Web based surveillance systems could improve disease detection and the response to emerging disease events

The Chinese government should be commended for its open, concerted, and rapid response to the recent H7N9 influenza outbreak. However, the first known case was not reported until 48 days after disease onset.1 Although the difficulties in detecting the virus and the lack of suitable diagnostic methods have been the focus of discussion,2 systematic limitations that may have contributed to this delay have hardly been discussed. The detection speed of surveillance systems is limited by the highly structured nature of information flow and hierarchical organisation of these systems. Flu surveillance usually relies on notification to a central authority of laboratory confirmed cases or presentations to sentinel practices for flu-like illness. Each step in this pathway presents a bottleneck at which information and time can be lost; this limitation must be dealt with...

T helper cell cytokine profiles following endurance exercise

Endurance exercise can cause immunosuppression and increase the risk of upper respiratory illness. The present study examined changes in the secretion of T helper (Th) cell cytokines after endurance exercise. Ten highly trained road cyclists [mean±SEM: age 24.2±1.7 years; height 1.82±0.02 m; body mass 73.8±2.0 kg; peak oxygen uptake 65.9±2.3 mL/(kg•min)] performed 2 h of cycling exercise at 90% of the second ventilatory threshold. Peripheral blood mononuclear cells were isolated and stimulated with phytohemagglutinin. Plasma cortisol concentrations and the concentration of Th1/Th2/Th17 cell cytokines were examined. Data were analyzed using both traditional statistics and magnitude-based inferences. Results revealed a significant decrease in plasma cortisol at 4–24 h postexercise compared with pre-exercise values. Qualitative analysis revealed postexercise changes in concentrations of plasma cortisol, IL-2, TNF, IL-4, IL-6, IL-10, and IL-17A compared with pre-exercise values. A Th1/Th2 shift was evident immediately postexercise. Furthermore, for multiple cytokines, including IL-2 and TNF (Th1), IL-6 and IL-10 (Th2), and IL-17 (Th17), no meaningful change in concentration occurred until more than 4 h postexercise, highlighting the duration of exercise-induced changes in immune function. These results demonstrate the importance of considering “clinically” significant versus statistically significant changes in immune cell function after exercise.

David L. Rosenhan (1929–2012)

Presents an obituary for David L. Rosenhan (1929–2012). A distinguished psychologist and professor emeritus at Stanford University, Rosenhan died February 6, 2012, at the age of 82, after a long illness. Born in Jersey City, New Jersey, on November 22, 1929, he received a bachelor’s degree in mathematics (1951) from Yeshiva College and a master’s degree in economics (1953) and a doctorate in psychology (1958) from Columbia University. A professor of law and of psychology at Stanford University from 1971 until his retirement in 1998, Rosenhan was a pioneer in applying psychological methods to the practice of law, including the examination of expert witnesses, jury selection, and jury deliberation. A former president of the American Psychology–Law Society and of the American Board of Forensic Psychology, Rosenhan was a fellow of the American Association for the Advancement of Science, of the American Psychological Association, and of the American Psychological Society. Before joining the Stanford Law School faculty, he was a member of the faculties of Swarthmore College, Princeton University, Haverford College, and the University of Pennsylvania. He also served as a research psychologist at the Educational Testing Service. As generations of Stanford students can attest, David Rosenhan was a spellbinding lecturer who managed to convey the sense that he was speaking to each individual, no matter how large the group. To his graduate students, he was consistently encouraging and optimistic, always ready to share a joke or story, and gently encouraging of their creativity and progressive independence as researchers. The lessons he cared most about offering, in the classroom as in his research, were about human dignity and the need to confront abuse of power and human frailties.

Heat strain and hydration status of surface mine blast crew workers

Objective Dehydration and symptoms of heat illness are common among the surface mining workforce. This investigation aimed to determine whether heat strain and hydration status exceeded recommended limits. Methods Fifteen blast crew personnel operating in the tropics were monitored across a 12-hour shift. Heart rate, core body temperature, and urine-specific gravity were continuously recorded. Participants self-reported fluid consumption and completed a heat illness symptom inventory. Results Core body temperature averaged 37.46 +/- 0.13[degrees]C, with the group maximum 37.98 +/- 0.19[degrees]C. Mean urine-specific gravity was 1.024 +/- 0.007, with 78.6% of samples 1.020 or more. Seventy-three percent of workers reported at least one symptom of heat illness during the shift. Conclusions Core body temperature remained within the recommended limits; however, more than 80% of workers were dehydrated before commencing the shift, and tended to remain so for the duration.

The Implications of Activity Based Funding for Emergency Departments : A Comprehensive Literature Review

Executive Summary Emergency Departments (EDs) locally, nationally and internationally are becoming increasingly busy. Within this context, it can be challenging to deliver a health service that is safe, of high quality and cost-effective. Whilst various models are described within the literature that aim to measure ED ‘work’ or ‘activity’, they are often not linked to a measure of costs to provide such activity. It is important for hospital and ED managers to understand and apply this link so that optimal staffing and financial resourcing can be justifiably sought. This research is timely given that Australia has moved towards a national Activity Based Funding (ABF) model for ED activity. ABF is believed to increase transparency of care and fairness (i.e. equal work receives equal pay). ABF involves a person-, performance- or activity-based payment system, and thus a move away from historical “block payment” models that do not incentivise efficiency and quality. The aim of the Statewide Workforce and Activity-Based Funding Modelling Project in Queensland Emergency Departments (SWAMPED) is to identify and describe best practice Emergency Department (ED) workforce models within the current context of ED funding that operates under an ABF model. The study is comprised of five distinct phases. This monograph (Phase 1) comprises a systematic review of the literature that was completed in June 2013. The remaining phases include a detailed survey of Queensland hospital EDs’ resource levels, activity and operational models of care, development of new resource models, development of a user-friendly modelling interface for ED mangers, and production of a final report that identifies policy implications. The anticipated deliverable outcome of this research is the development of an ABF based Emergency Workforce Modelling Tool that will enable ED managers to profile both their workforce and operational models of care. Additionally, the tool will assist with the ability to more accurately inform adequate staffing numbers required in the future, inform planning of expected expenditures and be used for standardisation and benchmarking across similar EDs. Summary of the Findings Within the remit of this review of the literature, the main findings include: 1. EDs are becoming busier and more congested Rising demand, barriers to ED throughput and transitions of care all contribute to ED congestion. In addition requests by organisational managers and the community require continued broadening of the scope of services required of the ED and further increases in demand. As the population live longer with more lifestyle diseases their propensity to require ED care continues to grow. 2. Various models of care within EDs exist Models often vary to account for site specific characteritics to suit staffing profile, ED geographical location (e.g. metropolitan or rural site), and patient demographic profile (e.g. paediatrics, older persons, ethnicity). Existing and new models implemented within EDs often depend on the target outcome requiring change. Generally this is focussed on addressing issues at the input, throughput or output areas of the ED. Even with models targeting similar demographic or illness, the structure and process elements underpinning the model can vary, which can impact on outcomes and variance to the patient and carer experience between and within EDs. Major models of care to manage throughput inefficiencies include: A. Workforce Models of Care focus on the appropriate level of staffing for a given workload to provide prompt, timely and clinically effective patient care within an emergency care setting. The studies reviewed suggest that the early involvement of senior medical decision maker and/or specialised nursing roles such as Emergency Nurse Practitioners and Clinical Initiatives Nurse, primary contact or extended scope Allied Health Practitioners can facilitate patient flow and improve key indicators such as length of stay and reducing the number of those who did not wait to be seen amongst others. B. Operational Models of Care within EDs focus on mechanisms for streaming (e.g. fast-tracking) or otherwise grouping patient care based on acuity and complexity to assist with minimising any throughput inefficiencies. While studies support the positive impact of these models in general, it appears that they are most effective when they are adequately resourced. 3. Various methods of measuring ED activity exist Measuring ED activity requires careful consideration of models of care and staffing profile. Measuring activity requires the ability to account for factors including: patient census, acuity, LOS, intensity of intervention, department skill-mix plus an adjustment for non-patient care time. 4. Gaps in the literature Continued ED growth calls for new and innovative care delivery models that are safe, clinically effective and cost effective. New roles and stand-alone service delivery models are often evaluated in isolation without considering the global and economic impact on staffing profiles. Whilst various models of accounting for and measuring health care activity exist, costing studies and cost effectiveness studies are lacking for EDs making accurate and reliable assessments of care models difficult. There is a necessity to further understand, refine and account for measures of ED complexity that define a workload upon which resources and appropriate staffing determinations can be made into the future. There is also a need for continued monitoring and comprehensive evaluation of newly implemented workforce modelling tools. This research acknowledges those gaps and aims to: • Undertake a comprehensive and integrated whole of department workforce profiling exercise relative to resources in the context of ABF. • Inform workforce requirements based on traditional quantitative markers (e.g. volume and acuity) combined with qualitative elements of ED models of care; • Develop a comprehensive and validated workforce calculation tool that can be used to better inform or at least guide workforce requirements in a more transparent manner.

A living sacrifice

"When Susannah Birch was two years old her mother cut her throat, in a ritual sacrifice, Susannah was very lucky to survive. This was the first of her mother’s psychotic episodes as she enacted a passage from The Old Testament...In this moving documentary Susannah and her father describe their memories of this shocking event and how it has affected them."--publisher website

Sedation breaks : are they good for the critically ill patient? A review.

Background:  Tradition has led us to believe that a heavily sedated patient is a comfortable, settled, compliant patient for whom sedation will improve outcome. The current move witnessed in clinical practice today of limiting sedation has led health care in recent years to question the benefit and necessity of routine, continuous sedation for all patients requiring mechanical ventilation. However, as a result there has been a rise in the amount of agitation being reported as being experienced by patients with the daily withdrawal of sedation. Aims:  The purpose of this paper is to review current arguments for and against perserving with agitation versus re-sedating, when it presents during the daily sedation breaks. Findings:  Of the literature reviewed, the question to re-sedate the mechanically ventilated agitated patient during sedation breaks remains an issue of contention. Although there is evidence focusing on the psychological effects of long-term sedation and sedation breaks specifically, the complex nature of critical illness in some cases means that individualized care is of paramount importance and in-depth assessment is crucial when deciding to re-sedate in the face of undetermined agitation. Agitation has been closely linked with several incidents that can be detrimental to patient safety, such as removal of lines and unplanned self-extubation. Conclusion:  The recommendations of this review are that nurses should re-commence sedation if the patient becomes agitated following a sedation break. Aims:  The purpose of this paper is to review current arguments for and against perserving with agitation versus re-sedating, when it presents during the daily sedation breaks. Findings:  Of the literature reviewed, the question to re-sedate the mechanically ventilated agitated patient during sedation breaks remains an issue of contention. Although there is evidence focusing on the psychological effects of long-term sedation and sedation breaks specifically, the complex nature of critical illness in some cases means that individualized care is of paramount importance and in-depth assessment is crucial when deciding to re-sedate in the face of undetermined agitation. Agitation has been closely linked with several incidents that can be detrimental to patient safety, such as removal of lines and unplanned self-extubation. Conclusion:  The recommendations of this review are that nurses should re-commence sedation if the patient becomes agitated following a sedation break.

Circles of care : should community development redefine the practice of palliative care?

Specialist palliative care, within hospices in particular, has historically led and set the standard for caring for patients at end of life. The focus of this care has been mostly for patients with cancer. More recently, health and social care services have been developing equality of care for all patients approaching end of life. This has mostly been done in the context of a service delivery approach to care whereby services have become increasingly expert in identifying health and social care need and meeting this need with professional services. This model of patient centred care, with the impeccable assessment and treatment of physical, social, psychological and spiritual need, predominantly worked very well for the latter part of the 20th century. Over the last 13 years, however, there have been several international examples of community development approaches to end of life care. The patient centred model of care has limitations when there is a fundamental lack of integrated community policy, development and resourcing. Within this article, we propose a model of care which identifies a person with an illness at the centre of a network which includes inner and outer networks, communities and service delivery organisations. All of these are underpinned by policy development, supporting the overall structure. Adoption of this model would allow individuals, communities, service delivery organisations and policy makers to work together to provide end of life care that enhances value and meaning for people at end of life, both patients and communities alike.

Psychological screening and injury among elite athletes

The purpose of the present investigation was to evaluate the effectiveness of the psychological component of the Queensland Academy of Sport (QAS) Health Screening Questionnaire in screening for injury/illness characteristics among elite athletes. In total, 793 scholarship athletes (409 females and 384 males) ranging in age from 11 to 41 years (M = 19, SD = 4.4) across 20 sports at the QAS in Brisbane, Australia, completed the QAS Health Screening Questionnaire. Psychological risk factors examined were life stress and mood, as measured by the Perceived Stress Scale - 10 (PSS-10) and the Brunel Mood Scale (BRUMS) respectively, in addition to disordered eating behaviours and history of diagnosed psychological disorders. Medical risk factors examined included asthma and back pain. Single-factor MANOVAs showed multivaritate effects for injury, second injury, back pain, asthma, anxiety disorder diagnosis, and fasting. Discriminant function analyses demonstrated that life stress and mood scores had significant utility in correctly classifying injury and second injury status, asthma, back pain, anxiety, and eating disorder diagnosis, in addition to the use of fasting and vomiting as weight control methods. The present findings suggest that the psychology component of the QAS Health Screening Questionnaire demonstrates significant utility as a screening tool regarding injury/illness characteristics among elite athletes.