Patients Undergoing Subacute Physical Rehabilitation following an Acute Hospital Admission Demonstrated Improvement in Cognitive Functional Task Independence

Objective. This study investigated cognitive functioning among older adults with physical debility not attributable to an acute injury or neurological condition who were receiving subacute inpatient physical rehabilitation. Design. A cohort investigation with assessments at admission and discharge. Setting. Three geriatric rehabilitation hospital wards. Participants. Consecutive rehabilitation admissions () following acute hospitalization (study criteria excluded orthopaedic, neurological, or amputation admissions). Intervention. Usual rehabilitation care. Measurements. The Functional Independence Measure (FIM) Cognitive and Motor items. Results. A total of 704 (86.5%) participants (mean age = 76.5 years) completed both assessments. Significant improvement in FIM Cognitive items (-score range 3.93–8.74, all ) and FIM Cognitive total score (-score = 9.12, ) occurred, in addition to improvement in FIM Motor performance. A moderate positive correlation existed between change in Motor and Cognitive scores (Spearman’s rho = 0.41). Generalized linear modelling indicated that better cognition at admission (coefficient = 0.398, ) and younger age (coefficient = −0.280, ) were predictive of improvement in Motor performance. Younger age (coefficient = −0.049, ) was predictive of improvement in FIM Cognitive score. Conclusions. Improvement in cognitive functioning was observed in addition to motor function improvement among this population. Causal links cannot be drawn without further research.

The silent and apparent neurological injury in transcatheter aortic valve implantation study (SANITY) : concept, design and rationale

Background The incidence of clinically apparent stroke in transcatheter aortic valve implantation (TAVI) exceeds that of any other procedure performed by interventional cardiologists and, in the index admission, occurs more than twice as frequently with TAVI than with surgical aortic valve replacement (SAVR). However, this represents only a small component of the vast burden of neurological injury that occurs during TAVI, with recent evidence suggesting that many strokes are clinically silent or only subtly apparent. Additionally, insult may manifest as slight neurocognitive dysfunction rather than overt neurological deficits. Characterisation of the incidence and underlying aetiology of these neurological events may lead to identification of currently unrecognised neuroprotective strategies. Methods The Silent and Apparent Neurological Injury in TAVI (SANITY) Study is a prospective, multicentre, observational study comparing the incidence of neurological injury after TAVI versus SAVR. It introduces an intensive, standardised, formal neurologic and neurocognitive disease assessment for all aortic valve recipients, regardless of intervention (SAVR, TAVI), valve-type (bioprosthetic, Edwards SAPIEN-XT) or access route (sternotomy, transfemoral, transapical or transaortic). Comprehensive monitoring of neurological insult will also be recorded to more fully define and compare the neurological burden of the procedures and identify targets for harm minimisation strategies. Discussion The SANITY study undertakes the most rigorous assessment of neurological injury reported in the literature to date. It attempts to accurately characterise the insult and sustained injury associated with both TAVI and SAVR in an attempt to advance understanding of this complication and associations thus allowing for improved patient selection and procedural modification.

"It broke our hearts": Understanding parents' lived experiences of their child's admission to an acute mental health care facility

This article reports the evaluative findings of an Early Psychosis Education Program (EPEP) designed to support parents caring for their child who was recently admitted to the psychiatric intensive care unit of an inpatient mental health care facility in Australia. The EPEP offered education on mental illness, treatment options, and medication, as well as information on the recovery model of care. The EPEP was facilitated by two RNs and was evaluated for educational effectiveness using a simple pre- and postevaluation questionnaire. The evaluation revealed two themes expressed by parents: "We didn't see it coming," and "Hopelessness and helplessness." The themes highlighted the parents' lack of mental health care knowledge prior to the EPEP, which had a significant impact on the parents' experiences and well-being. The evaluative findings highlighted a need for a nurse-led EPEP within the community. A community EPEP has the potential to strengthen the partnership between parents, families, and mental health service providers and to help with the provision of a recovery framework of care.

Performance-Based Quality Assurance/Quality Control (QA/QC) Acceptance Procedures for In-Place Soil Testing Phase 3

One of the objectives of this study was to evaluate soil testing equipment based on its capability of measuring in-place stiffness or modulus values. As design criteria transition from empirical to mechanistic-empirical, soil test methods and equipment that measure properties such as stiffness and modulus and how they relate to Florida materials are needed. Requirements for the selected equipment are that they be portable, cost effective, reliable, a ccurate, and repeatable. A second objective is that the selected equipment measures soil properties without the use of nuclear materials.The current device used to measure soil compaction is the nuclear density gauge (NDG). Equipment evaluated in this research included lightweight deflectometers (LWD) from different manufacturers, a dynamic cone penetrometer (DCP), a GeoGauge, a Clegg impact soil tester (CIST), a Briaud compaction device (BCD), and a seismic pavement analyzer (SPA). Evaluations were conducted over ranges of measured densities and moistures.Testing (Phases I and II) was conducted in a test box and test pits. Phase III testing was conducted on materials found on five construction projects located in the Jacksonville, Florida, area. Phase I analyses determined that the GeoGauge had the lowest overall coefficient of variance (COV). In ascending order of COV were the accelerometer-type LWD, the geophone-type LWD, the DCP, the BCD, and the SPA which had the highest overall COV. As a result, the BCD and the SPA were excluded from Phase II testing.In Phase II, measurements obtained from the selected equipment were compared to the modulus values obtained by the static plate load test (PLT), the resilient modulus (MR) from laboratory testing, and the NDG measurements. To minimize soil and moisture content variability, the single spot testing sequence was developed. At each location, test results obtained from the portable equipment under evaluation were compared to the values from adjacent NDG, PLT, and laboratory MR measurements. Correlations were developed through statistical analysis. Target values were developed for various soils for verification on similar soils that were field tested in Phase III. The single spot testing sequence also was employed in Phase III, field testing performed on A-3 and A-2-4 embankments, limerock-stabilized subgrade, limerock base, and graded aggregate base found on Florida Department of Transportation construction projects. The Phase II and Phase III results provided potential trend information for future research—specifically, data collection for in-depth statistical analysis for correlations with the laboratory MR for specific soil types under specific moisture conditions. With the collection of enough data, stronger relationships could be expected between measurements from the portable equipment and the MR values. Based on the statistical analyses and the experience gained from extensive use of the equipment, the combination of the DCP and the LWD was selected for in-place soil testing for compaction control acceptance. Test methods and developmental specifications were written for the DCP and the LWD. The developmental specifications include target values for the compaction control of embankment, subgrade, and base materials.

General practice coordinated chronic disease management to reduce avoidable hospital admission

Chronic disease accounts for about 80 per cent of the total disease burden in Australia, and its management accounts for 70 per cent of all current health expenditure.1 Effective prevention and management of chronic disease requires a coordinated approach between primary health care, acute care services, and the patients.2 However, what is not clear is whether improvements in primary healthcare management can have a clear benefit in the cost of care of patients with chronic disease. We recently completed a pilot study in rural Western Australia to ascertain the feasibility of a coordinated general practice-based approach to managing chronic respiratory and cardiovascular conditions, and to determine the direct cost savings to the public insurer through reduction in avoidable hospital admission. The aim of this correspondence is to share our preliminary findings and encourage debate on how such a project may be scaled up or adapted to other primary healthcare settings.

Trends in hospital admission for stroke in Calgary

Background Stroke incidence has fallen since 1950. Recent trends suggest that stroke incidence may be stabilizing or increasing. We investigated time trends in stroke occurrence and in-hospital morbidity and mortality in the Calgary Health Region. Methods All patients admitted to hospitals in the Calgary Health Region between 1994 and 2002 with a primary discharge diagnosis code (ICD-9 or ICD-10) of stroke were included. In-hospital strokes were also included. Stroke type, date of admission, age, gender,discharge disposition (died, discharged) and in-hospital complications (pneumonia, pulmonary embolism, deep venous thrombosis) were recorded. Poisson and simple linear regression was used to model time trends of occurrence by stroke type and age-group and to extrapolate future time trends. Results From 1994 to 2002, 11642 stroke events were observed. Of these, 9879 patients (84.8%) were discharged from hospital, 1763 (15.1%) died in hospital, and 591 (5.1%) developed in-hospital complications from pneumonia, pulmonary embolism or deep venous thrombosis. Both in-hospital mortality and complication rates were highest for hemorrhages. Over the period of study, the rate of stroke admission has remained stable. However, total numbers of stroke admission to hospital have faced a significant increase (p=0.012) due to the combination of increases in intracerebral hemorrhage (p=0.021) and ischemic stroke admissions (p=0.011). Sub-arachnoid hemorrhage rates have declined. In-hospital stroke mortality has experienced an overall decline due to a decrease in deaths from ischemic stroke, intracerebral hemorrhage and sub-arachnoid hemorrhage. Conclusions Although age-adjusted stroke occurrence rates were stable from 1994 to 2002, this is associated with both a sharp increase in the absolute number of stroke admissions and decline in proportional in-hospital mortality. Further research is needed into changes in stroke severity over time to understand the causes of declining in-hospital stroke mortality rates.

Pacific Rim treaty threatens public health: Patent law and medical procedures

Doctors, surgeons, and physicians around the Pacific Rim should be concerned by the proposals revealed by WikiLeaks in the Trans-Pacific Partnership (TPP). One of the most controversial features of the TPP is the proposal to provide for patent protection in respect of medical procedures. As Public Citizen observed, ‘Health providers, including surgeons, could be liable for the methods they use to treat patients.’ The civil society group noted: ‘Essentially, except for when a surgeon uses her bare hands, surgical methods would be patentable under the U.S. proposal.’ The TPP takes a broad approach to patents and medicine; lacks appropriate safeguards; and fails to address larger questions about equity, development, and human rights. Such a measure could result in greater litigation against medical professionals; barriers to access to medical procedures for patients; and skyrocketing health costs.

Policies and Procedures to Address Bullying at Australian Universities

While bullying is often researched in children and adolescents and in the workplace, there is limited research in the emerging adult population, especially in students at university. This is perhaps due to the fact that bullying generally declines as children and young people become older (e.g., Nansel et al., 2001; Wang, Iannotti, & Nansel, 2009). Although this may indeed be the case, it is apparent that bullying does not completely abate when students graduate from high school. The plethora of literature evidencing workplace bullying, clearly shows that bullying continues beyond the school years (e.g., Hoel, Cooper, & Faragher, 2001; Privitera & Campbell, 2009). With the advent of cyberbullying in the last decade it has been shown that this particular form of bullying may not decrease with age as does traditional bullying (Kowalski & Limber, 2007; Raskauskas & Stoltz, 2007). In addition, we know there is a spike in prevalence rates during the transition from primary to high school Pellegrini et al., 2010), so it is possible that new university students are at an increased risk of victimisation due to this being a transition period. This has led to some interest in examining the prevalence of bullying in the emerging adult population at universities (Chapell, Casey, & de la Cruz, 2004; Pontzer, 2010; Wensley & Campbell, 2009).

The Australian litigation landscape - Oral and Maxillofacial Surgery and general dentistry (oral surgery procedures): An analysis of litigation cases

Background: There are persistent concerns about litigation in the dental and medical professions. These concerns arise in a setting where general dentists are more frequently undertaking a wider range of oral surgery procedures, potentially increasing legal risk. Methods: Judicial cases dealing with medical negligence in the fields of general dentistry (oral surgery procedure) and Oral and Maxillofacial Surgery were located using the three main legal databases. Relevant cases were analysed to determine the procedures involved, the patients’ claims of injury, findings of negligence, and damages awarded. A thematic analysis of the cases was undertaken to determine trends. Results: Fifteen cases over a twenty-year period were located across almost all Australian jurisdictions (eight cases involved general dentists; seven cases involved Oral and Maxillofacial Surgeons). Eleven of the fifteen cases involved determinations of whether or not the practitioner had failed in their duty of care; negligence was found in six cases. Eleven of the fifteen cases related to molar extractions (eight specifically to third molar). Conclusions: Dental and medical practitioners wanting to manage legal risk should have regard to circumstances arising in judicial cases. Adequate warning of risks is critical, as is offering referral in appropriate cases. Pre-operative radiographs, good medical records, and processes to ensure appropriate follow-up are also important.

Tracking the patient journey by combining multiple hospital database systems

With new national targets for patient flow in public hospitals designed to increase efficiencies in patient care and resource use, better knowledge of events affecting length of stay will support improved bed management and scheduling of procedures. This paper presents a case study involving the integration of material from each of three databases in operation at one tertiary hospital and demonstrates it is possible to follow patient journeys from admission to discharge. What is known about this topic? At present, patient data at one Queensland tertiary hospital are assembled in three information systems: (1) the Hospital Based Corporate Information System (HBCIS), which tracks patients from in-patient admission to discharge; (2) the Emergency Department Information System (EDIS) containing patient data from presentation to departure from the emergency department; and (3) Operation Room Management Information System (ORMIS), which records surgical operations. What does this paper add? This paper describes how a new enquiry tool may be used to link the three hospital information systems for studying the hospital journey through different wards and/or operating theatres for both individual and groups of patients. What are the implications for practitioners? An understanding of the patients’ journeys provides better insight into patient flow and provides the tool for research relating to access block, as well as optimising the use of physical and human resources.

Evaluation framework to assess orthopaedic procedures

Introduction & aims The demand for evidence of efficacy of treatments in general and orthopaedic surgical procedures in particular is ever increasing in Australia and worldwide. The aim of this study is to share the key elements of an evaluation framework recently implemented in Australia to determine the efficacy of bone-anchored prostheses. Method The proposed evaluation framework to determine the benefit and harms of bone-anchored prostheses for individuals with limb loss was extracted from a systematic review of the literature including seminal studies focusing on clinical benefits and safety of procedures involving screw-type implant (e.g., OPRA) and press-fit fixations (e.g., EEFT, ILP, OPL). [1-64] Results The literature review highlighted that a standard and replicable evaluation framework should focus on: • The clinical benefits with a systematic recording of health-related quality of life (e.g., SF-26, Q-TFA), mobility predictor (e.g., AMPRO), ambulation abilities (e.g., TUG, 6MWT), walking abilities (e.g., characteristic spatio-temporal) and actual activity level at baseline and follow-up post Stage 2 surgery, • The potential harms with systematic recording of residuum care, infection, implant stability, implant integrity, injuries (e.g., falls) after Stage 1 surgery. There was a general consensus around the instruments to monitor most of the benefits and harms. The benefits could be assessed using a wide spectrum of complementary assessments ranging from subjective patient self-reporting to objective measurements of physical activity. However, this latter was assessed using a broad range of measurements (e.g., pedometer, load cell, energy consumption). More importantly, the lack of consistent grading of infections was sufficiently noticeable to impede cross-fixation comparisons. Clearly, a more universal grading system is needed. Conclusions Investigators are encouraged to implement an evaluation framework featuring the domains and instruments proposed above using a single database to facilitate robust prospective studies about potential benefits and harms of their procedure. This work is also a milestone in the development of national and international clinical outcome registries.

Improving SEA procedures within Italian regions: Towards a more effective evaluation of urban sustainability

Sustainable urban development, a major issue at global scale, will become more relevant according to population growth predictions in developed and developing countries. Societal and international recognition of sustainability concerns led to the development of specific tools and procedures, known as sustainability assessments/appraisals (SA). Their effectiveness however, considering that global quality life indicators have worsened since their introduction, has promoted a re-thinking of SA instruments. More precisely, Strategic Environmental Assessment (SEA), – a tool introduced in the European context to evaluate policies, plans, and programmes (PPPs), – is being reconsidered because of several features that seem to limit its effectiveness. Over time, SEA has evolved in response to external and internal factors dealing with technical, procedural, planning and governance systems thus involving a shift of paradigm from EIA-based SEAs (first generation protocols) towards more integrated approaches (second generation ones). Changes affecting SEA are formalised through legislation in each Member State, to guide institutions at regional and local level. Defining SEA effectiveness is quite difficult. Its’ capacity-building process appears quite far from its conclusion, even if any definitive version can be conceptualized. In this paper, we consider some European nations with different planning systems and SA traditions. After the identification of some analytical criteria, a multi-dimensional cluster analysis is developed on some case studies, to outline current weaknesses.

Implicit and multigrid procedures for steady-state computations with upwind algorithms

A computational study for the convergence acceleration of Euler and Navier-Stokes computations with upwind schemes has been conducted in a unified framework. It involves the flux-vector splitting algorithms due to Steger-Warming and Van Leer, the flux-difference splitting algorithms due to Roe and Osher and the hybrid algorithms, AUSM (Advection Upstream Splitting Method) and HUS (Hybrid Upwind Splitting). Implicit time integration with line Gauss-Seidel relaxation and multigrid are among the procedures which have been systematically investigated on an individual as well as cumulative basis. The upwind schemes have been tested in various implicit-explicit operator combinations such that the optimal among them can be determined based on extensive computations for two-dimensional flows in subsonic, transonic, supersonic and hypersonic flow regimes. In this study, the performance of these implicit time-integration procedures has been systematically compared with those corresponding to a multigrid accelerated explicit Runge-Kutta method. It has been demonstrated that a multigrid method employed in conjunction with an implicit time-integration scheme yields distinctly superior convergence as compared to those associated with either of the acceleration procedures provided that effective smoothers, which have been identified in this investigation, are prescribed in the implicit operator.