found. The specimen from the Philippines contained 2,3,4,5-tetrabromo-6-(2'-bromophenoxy) phenol (3) together with a novel chlorinated pyrrolidone (4). In addition, the sesquiterpenes dehydroherbadysidolide (5) and spirodysin (6) were detected in the digestive organs and mantle tissue of the nudibranchs from the Great Barrier Reef and from the Philippines, whereas these chemicals were not found in the specimen from northwestern Australia. All of the chemicals (1-3,5, and 6) have previously been isolated from the sponge Dysidea herbacea, as have chlorinated metabolites related to 4. This is the first time the characteristic halogenated metabolites that typify Dysidea herbacea have been reported from a carnivorous mollusk, which implies a dietary origin as opposed to de novo synthesis.

Behaviour of older people admitted for residential respite care

The aim of this pilot study was to determine whether residential respite care is used because of disruptive behaviour displayed by older people. The specific objectives were to 1) characterise older people being admitted for residential respite care, 2) obtain a preliminary estimate of the proportion of older people in residential respite care because of disruptive behaviour, and, 3) examine the relationship between residential respite care and disruptive behaviour. A quantitative approach using a cross-sectional survey was employed. The respite recipients were 35 older people with a mean age of 81.5 years (range 67-96 years). The respite recipients had been admitted for residential respite care to aged care hostels and nursing homes in a provincial city and its surrounding rural area. Nurses rated disruptive behaviour using the Dementia Behavior Disturbance Scale (DBDS). Additional reliability data for the DBDS are provided. The study found that the largest specific group of residential respite care users were widows (31.4%) who lived alone in their own home. The reason for over half (51.4%) of the residential respite admissions was to give a carer a 'break' from the older person. Although a large proportion (80%) of respite recipients were rated as having disruptive behaviour, the proportion of admissions because of disruptive behaviour was much less (28.6%). People with dementia (37.1%) scored significantly higher than people without dementia on the DBDS [F (1,33)=15.57, p

Psychologists as mental health case managers

The results of two independent surveys of professionals working in government-funded adult community mental health services were examined with a view to considering how psychologists rate their capacities as mental health case managers. Professional competency and personal efficacy self-report profiles for psychologists were compared with those of other professionals in related roles. The results obtained suggested that psychologists identified their strengths as being in traditional practice roles as individual clinicians. Relative to other professions, psychologists reported weaknesses in team and community-focused practice roles. The implications for professional practice and training are discussed.

Up close and personal on physical education teachers' identity: Is conflict an issue?

Much of the research on teachers' work is informed by role theory, that assumes teachers' identity is largely ascribed. When there are inconsistencies in teachers' and others' expectations for different occupational roles such as physical education teacher and sports coach, 'role conflict' is said to occur. This stud), sought to investigate if role conflict was a major concern for Australian physical education teacher/coaches. Findings, informed by case studies with five teacher/coaches, challenge the assumption that moving between professional responsibilities causes role conflict. Rather, in moving across contexts, the physical education teachers managed inconsistencies in ways that resulted in positive and rawarding work experiences.

Sponge halogenated natural products found at parts-per-million levels in marine mammals

Several unknown, abundant brominated compounds (BCs) were recently detected in the blubber of dolphins and other marine mammals from Queensland (northeast Australia). The BC were interpreted as potential natural products due to the lack of anthropogenic sources for these compounds. This study investigated whether some of the BCs accumulated by diverse marine mammal species are identical with natural BCs previously isolated from sponges (Dysidea sp.) living in the same habitat. Isolates from sponges and mollusks (Asteronotus cespitosus) were compared with the signals detected in the mammals' tissue. Mass spectra and gas chromatography retention times on four different capillary columns of the isolates from sponges and mammals were identical in all respects. This proves that the chemical name of the compound previously labeled BC-2 is 4,6-dibromo-2-(2'-dibromo)phenoxyanisole and that the chemical name of BC-11 is 3,5-dibromo-2-(3',5'-dibromo-2'-methoxy)phenoxyanisole. Using a quantitative reference solution of BC-2, we established that the concentrations of the brominated metabolies found in the marine mammals are frequently >1 mg/kg. The highest concentration (3.8 mg/kg), found in a sample of pygmy sperm whale (Kogia breviceps), indicates that BC-2 is a bioaccumulative, natural organohalogen compound. This is supported by the concentrations of the BCs in our samples being equal to the highest concentrations of anthropogenic BCs in any environmental sample. The quantitative determination of BC-2 in blubber of marine mammals from Africa and the Antarctic suggests that BC-2 is wide-spread. These results are direct proof that marine biota can produce persistent organic chemicals that accumulate to substantial concentrations in higher trophic organisms.

Outcome of stroke patients admitted to intensive care: Experience from an Australian teaching hospital

The objective of this study was to determine the mortality rate and the functional outcomes of stroke patients admitted to the intensive care unit (ICU) and to identify predictors of poor outcome in this population. The records of all patients admitted to the ICU with the diagnosis of stroke between January 1994 and December 1999 were reviewed. Patients with subarachnoid haemorrhage were excluded. Data were collected on clinical and biological variables, risk factors for stroke and the presence of comorbidities. Mortality (ICU, in-hospital and three-month) and functional outcome were used as end-points. In the six-year-period, 61 patients were admitted to the ICU with either haemorrhagic or ischaemic stroke. Medical records were available for only 58 patients. There were 23 ischaemic and 35 haemorrhagic strokes. The ICU, in-hospital and three-month mortality rates were 36%, 47% and 52% respectively. There were no significant differences in the prevalence of premorbid risk factors between survivors and non-survivors. The mean Barthel score was significantly different between the independent and dependent survivors (94 +/- 6 vs 45 +/- 26, P < 0.001). A substantial number of patients with good functional outcomes had lower Rankin scores (92% vs 11%, P < 0.001). Only 46% of those who were alive at three months were functionally independent. Intensive care admission was associated with a high mortality rate and a high likelihood of dependent lifestyle after hospital discharge. Haemorrhagic stroke, fixed dilated pupil(s) and GCS < 10 during assessment were associated with increased mortality and poor functional outcome.

Alternative technologies for producing sterile low acid food products

Four emerging high-energy non-thermal technologies may replace or augment heating for producing sterile low-acid food products. High pressure, high-voltage pulsed electric field, high-energy ultrasound and high-intensity pulsed light are all capable of reducing bacterial spore counts under certain conditions. However, only non-continuous high pressure treatments, at temperatures higher than ambient, are currently capable of completely inactivating spores and producing sterile food products. The first three technologies also reduce the resistance of spores to inactivation by heat.

Lipolysis in milk and dairy products: a research journey

In this paper, I describe my journey through a field of research in which I have been involved for some years - lipolysis in milk and dairy products. While I call it my journey, I have had many fellow travellers who have helped me along the way. These have been my research colleagues and collaborators, and, since I joined the University of Queensland, my students. The research has covered a variety of aspects but I have chosen to describe only a selection of these.