Towards a home-grown rural health workforce: Evidence from Tasmania, Australia

OBJECTIVE

To examine the association between place of origin and principal place of practice (PPP) of domestic Tasmanian health graduates who received end-to-end training with the University of Tasmania (UTAS).

METHODS

The 2022 PPP for all UTAS domestic Tasmanian graduates from medicine, nursing, pharmacy, psychology, medical radiation science and paramedicine between 2011 and 2020 was identified using the online Australian Health Practitioner Regulation Agency (Ahpra) registration database. The graduate's place of origin (home address at the time of course application), together with their 2022 PPP, was described using the Modified Monash Model (MM) classification system of remoteness. Data were analysed using STATA.

RESULTS

Over the 10-year period, 4079 domestic Tasmanians graduated from health courses at UTAS, of which 3850 (94.4%) were matched to an Australian PPP. In all, 78.3% of graduates were working in Tasmania, while the remainder (21.7%) were employed interstate. Of those with a Tasmanian PPP, 81.4% were working in a regional setting (MM2), while 77.6% of interstate employed graduates recorded a metropolitan (MM1) PPP. Rural place of origin (MM3-7) was associated with rural employment (MM3-7) in both Tasmania (OR, 37.08; 95% CI 29.01-47.39, p < 0.001), and on the Australian mainland (OR, 21.4; 95% CI 17.4-26.3, p < 0.001).

CONCLUSIONS

Most domestic Tasmanian origin UTAS health graduates contribute to the state's health workforce after qualifying. Further research is needed to explore PPP over time and to understand why some graduates are motivated to seek employment on the Australian mainland and in particular, metropolitan cities.

Ultrasound simulation training to meet the 2021 Royal College of Radiologists' curriculum for radiology trainees: South East London experience

AIM

To enhance ultrasound teaching delivery to radiology trainees using a simulation course matched to the 2021 Royal College of Radiologists (RCR) curriculum.

MATERIAL AND METHODS

An ultrasound simulation training course was designed for specialty trainees (ST) 1 in radiology, which was based on the 2021 RCR curriculum and covered the top ultrasound training priorities. The course was piloted initially on two occasions in a 1-day format to the August 2021 and the March 2022 ST1 intake trainees. Based on the feedback, a comprehensive 4-day course was developed and delivered between October and December 2022 for the August 2022 ST1 intake, funded by Health Education England. The outcomes measured were subjective trainee feedback using numerical scores and free text.

RESULTS

All King's College Hospital NHS Foundation Trust radiology ST1 trainees from the August 2021 to the August 2022 intake participated in ultrasound simulation training. The training matched the RCR curriculum and increased the trainees' confidence and competency in medical ultrasound.

CONCLUSIONS

Ultrasound simulation training can be successfully delivered to ST1 trainees to match the 2021 RCR curriculum and enhance training in medical ultrasound for radiologists.

Robotic distal pancreatectomy, a novel standard of care? First benchmark values for surgical outcomes from 14 international expert centers

Objective

Robotic distal pancreatectomy (DP) is emerging as the preferred treatment for body and tail tumors of the pancreas. To enable conclusive comparisons with the standard open or laparoscopic approaches and robotic surgery among centers, novel benchmark outcome values are urgently needed. Therefore, the aim of this study was to identify benchmark values from expert centers beyond the learning curve.

Methods

This multicenter study analyzed outcomes from consecutive patients undergoing robotic DP for resectable malignant or benign lesions from 14 international expert centers. After the learning curve, defined as the first 10 cases of robotic DP, all consecutive patients were included from the start of the program up to June 2020 with a minimum follow-up of 1 year. Benchmark patients were those without significant comorbidities including obesity (BMI &gt;35 kg/m2) cardiac disease, chronic pulmonary disease.

Benchmark cutoff values were derived from the 75th or the 25th percentile of the median values of all benchmark centers.

Results

After reaching the learning curve, 289 (47%) of a total of 614 consecutive patients qualified as benchmark cases. The proportion of benchmark patients varied between 24%-64% per center. Benchmark cut-offs showed a low 6 month- postoperative mortality (&lt;0.6%), but high overall morbidity (&lt;58.3%). Benchmark cutoffs for operative time (&lt;300 min), conversion rate (&lt;3%), clinically relevant pancreatic fistulas (&lt;26.9%), CCI at 90-days (&lt;14.8), hospital stay (&lt;7 days) and readmission rate (&lt;22.9%). Benchmark cut-offs for complications remained unchanged after 3 months follow-up. For ductal adenocarcinoma benchmark cutoffs for number of lymph nodes were &gt; 19 with an R0 resection rate of &gt; 85%, and an overall survival of &gt;86% and &gt;52% after 1- and 5-years, respectively. Centers with a low cohort of benchmark patients (more difficult cases) had less clinically relevant pancreatic fistula (9% vs. 23%) and less overall complications (32% vs. 48%).

Conclusion

This benchmark analysis sets novel reference values for robotic DP, indicating favorable outcomes as compared to laparoscopic and open DP. These references values may serve for quality control of surgery in centers embarking in robotic DP, and include the procedure in the standard of care.

Fruit and Vegetable Intake and Non-Communicable Diseases among Adults Aged ≥50 Years in Low- and Middle-Income Countries

OBJECTIVES

The relationship between consuming ≥2 servings of fruits and ≥3 servings of vegetables a day, which has been identified as optimal for health (i.e., adequate fruit/vegetable consumption), and non-communicable diseases (NCDs) in low- and middle-income countries (LMICs) is largely unknown. Therefore, using data from six LMICs, we investigated the independent association between inadequate fruit/vegetable consumption and 12 NCDs, and estimated the prevalence of inadequate fruit/vegetable consumption among people with NCDs.

DESIGN AND SETTING

Cross-sectional, nationally representative data from the WHO Study on global AGEing and adult health (SAGE) were analyzed.

PARTICIPANTS

Data on 34129 individuals aged ≥50 years were analyzed [mean (SD) age 62.4 (16.0); maximum age 114 years; 52.1% females].

MEASUREMENTS

Information on the number of servings of fruits and vegetables consumed on a typical day was self-reported. Twelve NCDs were assessed. Multivariable logistic regression analysis was conducted.

RESULTS

Overall, 67.2% had inadequate fruit/vegetable consumption. Inadequate fruit/vegetable consumption was independently associated with significantly higher odds for chronic lung disease (OR=1.25), diabetes (OR=1.45), hearing problems (OR=1.75), and visual impairment (OR=2.50). The prevalence of inadequate fruit/vegetable consumption was particularly high among people with visual impairment (92.5%), depression (90.5%), asthma (79.8%), and hearing problems (78.4%).

CONCLUSION

Promotion of fruit and vegetable consumption (≥2 servings of fruits and ≥3 servings of vegetables a day) in LMICs may lead to prevention of some NCDs (e.g., diabetes, chronic lung disease). Furthermore, people with certain NCDs (e.g., visual impairment, depression) had particularly high prevalence of inadequate fruit/vegetable consumption, and it is thus important to target this population to increase fruit/vegetable consumption.

A comparison of meat composition, tenderness and the fatty acid profile of three muscles from Holstein-Friesian bulls from production system resulting in final ages of either <16 or 19 months

Context The increased number of male dairy origin calves in Ireland due to the abolition of European Union milk quotas is a potential resource for the beef industry. Rearing these animals as bulls rather than steers is more efficient from a production perspective. Ensuring satisfactory quality of bull beef from dairy origin is essential. Aim To determine the effect of two production systems and three muscle types on physico-chemical characteristics and fatty acid (FA) profile of beef from Holstein-Friesian (HF) bulls. Methods Thirty HF bulls were equally assigned to two production systems, namely, slaughter at under 16 months of age or slaughter at 19 months of age. Longissimus thoracis (LT), Semitendinosus (ST) and Gluteus medius (GM) muscles were excised post-slaughter for determination of pH, colour, Warner–Bratzler (WB) variables, cook loss, chemical composition [intramuscular fat (IMF), moisture, protein, ash], collagen characteristics and FA profile. Results WB variables and cook loss after 14 days postmortem ageing, and insoluble and total collagen contents were higher, while IMF content, redness and saturation at 24 h post-blooming were lower for muscles from the 19-month production system. Muscles from the under 16-month production system had a higher saturated fatty acid (SFA) proportion and n-6:n-3 polyunsaturated fatty acid (PUFA) ratio, while muscle from the 19-month production system had a higher PUFA proportion, n-3 PUFA proportion and PUFA:SFA ratio. The GM muscle had the lowest L* value, followed by LT and ST. Yellowness, saturation and hue angle were greater in ST. LT had lower WB variables, cook loss, moisture, and a higher IMF content than ST and GM. The PUFA proportion and PUFA:SFA ratio were highest in ST, followed by GM and LT. IMF, total FA, SFA and monounsaturated fatty acid (MUFA) concentrations were higher in LT from the under 16-month production system bulls (the interaction). Conclusions Beef from the under 16-month production system compared with beef from the 19-month production system, and LT compared with ST and GM muscles had better quality characteristics. Implications Dairy bulls can produce beef of acceptable quality. The findings will guide selection of the combination of production system and muscle type most appropriate to specific market requirements.

Modulating medial prefrontal cortex activity using real-time fMRI neurofeedback: Effects on reality monitoring performance and associated functional connectivity

Neuroimaging studies have found ‘reality monitoring’, our ability to distinguish internally generated experiences from those derived from the external world, to be associated with activity in the medial prefrontal cortex (mPFC) of the brain. Here we probe the functional underpinning of this ability using real-time fMRI neurofeedback to investigate the involvement of mPFC in recollection of the source of self-generated information. Thirty-nine healthy individuals underwent neurofeedback training in a between groups study receiving either Active feedback derived from the paracingulate region of the mPFC (21 subjects) or Sham feedback based on a similar level of randomised signal (18 subjects). Compared to those in the Sham group, participants receiving Active signal showed increased mPFC activity over the course of three real-time neurofeedback training runs undertaken in a single scanning session. Analysis of resting state functional connectivity associated with changes in reality monitoring accuracy following Active neurofeedback revealed increased connectivity between dorsolateral frontal regions of the fronto-parietal network (FPN) and the mPFC region of the default mode network (DMN), together with reduced connectivity within ventral regions of the FPN itself. However, only a trend effect was observed in the interaction of the recollection of the source of Imagined information compared with recognition memory between participants receiving Active and Sham neurofeedback, pre- and post- scanning. As such, these findings demonstrate that neurofeedback can be used to modulate mPFC activity and increase cooperation between the FPN and DMN, but the effects on reality monitoring performance are less clear.

Recent developments in the objective measurement of carcass and meat quality for industrial application

This paper summarises the contents of this Special Edition. The papers cover a range of advanced technologies for the objective measurement of carcass characteristics that influence the yield and potential eating quality of beef and lamb carcasses. All the research has been carried out in Australia and New Zealand and has been centrally funded with collaboration between various groups. This Special Edition is timely since the meat industry is coming under pressure on environmental grounds in addition to health warnings about excessive meat consumption. In this respect it is encouraging that so many of the papers relate to eating quality. The emphasis on objective methods is also important as moving away from traditional subjective grading will improve accuracy and consistency and thereby increase efficiency. Some differences in the approach taken in other parts of the world are discussed.

Blind spot in sepsis management - Tissue level changes in microcirculation

In sepsis cytokine-mediated inflammation, clotting cascade activation and glycocalyx shedding impair both function and structure of the microcirculation, compromising adequate tissue oxygenation/perfusion. Such mismatch results in "dysoxia", an imbalance in mitochondrial respiration.Microvessel injuries can be grouped into four types: cytotoxic oedema, micro-vessel heterogeneity, sluggish/absent flow, and focal anaemia. Recognition of such diversity in microcirculatory pathology, alongside with the implementation of novel biomarkers might reveal previously unobserved heterogeneity in adults diagnosed with sepsis. Early identification of distinct subtypes may help not only to better stratify disease severity but may also provide explanation to the often seen insufficient/absent response to resuscitative treatment. Experimental evidence suggests that impaired microcirculatory flow may correlate with organ dysfunction and mortality. Therefore, reliable/reproducible diagnostic tools, that provide real-time information about the dynamic state of the microcirculation, might be practice changers in managing the critically ill.The sublingual mucosa and the nailfolds provide easy access to microcirculation via hand-held, point-of-care devices. Accessing these windows, clinicians may recognise, understand and potentially correct the underlying tissue oxygenation/perfusion mismatch. This new clinical information might facilitate an individualised approach vs protocolised care aiming to administer the right balance of intravenous fluids/vasopressors, time/dose auxiliary treatment modalities and, most importantly, might also guide determining the optimal duration of resuscitation to avoid/minimise harm and maximise benefits in sepsis management. However, before every-day clinical use of such point-of-care microcameras, validation studies are needed to establish not only feasibility but reliability and reproducibility as well.

Do the effects of cannabis on the hippocampus and striatum increase risk for psychosis?

Cannabis use is associated with increased risk of psychotic symptoms and in a small number of cases it can lead to psychoses. This review examines the neurobiological mechanisms that mediate the link between cannabis use and psychosis risk. We use an established preclinical model of psychosis, the methylazoxymethanol acetate (MAM) rodent model, as a framework to examine if psychosis risk in some cannabis users is mediated by the effects of cannabis on the hippocampus, and this region's role in the regulation of mesolimbic dopamine. We also examine how cannabis affects excitatory neurotransmission known to regulate hippocampal neural activity and output. Whilst there is clear evidence that cannabis/cannabinoids can affect hippocampal and medial temporal lobe function and structure, the evidence that cannabis/cannabinoids increase striatal dopamine function is less robust. There is limited evidence that cannabis use affects cortical and striatal glutamate levels, but there are currently too few studies to draw firm conclusions. Future work is needed to test the MAM model in relation to cannabis using multimodal neuroimaging approaches.

Analysis of the Attune tibial tray backside: A comparative retrieval study

Objectives

The Attune total knee arthroplasty (TKA) has been used in over 600 000 patients worldwide. Registry data show good clinical outcome; however, concerns over the cement-tibial interface have been reported. We used retrieval analysis to give further insight into this controversial topic.

Methods

We examined 12 titanium (Ti) PFC Sigma implants, eight cobalt-chromium (CoCr) PFC Sigma implants, eight cobalt-chromium PFC Sigma rotating platform (RP) implants, and 11 Attune implants. We used a peer-reviewed digital imaging method to quantify the amount of cement attached to the backside of each tibial tray. We then measured: 1) the size of tibial tray thickness, tray projections, peripheral lips, and undercuts; and 2) surface roughness (Ra) on the backside and keel of the trays. Statistical analyses were performed to investigate differences between the two designs.

Results

There was no evidence of cement attachment on any of the 11 Attune trays examined. There were significant differences between Ti and CoCr PFC Sigma implants and Attune designs (p < 0.05); however, there was no significant difference between CoCr PFC Sigma RP and Attune designs (p > 0.05). There were significant differences in the design features between the investigated designs (p < 0.05).

Conclusion

The majority of the earliest PFC Sigma designs showed evidence of cement, while all of the retrieved Attune trays and the majority of the RP PFC trays in this study had no cement attached. This may be attributable to the design differences of these implants, in particular in relation to the cement pockets. Our results may help explain a controversial aspect related to cement attachment in a recently introduced TKA design.Cite this article: A. Cerquiglini, J. Henckel, H. Hothi, P. Allen, J. Lewis, A. Eskelinen, J. Skinner, M. T. Hirschmann, A. J. Hart. Analysis of the Attune tibial tray backside: A comparative retrieval study. Bone Joint Res 2019;8:136-145. DOI: 10.1302/2046-3758.83.BJJ-2018-0102.R2.

Longitudinal alterations in motivational salience processing in ultra-high-risk subjects for psychosis

BACKGROUND

Impairments in the attribution of salience are thought to be fundamental to the development of psychotic symptoms and the onset of psychotic disorders. The aim of the present study was to explore longitudinal alterations in salience processing in ultra-high-risk subjects for psychosis.

METHOD

A total of 23 ultra-high-risk subjects and 13 healthy controls underwent functional magnetic resonance imaging at two time points (mean interval of 17 months) while performing the Salience Attribution Test to assess neural responses to task-relevant (adaptive salience) and task-irrelevant (aberrant salience) stimulus features.

RESULTS

At presentation, high-risk subjects were less likely than controls to attribute salience to relevant features, and more likely to attribute salience to irrelevant stimulus features. These behavioural differences were no longer evident at follow-up. When attributing salience to relevant cue features, ultra-high-risk subjects showed less activation than controls in the ventral striatum at both baseline and follow-up. Within the high-risk sample, amelioration of abnormal beliefs over the follow-up period was correlated with an increase in right ventral striatum activation during the attribution of salience to relevant cue features.

CONCLUSIONS

These findings confirm that salience processing is perturbed in ultra-high-risk subjects for psychosis, that this is linked to alterations in ventral striatum function, and that clinical outcomes are related to longitudinal changes in ventral striatum function during salience processing.