Implementation of a chest pain management service improves patient care and reduces length of stay

Objective Chest pain is one of the most common complaints in patients presenting to an emergency department. Delays in management due to a lack of readily available objective tests to risk stratify patients with possible acute coronary syndromes can lead to an unnecessarily lengthy admission placing pressure on hospital beds or inappropriate discharge. The need for a co-ordinated system of clinical management based on enhanced communication between departments, timely and appropriate triage, clinical investigation, diagnosis, and treatment was identified. Methods An evidence-based Chest Pain Management Service and clinical pathway were developed and implemented, including the introduction of after-hours exercise stress testing. Results Between November 2005 and March 2013, 5662 patients were managed according to a Chest Pain Management pathway resulting in a reduction of 5181 admission nights by more timely identification of patients at low risk who could then be discharged. In addition, 1360 days were avoided in high-risk patients who received earlier diagnosis and treatment. Conclusions The creation of a Chest Pain Management pathway and the extended exercise stress testing service resulted in earlier discharge for low-risk patients; and timely treatment for patients with positive and equivocal exercise stress test results. This service demonstrated a significant saving in overnight admissions.

Diabetes in South Asians

Economic, dietary and other lifestyle transitions have been occurring rapidly in most South Asian countries, making their populations more vulnerable to developing Type 2 diabetes and cardiovascular diseases. Recent data show an increasing prevalence of Type 2 diabetes in urban areas as well as in semi-urban and rural areas, inclusive of people belonging to middle and low socio-economic strata. Prime determinants for Type 2 diabetes in South Asians include physical inactivity, imbalanced diets, abdominal obesity, excess hepatic fat and, possibly, adverse perinatal and early life nutrition and intra-country migration. It is reported that Type 2 diabetes affects South Asians a decade earlier and some complications, for example nephropathy, are more prevalent and progressive than in other races. Further, prevalence of pre-diabetes is high, and so is conversion to diabetes, while more than 50% of those who are affected remain undiagnosed. Attitudes, cultural differences and religious and social beliefs pose barriers in effective prevention and management of Type 2 diabetes in South Asians. Inadequate resources, insufficient healthcare budgets, lack of medical reimbursement and socio-economic factors contribute to the cost of diabetes management. The challenge is to develop new translational strategies, which are pragmatic, cost-effective and scalable and can be adopted by the South Asian countries with limited resources. The key areas that need focus are: generation of awareness, prioritizing health care for vulnerable subgroups (children, women, pregnant women and the underprivileged), screening of high-risk groups, maximum coverage of the population with essential medicines, and strengthening primary care. An effective national diabetes control programme in each South Asian country should be formulated, with these issues in mind.

Transcutaneous bone-anchoring prosthesis with hip replacement: A novel treatment for amputees

Background Over the last two decades, Transcutaneous Bone-Anchored Prosthesis (TCBAP) has proven to be an effective alternative for prosthetic attachment for above knee amputees, particularly for individuals suffering from socket interface related complications. [1-17] Amputees with a very short femoral residuum (<15 cm) are at a considerable higher risk for these complications as well as high risk of implant failure, if they underwent a typical TCBAP due to the relatively small bony-implant contact leading to a need of a novel technique. Aim A. To describe the surgical procedure combining THR with TCBAP for the first time; and B. To present preliminary data on potential risks and benefits with assessment of clinical and functional outcomes at follow up Method We used a TCBAP connected to the stem of a Total Hip Replacement (THR) prosthesis enabling the femoral residuum and the hip joint to act as weight sharing structures by transferring the load directly to the pelvis. We performed a tri-polar THR connected to a custom made TCBAP at the first stage followed by creating a skin implant interface as a second stage. We retrospectively reviewed three cases of transfemoral amputations presenting with extremely short femoral residuum. Patients were assessed clinically and functionally including standard measures of health-related quality of life, amputee mobility predictor tool, ambulation tests and actual activity level. Progress was monitored for 6-24 months. Results Clinical outcomes including adverse events show no major complications. Functional outcomes improved for all participants as early as 6 months follow up. All cases were wheelchair bound preoperatively (K0 – AMPRO) improved to walking with One stick (K3 – AMPRO) at 3 months follow up. Discussion & Conclusion THR and TCBAP were combined for the first time in this proof-of-concept case series. The preliminary outcomes indicated that this procedure is potentially a safe and effective alternative despite the theoretical increase in risk of ascending infection through the skin-implant interface to the external environment for this patient group. We suggest larger comparative series to further validate these results.

Founder p.Arg 446* mutation in the PDHX gene explains over half of cases with congenital lactic acidosis in Roma children

Investigation of 31 of Roma patients with congenital lactic acidosis (CLA) from Bulgaria identified homozygosity for the R446* mutation in the PDHX gene as the most common cause of the disorder in this ethnic group. It accounted for around 60% of patients in the study and over 25% of all CLA cases referred to the National Genetic Laboratory in Bulgaria. The detection of a homozygous patient from Hungary and carriers among population controls from Romania and Slovakia suggests a wide spread of the mutation in the European Roma population. The clinical phenotype of the twenty R446* homozygotes was relatively homogeneous, with lactic acidosis crisis in the first days or months of life as the most common initial presentation (15/20 patients) and delayed psychomotor development and/or seizures in infancy as the leading manifestations in a smaller group (5/20 patients). The subsequent clinical picture was dominated by impaired physical growth and a very consistent pattern of static cerebral palsy-like encephalopathy with spasticity and severe to profound mental retardation seen in over 80% of cases. Most patients had a positive family history. We propose testing for the R446* mutation in PDHX as a rapid first screening in Roma infants with metabolic acidosis. It will facilitate and accelerate diagnosis in a large proportion of cases, allow early rehabilitation to alleviate the chronic clinical course, and prevent further affected births in high-risk families.

Students' responses to the RACQ docudrama program

Young people are over-represented in road crashes and school-based education programs, including the RACQ Docudrama program, represent initiatives aimed at improving road safety among this high-risk group. The aim of the study was to apply an extended Theory of Planned Behaviour framework to understand more about the extent to which the program influenced individuals‟ intentions to speak up to a driver engaging in risky behaviours (e.g., speeding). Senior high school students (N=260) from 5 Queensland schools completed a survey in class. The study included a Control group (n = 86) who responded to the survey prior to completing the Docudrama program and an Intervention group comprising an Intervention-Immediate (n=100) and an Intervention-Delayed group (n = 74) who completed the survey after having participated in the program either on the day or up to a week later, respectively. Overall, the findings provided support for the beneficial effects of the program. Some of the study’s key findings included: (i) Intervention group participants consistently reported significantly stronger intentions to speak up than participants in the control group; (ii) among the significant predictors of intentions, a notable finding was that the more individuals anticipated feeling regretful for not having spoken up to a risky driver, the stronger their intentions were to speak up, and; (iii) the level of fear reported by students significantly decreased and was lowest at the conclusion of the program, following facilitated group discussion. The implications of the results for future research, program development and practice are discussed.

LGBTIQ experiences in the workforce

The experience of lesbian, gay, bisexual, transgender, intersex and queer (LGBTIQ) health consumers has, in the last decade, gained attention and is now recognised as one of the social determinants of health. Our recent meta-synthesis on the experiences of LGBTIQ health and medical professionals demonstrated that they are susceptible to higher levels of anxiety and depression partially due to lack of acceptance in their workplace. The paramedic workforce is known to be a high risk occupational group for post-traumatic stress disorder and depression. Theoretically, LGBTIQ paramedics working in a heteronormative culture may experience increased level of discrimination and stress than their heterosexual colleagues. The integration of LGBTIQ into the paramedic workforce is unfeatured in our systematic review. While LGBTIQ health professionals receive legislative protection against discrimination, discrimination still exists in practice through lack of visibility. There is a common misconception that LGBTIQ is a homogenous group with equal needs. Effective and efficient integration of LGBTIQ health professionals could improve workplace satisfaction, workforce retention, and equity of access by marginalised groups.

Examining novice education: What can we learn from a compulsory program delivered to both mature-age and young pre-learner licence drivers?

This paper reports results from a qualitative evaluation of a compulsory pre-Learner driver education program within the Australian Capital Territory(ACT), Australia. Two methods were used to obtain feedback from those involved in the delivery of the program as well as those who participated in programs. The first, semi-structured interviews, was undertaken with class room teachers who run the program in their schools, group facilitators running the program with more mature-age students at private facilities (n = 15 in total), and former participants in both school-based and private-based versions of the program (n = 19). The second method used an on-line survey for students (n = 79). Results from both methods were consistent with each other, indicating that strengths of the program were perceived as being its interactive components and the high level of engagement of the target audience. There was strong support from young and mature-age students for the program to remain compulsory. However, consistent with other findings on novice driver education, mature-age participants identified that the program was less relevant to them. It may be that to have greater relevance to mature-age learners, content could address and challenge perceptions about behaviours other than intentional high-risk behaviours (e.g. low level speeding, fatigue) as well as encourage planning/strategies to avoid them. While a longer term, outcome focussed, evaluation of the pre-learner education program is needed, this study suggests that the program is well received by pre-licence drivers and that teachers and facilitators perceive it as both effective and beneficial.

Iron oxide particles for atheroma imaging

The selection of patients for vascular interventions has been solely based on luminal stenosis and symptomatology. However, histological data from both the coronary and carotid vasculature suggest that other plaque features such as inflammation may be more important in predicting future thromboembolic events. Ultrasmall superparamagnetic iron oxide (USPIO) contrast agents have been used for noninvasive MRI assessment of atherosclerotic plaque inflammation in humans. It has reached the stage of development to have been recently used in an interventional drug study to not only assess inflammatory progression but also select patients at high risk. This article reviews the basic science behind the use of USPIO contrast agents in atheroma MR imaging, experimental work in animals, and how this has led to the emergence of this promising targeted imaging platform for assessment of high risk carotid atherosclerosis in humans.

Combined PET-FDG and USPIO-enhanced MR imaging in patients with symptomatic moderate carotid artery stenosis

Introduction: PET-FDG and USPIO-enhanced MRI are increasingly being used in depicting carotid atheroma inflammation - a risk factor for the high risk plaque. Their combined use has not been previously reported. Report: Two patients presenting with stroke and identified with 50% carotid stenosis on duplex ultrasonography, underwent PET FDG and USPIO-enhanced MR imaging. Results were concordant and complementary suggesting that both techniques reflect similar metabolic processes. Discussion: The selection of patients for carotid revascularisation has largely been based on the severity of luminal stenosis alone. The two imaging modalities, which identify inflammatory activity, may be potential surrogate risk markers in the selection of patients eligible for carotid surgery, if plaque inflammation can be correlated with risk of developing clinical symptoms.

Non-invasive MR imaging of inflammation in a patient with both asymptomatic carotid atheroma and an abdominal aortic aneurysm: A case report

Inflammation is a recognized risk factor for the vulnerable atherosclerotic plaque. USPIO-enhanced MRI imaging is a promising non-i nvasive method to identify high-risk atheromatous plaque inflammation in vivo in humans, in which areas of focal signal loss on MR images have been shown to correspond to the location of activated macrophages, typically at the shoulder regions of the plaque. This is the first report in humans describing simultaneous USPIO uptake within atheroma in two different arterial territories and again emphasises that atherosclerosis is a truly systemic disease. With further work, USPIO-enhanced MR imaging may be useful in identifying inflamed vulnerable atheromatous plaques in vivo, so refining patient selection for intervention and allowing appropriate early aggressive pharmacotherapy to prevent plaque rupture.

How critical is fibrous cap thickness to carotid plaque stability? A flow-plaque interaction model

Background and Purpose Acute cerebral ischemic events are associated with rupture of vulnerable carotid atheroma and subsequent thrombosis. Factors such as luminal stenosis and fibrous cap thickness have been thought to be important risk factors for plaque rupture. We used a flow-structure interaction model to simulate the interaction between blood flow and atheromatous plaque to evaluate the effect of the degree of luminal stenosis and fibrous cap thickness on plaque vulnerability. Methods A coupled nonlinear time-dependent model with a flow-plaque interaction simulation was used to perform flow and stress/strain analysis in a stenotic carotid artery model. The stress distribution within the plaque and the flow conditions within the vessel were calculated for every case when varying the fibrous cap thickness from 0.1 to 2 mm and the degree of luminal stenosis from 10% to 95%. A rupture stress of 300 kPa was chosen to indicate a high risk of plaque rupture. A 1-sample t test was used to compare plaque stresses with the rupture stress. Results High stress concentrations were found in the plaques in arteries with >70% degree of stenosis. Plaque stresses in arteries with 30% to 70% stenosis increased exponentially as fibrous cap thickness decreased. A decrease of fibrous cap thickness from 0.4 to 0.2 mm resulted in an increase of plaque stress from 141 to 409 kPa in a 40% degree stenotic artery. Conclusions There is an increase in plaque stress in arteries with a thin fibrous cap. The presence of a moderate carotid stenosis (30% to 70%) with a thin fibrous cap indicates a high risk for plaque rupture. Patients in the future may be risk stratified by measuring both fibrous cap thickness and luminal stenosis.

Workplace acceptance and experiences of LGBTIQ health professionals: A systematic literature review

Background The purpose of this study was to explore the workplace acceptance and experiences of lesbian, gay, bisexual, transgender, intersex and queer (LGBTIQ) paramedics. Methods A systematic search of academic databases and reference lists from selected papers were the sources of the data. Inclusion criteria were research papers published in English, which focused on workplace acceptance and experiences of LGBTIQ health personnel. Results The initial focus of this systematic review was the workplace acceptance and experiences of LGBTIQ paramedics. However due to no published research specific to the paramedic profession the scope of the review was broadened to include of all LGBTIQ health personnel. Thirty-three papers were included in this review. Evidence indicated that LGBTIQ health professionals experienced discrimination from their patients, heterosexual colleagues and ‘closeted’ LGBTIQ peers. Positive contribution of LGBTIQ health professionals include improved patient care and role models for LGBTIQ peers. Inclusive policy is required for LGBTIQ health professional workforce retention. Conclusions The paramedic workforce is known to be a high risk occupational group for post-traumatic stress disorder and depression. Theoretically, LGBTIQ paramedics working in a heteronormative culture experience increased level of stress. While LGBTIQ health professionals receive legislative protection against discrimination, discrimination still exists in practice through lack of visibility. Effective and efficient integration of LGBTIQ health professionals could improve workplace satisfaction, workforce retention, and equity of access by marginalised groups. An inclusive workplace policy of LGBTIQ embraces and celebrates the value of diversity.

Development of hazard site surveillance programs for forest invasive species: A case study from Brisbane, Australia

Hazard site surveillance is a system for post-border detection of new pest incursions, targeting sites that are considered potentially at high risk of such introductions. Globalisation, increased volumes of containerised freight and competition for space at domestic ports means that goods are increasingly being first opened at premises some distance from the port of entry, thus dispersing risk away from the main inspection point. Hazard site surveillance acts as a backstop to border control to ensure that new incursions are detected sufficiently early to allow the full range of management options, including eradication and containment, to be considered. This is particularly important for some of the more cryptic forest pests whose presence in a forest often is not discovered until populations are already high and the pest is well established. General requirements for a hazard site surveillance program are discussed using a program developed in Brisbane, Australia, in 2006 as a case study. Some early results from the Brisbane program are presented. In total 67 species and 5757 individuals of wood-boring beetles have been trapped and identified during the program to date. Scolytines are the most abundant taxa, making up 83% of the catch. No new exotics have been trapped but 19 of the species and 60% of all specimens caught are exotics that are already established in Australia.

On the moderators of trait avoidance motivation in predicting cognitive biases and adjustment

The present research focused on motivational and personality traits measuring individual differences in the experience of negative affect, in reactivity to negative events, and in the tendency to avoid threats. In this thesis, such traits (i.e., neuroticism and dispositional avoidance motivation) are jointly referred to as trait avoidance motivation. The seven studies presented here examined the moderators of such traits in predicting risk judgments, negatively biased processing, and adjustment. Given that trait avoidance motivation encompasses reactivity to negative events and tendency to avoid threats, it can be considered surprising that this trait does not seem to be related to risk judgments and that it seems to be inconsistently related to negatively biased information processing. Previous work thus suggests that some variable(s) moderate these relations. Furthermore, recent research has suggested that despite the close connection between trait avoidance motivation and (mal)adjustment, measures of cognitive performance may moderate this connection. However, it is unclear whether this moderation is due to different response processes between individuals with different cognitive tendencies or abilities, or to the genuinely buffering effect of high cognitive ability against the negative consequences of high trait avoidance motivation. Studies 1-3 showed that there is a modest direct relation between trait avoidance motivation and risk judgments, but studies 2-3 demonstrated that state motivation moderates this relation. In particular, individuals in an avoidance state made high risk judgments regardless of their level of trait avoidance motivation. This result explained the disparity between the theoretical conceptualization of avoidance motivation and the results of previous studies suggesting that the relation between trait avoidance motivation and risk judgments is weak or nonexistent. Studies 5-6 examined threat identification tendency as a moderator for the relationship between trait avoidance motivation and negatively biased processing. However, no evidence for such moderation was found. Furthermore, in line with previous work, the results of studies 5-6 suggested that trait avoidance motivation is inconsistently related to negatively biased processing, implying that theories concerning traits and information processing may need refining. Study 7 examined cognitive ability as a moderator for the relation between trait avoidance motivation and adjustment, and demonstrated that cognitive ability moderates the relation between trait avoidance motivation and indicators of both self-reported and objectively measured adjustment. Thus, the results of Study 7 supported the buffer explanation for the moderating influence of cognitive performance. To summarize, the results showed that it is possible to find factors that consistently moderate the relations between traits and important outcomes (e.g. adjustment). Identifying such factors and studying their interplay with traits is one of the most important goals of current personality research. The present thesis contributed to this line of work in relation to trait avoidance motivation.

Truckies and workplace health promotion: Targeting a hard-to-reach group

- Introduction Research identifies truck drivers as being at high risk of chronic disease. For most truck drivers their workplace is their vehicle. Truck drivers’ health is impacted by the limitations of this unique working environment, including reduced opportunities for physical activity and the intake of healthy foods. Workplaces are widely recognised as effective platforms for health promotion. However, the effectiveness of traditional and contemporary health promotion interventions in truck drivers’ novel workplace is unknown. - Methods This project worked with six transport industry workplaces in Queensland, Australia over a two-year period. Researchers used Participatory Action Research (PAR) processes to engage truck drivers and workplace managers in the implementation and evaluation of six workplace health promotion interventions. These interventions were designed to support truck drivers to increase their physical activity and access to healthy foods at work. They included traditional health promotion interventions such as a free fruit initiative, a ten thousand steps challenge, personal health messages and workplace posters, and a contemporary social media intervention. Participants were engaged via focus groups, interviews and mixed-methods surveys. - Results The project achieved positive changes in truck drivers’ health knowledge and health behaviours, particularly related to nutrition. There were positive changes in truck drivers’ self-reported health rating, body mass index (BMI) and readiness to make health-related lifestyle changes. There were also positive changes in truck drivers reporting their workplace as a key source of health information. These changes were underpinned by a positive shift in the culture of participating workplaces. Truck drivers’ perceptions of their workplace valuing, encouraging, modelling and facilitating healthy nutrition and physical activity behaviours improved. PAR processes enabled researchers to develop relationships with workplace managers, contextualise interventions and deliver rigorous outcomes. Despite the novelty of truck drivers’ mobile workplace, traditional health promotion interventions were more effective than contemporary ones. - Conclusion In this workplace health promotion project targeting a ‘hard-to-reach’ group of truck drivers, a combination of well-designed traditional workplace interventions and the PAR process resulted in positive health outcomes.