Exploring the impact of Aboriginal health placement experiences on the preparation of dietetic graduates for practice with Aboriginal communities

AIM

A health workforce with the ability to practice with Aboriginal communities is crucial to bridge the health gap between Aboriginal and non-Aboriginal Australians. This study aimed to explore the impact of university Aboriginal health placements on preparing dietetic graduates for practice with Aboriginal communities.

METHODS

A mixed methods sequential explanatory design was used. A sample of 594 dietetic graduates was invited to complete a survey that identified Aboriginal health experiences and measured attitudes and self-confidence towards working in Aboriginal health using a five-point Likert scale. Participants were divided into placement versus no-placement groups and compared using chi-squared tests. Sixteen of 33 participants who had completed an Aboriginal health placement were invited to participate in a semi-structured interview to explore how placement influenced practice with Aboriginal communities. Interviews were analysed using content analysis.

RESULTS

A final sample of 120 participants showed that placement participants reported significantly higher self-confidence towards working in Aboriginal health compared with no-placement participants (No-placement = 35% agree, 36% neutral, 29% disagree; Placement = 74% agree, 11% neutral, 16% disagree; χ² (2, 88) = 9.4; P = 0.01). Fifteen participants were interviewed. Interview data indicated that situated learning experiences, breaking down stereotypes, empathy through learning from Aboriginal people, and Aboriginal health role-models were key components of Aboriginal health placements in preparing dietetic graduates for practice with Aboriginal communities.

CONCLUSIONS

The results suggest that Aboriginal health placements may be an effective strategy for preparing dietetic graduates for practice with Aboriginal communities. The feasibility of placement or alternative curriculum content needs to be explored.

Sectoral system capacity development in health promotion: evaluation of an Aboriginal nutrition program

Issue addressed The study examined effective ways to build the capacity of health organisations and professionals in the public health sector to reduce Aboriginal chronic disease risk factors. It investigated the capacity-building strategies of the Victorian Aboriginal Community Controlled Health Organisation (VACCHO) nutrition team in the facilitation of the statewide implementation of the Victorian Aboriginal Nutrition and Physical Activity Strategy 2009-2014 (VANPAS). Methods Using a qualitative design, the study analysed the VACCHO program from 2009-2014 across five domains of capacity development: workforce, resources, organisations, partnerships and leadership. Data were sourced from archival program documents and 62 semi-structured participant interviews. Results Diverse Aboriginal and non-Aboriginal professional, organisation representatives and community participants engaged in the implementation of the VANPAS. The VACCHO team used the VANPAS to solidify participant buy-in, strengthen workforce effectiveness, increase health promotion and resource appropriateness, improve organisational policy and build an evidence-base through collaborative dialogue using action-reflection principles. Conclusion A credible, high-profile Aboriginal community led and evidence-based statewide program and a commitment to dialogue through action-reflection provided a meaningful basis for both Aboriginal community and mainstream organisational engagement. Upon this foundation, the VACCHO team built a coherent sectoral system with increased capacity to enhance the nutrition of Aboriginal Victorians. So what? In an historical context of mistrust and unmet expectations, program implementation methods that build confidence amongst collaborating Aboriginal and non-Aboriginal health agencies is fundamental to building capacity to enhance Aboriginal nutrition and health.

Food and nutrition programs for Aboriginal and Torres Strait Islander Australians: an overview of systematic reviews

Objective To provide an overview of previous reviews of programs that aimed to improve nutritional status or diet-related health outcomes for Aboriginal and Torres Strait Islander peoples, in order to determine what programs are effective and why. Methods A systematic search of databases and relevant websites was undertaken to identify reviews of nutrition interventions for Aboriginal and Torres Strait Islander Australians. Pairs of reviewers undertook study selection and data extraction and performed quality assessment using a validated tool. Results Twelve papers reporting 11 reviews were identified. Two reviews were rated high quality, three were rated medium and six were rated low quality. The reviews demonstrated that a positive effect on nutrition and chronic disease indicators can be a result of: 1) incorporating nutrition and breastfeeding advice into maternal and child health care services; and 2) multifaceted community nutrition programs. The evidence suggests that the most important factor determining the success of Aboriginal and Torres Strait Islander food and nutrition programs is community involvement in (and, ideally, control of) program development and implementation. Conclusions Community-directed food and nutrition programs, especially those with multiple components that address the underlying causes of nutrition issues, can be effective in improving nutrition-related outcomes. What is known about the topic? More effective action is urgently required in order to reduce the unacceptable health inequalities between Aboriginal and Torres Strait Islander peoples and non-Indigenous Australians. Food insecurity and nutrition-related chronic conditions are responsible for a large proportion of the ill health experienced by Australia’s First Peoples. What does this paper add? This narrative overview of 11 reviews published between 2005 and 2015 provides a synthesis of the current evidence for improving Aboriginal and Torres Strait Islander nutrition across the lifespan. The findings suggest that community-based and community-controlled programs, especially those with multiple components that address the underlying causes of nutrition issues, have the greatest potential to improve nutrition-related health outcomes. What are the implications for practitioners? Food and nutrition programs that are initiated and designed by local Aboriginal and Torres Strait Islander people are most likely to be effective. Nutrition and breastfeeding education and advice should be consistently incorporated into maternal and child healthcare services. Nutrition issues should be addressed through multifaceted approaches that address improving individual knowledge and skills, as well as strategies that increase access to nutritious food and provide a healthy food environment.

How's Your Sugar? Evaluation of a Website for Aboriginal People With Diabetes

Background

Australia’s Aboriginal and Torres Strait Islander peoples (hereafter referred to as “Aboriginal people”) have the longest continuing culture in the world, living sustainably for at least 65,000 years on the Australian continent. In relatively recent times, colonization processes have resulted in Aboriginal people experiencing unacceptable health inequalities compared with other Australians. One disease introduced due to colonization is diabetes, the second leading cause of death for Aboriginal peoples.

Objectives

The objective of this study was to describe the construction and utilization of the website “How’s Your Sugar, ” a website for Aboriginal people with type 2 diabetes (herein after referred to as diabetes). The questions for the evaluation were as follows: how was the website constructed; did target groups utilize the website; and did engagement with the website improve diabetes management.

Methods

A mixed-method study design was employed. A content analysis of project documents provided information about the website construction. Data from Google analytics provided information about website utilization. To describe patterns of website sessions, percentages and numbers were calculated. A voluntary survey provided more information on website utilization and diabetes self-management. Percentage, numbers, and 95% CIs were calculated for each variable. A chi-square test was performed for Aboriginal status, age, gender, and Aboriginal diabetic status using Australian population estimates and Aboriginal diabetes rates.

Results

The website development drew on Aboriginal health, social marketing, interactive health promotion frameworks, as well as evidence for diabetes self-management. The website build involved a multidisciplinary team and participation of Aboriginal diabetics, Aboriginal diabetic family members, and Aboriginal health workers. This participation allowed for inclusion of Aboriginal ways of knowing and being. The highest number of website sessions came from Australia, 98.15% (47,717/48,617) and within Australia, Victoria 50.97% (24,323/47,717). There were 129 survey respondents, and the distribution had more female, 82.9% (107/129, 95% CI 76-88), Aboriginal, 21.7% (28/129, 95% CI 16-30), and Aboriginal diabetic, 48% (13/27, 95% CI 31-66) respondents than expected with P<.001 for these three groups. Most common reasons for visits were university assignment research, 40.6% (41/101), and health workers looking for information, 20.8% (21/101). The sample size was too small to calculate diabetes self-management change.

Conclusions

Inclusion of Aboriginal ways of knowing and being alongside other theoretical and evidence models in Web design is possible. Aboriginal people do utilize Web-based health promotion, and further understanding about reaching to this population would be of use. Provision of an education resource would likely have enhanced educational engagement. Web-based technologies are rapidly evolving, and these can potentially measure behavior change in engaging ways that also have benefits for the participant. A challenge for designers is inclusivity of cultural diversity for self-determination.

Sharing the tracks to good tucker: identifying the benefits and challenges of implementing community food programs for Aboriginal communities in Victoria

Food insecurity is a significant issue in the Victorian Aboriginal population, contributing to the health disparity and reduced life expectancy. Community food programs are a strategy used to minimise individual level food insecurity, with little evidence regarding their effectiveness for Aboriginal populations. The aim of this study was to explore the role of community food programs operating for Aboriginal people in Victoria and their perceived influence on food access and nutrition. Semistructured interviews were conducted with staff (n=23) from a purposive sample of 18 community food programs across Victoria. Interviews explored the programs' operation, key benefits to the community, challenges and recommendations for setting up a successful community food program. Results were analysed using a qualitative thematic approach and revealed three main themes regarding key factors for the success of community food programs: (1) community food programs for Aboriginal people should support access to safe, affordable, nutritious food in a socially and culturally acceptable environment; (2) a community development approach is essential for program sustainability; and (3) there is a need to build the capacity of community food programs as part of a strategy to ensure sustainability. Community food programs may be an effective initiative for reducing food insecurity in the Victorian Aboriginal population.

Establishing health-promoting workplaces in Aboriginal community organisations: healthy eating policies

Aboriginal community controlled health organisations (ACCHOs) and cooperatives function at the centre of community life for local Aboriginal people across Victoria. Local Aboriginal people govern them, work within them as managers and service providers, access health and community services from them and form the constituents who determine their directions. Victorian ACCHOs reflect the unique characteristics of the local Aboriginal community. Thus, potentially, Victorian ACCHOs are key strategic sites for health promotion activities that seek to establish and nurture healthy community, family and peer norms. The Victorian Aboriginal Community Controlled Health Organisation (VACCHO) partnered five metropolitan, regional and rural ACCHOs in a pilot project towards the establishment of healthy food policies and practices in their organisations. Project activities combined both ‘top-down’ policy-oriented and ‘bottom-up’ practice-oriented strategies. This paper, drawing upon both baseline and follow-up quantitative and qualitative data, describes initiatives leading to increases in healthy catering choices and related challenges for Aboriginal workplace health promotion practice.

Mass Measurement of 56Sc Reveals a Small A = 56 Odd-Even Mass Staggering, Implying a Cooler Accreted Neutron Star Crust

We present the mass excesses of (52-57)Sc, obtained from recent time-of-flight nuclear mass measurements at the National Superconducting Cyclotron Laboratory at Michigan State University. The masses of 56Sc and 57Sc were determined for the first time with atomic mass excesses of -24.85(59)((-54)(+0))  MeV and -21.0(1.3)  MeV, respectively, where the asymmetric uncertainty for 56Sc was included due to possible contamination from a long-lived isomer. The 56Sc mass indicates a small odd-even mass staggering in the A = 56 mass chain towards the neutron drip line, significantly deviating from trends predicted by the global FRDM mass model and favoring trends predicted by the UNEDF0 and UNEDF1 density functional calculations. Together with new shell-model calculations of the electron-capture strength function of 56Sc, our results strongly reduce uncertainties in model calculations of the heating and cooling at the 56Ti electron-capture layer in the outer crust of accreting neutron stars. We find that, in contrast to previous studies, neither strong neutrino cooling nor strong heating occurs in this layer. We conclude that Urca cooling in the outer crusts of accreting neutron stars that exhibit superbursts or high temperature steady-state burning, which are predicted to be rich in A≈56 nuclei, is considerably weaker than predicted. Urca cooling must instead be dominated by electron capture on the small amounts of adjacent odd-A nuclei contained in the superburst and high temperature steady-state burning ashes. This may explain the absence of strong crust Urca cooling inferred from the observed cooling light curve of the transiently accreting x-ray source MAXI J0556-332.

Mass measurements demonstrate a strong N=28 shell gap in argon

We present results from recent time-of-flight nuclear mass measurements at the National Superconducting Cyclotron Laboratory at Michigan State University. We report the first mass measurements of ^{48}Ar and ^{49}Ar and find atomic mass excesses of -22.28(31)  MeV and -17.8(1.1)  MeV, respectively. These masses provide strong evidence for the closed shell nature of neutron number N=28 in argon, which is therefore the lowest even-Z element exhibiting the N=28 closed shell. The resulting trend in binding-energy differences, which probes the strength of the N=28 shell, compares favorably with shell-model calculations in the sd-pf shell using SDPF-U and SDPF-MU Hamiltonians.

Determining the rp-process flow through 56Ni: resonances in 57Cu(p,γ)58Zn identified with GRETINA

An approach is presented to experimentally constrain previously unreachable (p, γ) reaction rates on nuclei far from stability in the astrophysical rp process. Energies of all critical resonances in the (57)Cu(p,γ)(58)Zn reaction are deduced by populating states in (58)Zn with a (d, n) reaction in inverse kinematics at 75 MeV/u, and detecting γ-ray-recoil coincidences with the state-of-the-art γ-ray tracking array GRETINA and the S800 spectrograph at the National Superconducting Cyclotron Laboratory. The results reduce the uncertainty in the (57)Cu(p,γ) reaction rate by several orders of magnitude. The effective lifetime of (56)Ni, an important waiting point in the rp process in x-ray bursts, can now be determined entirely from experimentally constrained reaction rates.

Early childhood nutrition concerns, resources and services for Aboriginal families in Victoria

OBJECTIVE

To investigate the child nutrition concerns of Aboriginal families with young children attending Aboriginal health and early childhood services in Victoria; training needs of early childhood practitioners; and sources of nutrition and child health information and advice for Aboriginal families with young children.

METHOD

Qualitative needs assessment involving consultation with Aboriginal parents of young children aged 0-8 years attending Aboriginal health and early childhood services, and early childhood practitioners from Aboriginal health and early childhood services in urban and regional Victoria. Focus groups were conducted with 35 Aboriginal parents and interviews conducted with 45 health and early childhood practitioners. Thematic analysis was used to generate and then refine distinct, internally consistent common themes from the data.

RESULTS

The most frequent issues identified were low levels of breastfeeding, inappropriate introduction of solids, reliance on bottles, sweet drinks, and energy-dense foods, poor oral health and overweight. Concerns about staff training and capacity, and access to maternal and child health services were also common.

CONCLUSION AND IMPLICATION

This study identifies major gaps in service delivery for Aboriginal families with young children and points to the need for a coordinated, culturally responsive systems approach to providing support for breastfeeding and child nutrition advice and support for Aboriginal families, including capacity building for staff, and supportive systems and policy.

Feltman: evaluating the acceptability of a diabetes education tool for Aboriginal health workers

There is an urgent need to address the lack of Aboriginal-specific diabetes prevention and management resources. Following consultation with Victorian Aboriginal health workers, the Victorian Aboriginal Community Controlled Health Organisation and Diabetes Australia – Victoria developed ‘Feltman’, a life-sized felt body showing the main organs involved in the digestion and metabolism of food, and the main parts of the body affected by diabetes. Feltman was distributed to all Victorian Aboriginal Community Controlled Health Organisations and an additional 32 Victorian organisations. In total, 276 people from 57 organisations were trained to use Feltman. An online evaluation survey was developed and sent to all people who were trained to use Feltman in Victoria. Sixty-six people completed the survey. All respondents agreed Feltman was an appropriate tool for the Aboriginal community, 89% of health workers felt more confident in their ability to discuss diabetes with their community but would like further training to maintain skills and confidence and 70% of workers had used Feltman with the community. Qualitative feedback noted its strength as a highly visual resource that was popular with the Aboriginal community. Workers reported that Feltman was a highly acceptable diabetes education resource, which they believed had increased knowledge and improved the management of diabetes among clients.

epic3: national evidence-based guidelines for preventing healthcare-associated infections in NHS hospitals in England

National evidence-based guidelines for preventing healthcare-associated infections (HCAI) in National Health Service (NHS) hospitals in England were originally commissioned by the Department of Health and developed during 1998-2000 by a nurse-led multi-professional team of researchers and specialist clinicians. Following extensive consultation, they were first published in January 2001(1) and updated in 2007.(2) A cardinal feature of evidence-based guidelines is that they are subject to timely review in order that new research evidence and technological advances can be identified, appraised and, if shown to be effective for the prevention of HCAI, incorporated into amended guidelines. Periodically updating the evidence base and guideline recommendations is essential in order to maintain their validity and authority. The Department of Health commissioned a review of new evidence and we have updated the evidence base for making infection prevention and control recommendations. A critical assessment of the updated evidence indicated that the epic2 guidelines published in 2007 remain robust, relevant and appropriate, but some guideline recommendations required adjustments to enhance clarity and a number of new recommendations were required. These have been clearly identified in the text. In addition, the synopses of evidence underpinning the guideline recommendations have been updated. These guidelines (epic3) provide comprehensive recommendations for preventing HCAI in hospital and other acute care settings based on the best currently available evidence. National evidence-based guidelines are broad principles of best practice that need to be integrated into local practice guidelines and audited to reduce variation in practice and maintain patient safety. Clinically effective infection prevention and control practice is an essential feature of patient protection. By incorporating these guidelines into routine daily clinical practice, patient safety can be enhanced and the risk of patients acquiring an infection during episodes of health care in NHS hospitals in England can be minimised.

The potential of algae blooms to produce renewable gaseous fuel

Ulva lactuca (commonly known as sea letuce) is a green sea weed which dominates Green Tides or algae blooms. Green Tides are caused by excess nitrogen from agriculture and sewage outfalls resulting in eutrophication in shallow estuaries. Samples of U. lactuca were taken from the Argideen estuary in West Cork on two consecutive years. In year 1 a combination of three different processes/pretreatments were carried out on the Ulva. These include washing, wilting and drying. Biomethane potential (BMP) assays were carried out on the samples. Fresh Ulva has a biomethane yield of 183LCH4/kgVS. For dried, washed and macerated Ulva a BMP of 250LCH4/kgVS was achieved. The resource from the estuary in West Cork was shown to be sufficient to provide fuel to 264 cars on a year round basis. Mono-digestion of Ulva may be problematic; the C:N ratio is low and the sulphur content is high. In year 2 co-digestion trials with dairy slurry were carried out. These indicate a potential increase in biomethane output by 17% as compared to mono-digestion of Ulva and slurry.

Association between healthcare water systems and Pseudomonas aeruginosa infections: a rapid systematic review

BACKGROUND

Pseudomonas aeruginosa is an opportunistic pathogen with a particular propensity to cause disease in the immunocompromised. Water systems have been reported to contribute to P. aeruginosa transmission in healthcare settings.

AIM

To systematically assess the evidence that healthcare water systems are associated with P. aeruginosa infection; to review aspects of design that can increase their potential to act as a reservoir; and to compare the efficacy of strategies for eradicating contamination and preventing infection.

METHODS

A rapid review methodology with a three-step search strategy was used to identify published studies. Scientific advisors were used to identify unpublished studies.

FINDINGS

Twenty-five relevant studies were included. There was plausible evidence of transmission of P. aeruginosa from water systems to patients and vice versa, although no direct evidence to explain the exact mode of transfer. Two studies provided plausible evidence for effective interventions: point-of-use filters and increasing chlorine disinfection. Non-touch taps and aspects of water system design were identified as probable risk factors for P. aeruginosa biofilm formation and subsequent transmission to patients. Poor hand hygiene or compliance with contact precautions were identified as potential contributory factors; plausible evidence to confirm this was not available.

CONCLUSIONS

Water systems can act as a source of P. aeruginosa infection in healthcare settings, although the route of transmission is unclear. Contamination appears to be confined to the distal ends of a water system and can persist for prolonged periods. Further studies are required to establish effective methods of preventing transmission and eradicating P. aeruginosa from plumbing systems.

Use of participatory research and photo-voice to support urban Aboriginal healthy eating

The aim of this research was to work collaboratively with an urban Aboriginal community to understand meanings of food and food insecurity and strengthen responses to this issue. The project took place at the Wathaurong Aboriginal Cooperative in Geelong, South Eastern Australia in 2009-2010. Photo-voice research methods were used to explore meanings of food and food insecurity. This identified that food selections were influenced by family harmony, collectivism and satiation of hunger with cheap high carbohydrate and fat foods. People were also proud of their hunter-gatherer heritage and saw the Wathaurong Aboriginal Cooperative as leaders in healthy food provision. Action research cycles were used to develop responses including plates depicting healthy food portions, social cooking opportunities, development of a cooking television series and a specialised cook-book. The partnership required researchers to listen carefully to respond to needs of the Wathaurong Aboriginal Cooperative, and this meant adapting research plans to suit the local environment and community partner needs. There is potential for Aboriginal organisations to provide further leadership for healthy eating and food security through workplace food policies and partnerships with food security agencies. Use of Aboriginal nutrition knowledge to provide nutrition education may be useful in health promotion approaches.

Seroprevalence of Trypanosoma cruzi in blood donors at the National Blood Transfusion Services--Guyana

INTRODUCTION

Blood transfusion is an important transmission route of Trypanosoma cruzi (T cruzi), a major parasitic infection in Central and South America. The limited treatment options are most effective in acute Chagas' infection. At present, there is no current data on the prevalence of T cruzi in the blood donor population of Guyana. This information is necessary to protect the supply of the blood donation programme. This study sought to determine the prevalence of T cruzi in the blood supply at the National Blood Transfusion Services of Guyana with the hope of providing knowledge to the on-going surveillance for Chagas' disease worldwide and therefore address the risk of its spread by blood transfusion.

METHODS

Two commercialized ELISAs utilizing crude or recombinant T cruzi antigens were used to study 2000 blood samples voluntarily donated for the purpose of altruistic or family replacement donation retrospectively.

RESULTS

The results showed that approximately 1 in 286 donations tested positive for antibodies to T cruzi.

CONCLUSION

These results indicate that T cruzi continues to be a risk in Guyana and there is a need to continue screening donated blood. Trypanosoma cruzi is a life-long infection and infected persons may be asymptomatic chronic carriers of the disease. Education, housing improvement, and controlled use of insecticides should be introduced to contain Chagas' disease.

Personal resuscitation plans and end of life planning for children with disability and life-limiting/life-threatening conditions

This article discusses the need for person-specific planning for the increasing numbers of disabled children with life-limiting and life-threatening conditions. It describes the system developed in Nottingham for this client group to have a family-held personal resuscitation plan, (PRP) which is developed with the child and family by their lead paediatrician. The PRP is an emergency medical care plan which supports the provision of the most appropriate level of intervention for the child whether they are at home, school, short break unit or hospital. The PRP template is presented with advice on implementation and case examples. Feedback from families, medical and nursing staff is that PRPs are useful and empowering. The system supports timely discussions about appropriate care in an emergency and the communication of decisionsmade jointly by the child, family and medical team to all concerned. A flexible and person-specific PRP stating what interventions to do such as airway clearance, facial oxygen, trial of bag and mask ventilation is preferable to a do not attempt resuscitation form which is an 'all or nothing system' and can seem very negative to families. A PRP in the home can support appropriate action from local rapid response teams set up to review unexpected child deaths.

Alcohol and drug use in Australian male sex workers: Its relationship to the safety outcome of the sex encounter

This paper describes the self-reporting patterns of alcohol and drug consumption among male sex workers (MSWs) in three Australian cities during commercial sex encounters, and examines to what extent alcohol and drugs are used and whether this is related to the safe/unsafe outcome of the commercial sex encounter. One hundred and eighty-six MSWs from Brisbane, Sydney and Melbourne completed a diary following each commercial sex encounter over a two-week period. MSWs reported 2,087 commercial sex encounters during the study period. Alcohol or drug consumption was reported in 50.5% of the encounters. There were 488 instances of marijuana use reported before or during a commercial sex encounter, 210 instances of volatile inhalants use, 149 instances of heroine use and 151 of other drug use, including benzodiasepines, ecstasy, speed and cocaine. These substances were consumed either alone or combined. Marijuana consumption was associated with the commercial sex encounter occurring at the MSWs' place of residence and consumption of alcohol, marijuana and nitrites with the client's place. The results also reveal that consumption of drugs and alcohol was statistically related to length of the encounter, and that clients obtained through escort agencies or brothels were significantly associated with marijuana, other drug consumption and heroine use. Interestingly, a multivariate analysis indicated that encounters where the MSW consumed marijuana or did not consume any substance were less likely to have an unsafe outcome. The paper argues that it is necessary to identify and target risk groups and behaviours that are usually not included in broad based health education messages.

Darwin the scientist

Charles Darwin's experimental investigations show him to have been a superb practical researcher. These skills are often underestimated today when assessing Darwin's achievement in the Origin of Species and his other books. Supported by a private income, he turned his house and gardens into a Victorian equivalent of a modern research station. Darwin participated actively in the exchange of scientific information via letters and much of his research was also carried out through correspondence. Although this research was relatively small scale in practice, it was large scale in intellectual scope. Darwin felt he had a strong desire to understand or explain whatever he observed.

Can guidelines improve referral to elective surgical specialties for adults? A systematic review

Aim

To assess effectiveness of guidelines for referral for elective surgical assessment.

Method

Systematic review with descriptive synthesis.

Data sources

Medline, EMBASE, CINAHL and Cochrane database up to 2008. Hand searches of journals and websites.

Selection of studies

Studies evaluated guidelines for referral from primary to secondary care, for elective surgical assessment for adults.

Outcome measures

Appropriateness of referral (usually measured as guideline compliance) including clinical appropriateness, appropriateness of destination and of pre-referral management (eg, diagnostic investigations), general practitioner knowledge of referral appropriateness, referral rates, health outcomes and costs.

Results

24 eligible studies (5 randomised control trials, 6 cohort, 13 case series) included guidelines from UK, Europe, Canada and the USA for referral for musculoskeletal, urological, ENT, gynaecology, general surgical and ophthalmological conditions. Interventions varied from complex (“one-stop shops”) to simple guidelines. Four randomized control trials reported increases in appropriateness of pre-referral care (diagnostic investigations and treatment). No evidence was found for effects on practitioner knowledge. Mixed evidence was reported on rates of referral and costs (rates and costs increased, decreased or stayed the same). Two studies reported on health outcomes finding no change.

Conclusions

Guidelines for elective surgical referral can improve appropriateness of care by improving pre-referral investigation and treatment, but there is no strong evidence in favour of other beneficial effects.

Factors associated with the health status of internally displaced persons in northern Uganda

Background:

Globally, there are over 24 million internally displaced persons (IDPs) who have fled their homes due to violence and insecurity but who remain within their own country. There have been up to 2 million IDPs in northern Uganda alone. The objective of this study was to investigate factors associated with mental and physical health status of IDPs in northern Uganda.

Methods:

A cross-sectional survey was conducted in November 2006 in IDP camps in the Gulu and Amuru districts of northern Uganda. The study outcome of physical and mental health was measured using the SF-8 instrument, which produces physical (PCS) and mental (MCS) component summary measures. Independent demographic, socio-economic, and trauma exposure (using the Harvard Trauma Questionnaire) variables were also measured. Multivariate regression linear regression analysis was conducted to investigate associations of the independent variables on the PCS and MCS outcomes.

Results:

1206 interviews were completed. The respective mean PCS and MCS scores were 42.2 (95% CI 41.32 to 43.10) and 39.3 (95% CI 38.42 to 40.13), well below the instrument norm of 50, indicating poor health. Variables with negative associations with physical or mental health included gender, age, marital status, income, distance of camp from home areas, food security, soap availability, and sense of safety in the camp. A number of individual trauma variables and the frequency of trauma exposure also had negative associations with physical and mental health.

Conclusions:

This study provides evidence on the impact on health of deprivation of basic goods and services, traumatic events, and fear and uncertainty amongst displaced and crisis affected populations.

Quality of stroke care at an Irish Regional General Hospital and Stroke Rehabilitation Unit

BACKGROUND

Robust international data support the effectiveness of stroke unit (SU) care. Despite this, most stroke care in Ireland are provided outside of this setting. Limited data currently exist on the quality of care provided.

AIM

The aim of this study is to examine the quality of care for patients with stroke in two care settings-Regional General Hospital (RGH) and Stroke Rehabilitation Unit (SRU).

METHODS

A retrospective analysis of the stroke records of consecutive patients admitted to the SRU between May-November 2002 and April-November 2004 was performed applying the UK National Sentinel Audit of Stroke (NSAS) tool.

RESULTS

The results of the study reveal that while SRU processes of care was 74% compliant with standards; compliance with stroke service organisational standards was only 15 and 43% in the RGH and SRU, respectively.

CONCLUSION

The quality of stroke care in our area is deficient. Comprehensive reorganisation of stroke services is imperative.

Comparison of effects of combined ACE inhibitor and low-dose thiazide diuretic with ACE inhibitor alone on insulin action in patients with hypertension and Type 2 diabetes: a double-blind crossover study

AIMS

To establish the safety in terms of insulin sensitivity of a low dose thiazide/ACE inhibitor combination.

METHODS

We examined the effects on insulin sensitivity of captopril either alone or in combination with low-dose bendroflumethiazide (1.25 mg) in 15 hypertensive Type 2 diabetic patients. Insulin action was assessed using an isoglycaemic hyperinsulinaemic clamp in a double-blind, randomised, crossover study after a 6-week placebo run-in and following two 12-week treatment periods with captopril (C) (100 mg) alone or in combination with bendroflumethiazide (CB) (1.25 mg).

RESULTS

Blood pressure was lower following CB compare to C (138/83 vs. 144/85 mmHg; P < 0.05) and both were lower than baseline (153/92 mmHg; P < 0.01). CB resulted in a significant increase in fasting plasma glucose compared to C (9.6 +/- 2.6 vs. 8.5 +/- 1.6 mmol/l; P < 0.05). Exogenous glucose infusion rates required to maintain isoglycaemia during hyperinsulinaemia were lower after CB compared to C (25.1 +/- 13.3 vs. 34.2 +/- 16.8 micromol/kg/min; P < 0.01) as were isotopically determined glucose utilisation rates (29.0 +/- 12.4 vs. 36.6 +/- 17.3 micromol/kg/min; P < 0.05). There was no significant difference in fasting endogenous glucose production between treatments (CB 9.3 +/- 3.3 vs. C 8.6 +/- 1.6 micromol/kg/min), nor between suppression following insulin (CB 4.0 +/- 2.1 vs. C 4.3 +/- 3.1 micromol/kg/min).

CONCLUSIONS

Combination of low-dose bendroflumethiazide with captopril lowered blood pressure but resulted in deleterious effects on insulin action compared to captopril alone.

Variation in day-case nasal surgery - why cannot we improve our day-case rates?

OBJECTIVES

The NHS plan states that 75% of all elective operations should be performed as day-cases. We set out to evaluate day surgery rates in sinonasal surgery and to identify factors limiting current practice.

STUDY DESIGN AND SETTING

Prospective multicentre cohort study.

PARTICIPANTS

3128 patients undergoing sinonasal surgery during 2000 and 2001.

OUTCOME MEASURES

Same day discharge, complication and readmission rates.

RESULTS

There is potential selection bias due to the non-random selection of NHS Trusts and patients in this study. However, as results are similar to Hospital Episode Statistics data such bias is probably small. Only 15.5% of all procedures are performed as day surgery. We are achieving day-case rates of 18, 20 and 6% for nasal polypectomy, intranasal antrostomy and extensive FESS respectively, compared with recently published targets of 90%, 80% and 50%. Factors significantly associated with overnight admission were use of packs, extensive surgery, excess post-operative bleeding and high ASA grade. There was considerable unexplained variation in day-case rates and the use of packs between different surgeons. A third of consultants pack all patients post-operatively. More than 51% of consultants admit all patients, while 5% discharge all patients on the day of surgery. There were no excess adverse events or readmissions amongst the day surgery patients. However, only 17% of in-patients would have liked to be discharged on the day of surgery. Both patient and surgeon must overcome resistance to day case surgery before targets can be reached.

CONCLUSIONS

Strategies for improving day-case rates in sinonasal surgery. All ASA grade 1 and 2 patients could be considered for day-case surgery, but particularly those with less extensive disease on radiography, and those planned to undergo less extensive procedures. Excess peri-operative bleeding was reported in 6% of patients. There must therefore be provision for overnight admission if required. Greater utilisation of day-case units, selective use of packs, and earlier removal may increase the proportion of patients managed as day-cases. There remains considerable variation in practice at both consultant and trust levels. Units should continue to audit their own figures and compare them against national rates in order to reduce nationwide variation in practice.

High quality acute care for the severely injured is not consistently available in England, Wales and Northern Ireland: report of a survey by the Trauma Committee, The Royal College of Surgeons of England

INTRODUCTION

A survey was undertaken to determine the extent to which acute hospitals in England, Wales and Northern Ireland were meeting the acute trauma management standards published in 2000 by The Royal College of Surgeons of England and the British Orthopaedic Association.

METHODS

A questionnaire comprising 72 questions in 16 categories of management was distributed in July 2003 to all eligible hospitals via the link network of the British Orthopaedic Association. Data were collected over a 3-month period.

RESULTS

Of 213 eligible hospitals, 161 (76%) responded. In every category of acute care, failure to meet the standards was reported. Only 34 (21%) hospitals met all the 13 indicative standards that were considered pivotal to good trauma care, but all hospitals met at least 7 of these standards. Failures were usually in the organisation of services rather than a lack of resources, with the exception of the inadequate capacity for admission to specialist neurosurgery units. A minority of hospitals reported an inability to provide emergency airway control or insertion of chest tube. The data have not been verified and deficiencies in reporting cannot be excluded.

CONCLUSIONS

The findings of this survey suggest that high quality care for the severely injured is not available consistently across England, Wales and Northern Ireland, and appear to justify concerns about the ability of the NHS to deal effectively with the current trauma workload and the consequences of a major incident.

Divergent mechanisms of cis 9, trans 11 ‐ and trans 10 , cis 12 ‐ conjugated linoleic acid affecting insulin resistance and inflammation in apolipoprotein E knockout mice: a proteomics approach

Conjugated linoleic acids (CLA) affect atherogenesis, but mechanisms are not well understood. We explored how two isomers of CLA, cis9, trans11-CLA and trans10, cis12-CLA, affected lipid and glucose metabolism, as well as hepatic protein expression, in apolipoprotein E knockout mice. After 12 wk of intervention, plasma triglyceride, NEFA, and glucose concentrations were significantly higher in the trans10, cis12-CLA group, whereas plasma triglyceride, NEFA, glucose, and insulin concentrations were significantly lower in the cis9, trans11-CLA group, compared with control mice consuming linoleic acid. Proteomics identified significant up- or down-regulation of 113 liver cytosolic proteins by either CLA isomer. Principal component analysis revealed that the treatment effect of cis9, trans11-CLA was mainly explained by the up-regulation of different posttranslational forms of heat shock protein 70 kD. In contrast, the treatment effect of trans10, cis12-CLA was mainly explained by up-regulation of key enzymes in the gluconeogenic, beta-oxidation, and ketogenesic pathways. Correlation analysis again emphasized the divergent effects of both CLA isomers on different pathways, but also revealed a linkage between insulin resistance and increased levels of hepatic serotransferrin. Thus, our systems biology approach provided novel insights into the mechanisms by which individual CLA isomers differentially affect pathways related to atherogenesis, such as insulin resistance and inflammation.

Evaluation of endocervical, first-void urine and self-administered vulval swabs for the detection of Chlamydia trachomatis in a miscarriage population

OBJECTIVE

To compare, in parallel, different approaches of opportunistically screening women with bleeding in early pregnancy for Chlamydia trachomatis.

DESIGN

Prospective observational [corrected] study.

SETTING

Early pregnancy assessment unit, University hospital, Scotland, UK.

POPULATION

Over 200 consecutive women admitted to an early pregnancy assessment unit were recruited. All had a positive pregnancy test, a history of vaginal bleeding and were less than 24 weeks of gestation. Women with recent antibiotic use, heavy vaginal bleeding and cervical shock excluded.

METHODS

Each women provided two or more of the following specimens: a self-administered vulval swab, first-void urine and/or endocervical swab. Following screening, each completed a semi-structured questionnaire assessing the acceptability of each method undertaken.

MAIN OUTCOME MEASURE

Subjective rating of the screening methods; prevalence; method performance, including proportion requiring repeat testing.

RESULTS

The majority accepted screening, with moderate prevalence rates (95% CI) 3.9% (2.0-7.4%) identified. All positive women were less than 30 years of age. Parallel screening exposed the potential of reduced test performance with urine. Non-invasive sampling was more acceptable, but more likely to require repeat testing.

CONCLUSION

Both acceptability and the effect of bleeding on test performance need further assessment before a particular specimen can be recommended for screening this population of women for C. trachomatis.

A meta-analysis of variables that predict significant intracranial injury in minor head trauma

BACKGROUND

Previous studies have presented conflicting results regarding the predictive effect of various clinical symptoms, signs, and plain imaging for intracranial pathology in children with minor head injury.

AIMS

To perform a meta-analysis of the literature in order to assess the significance of these factors and intracranial haemorrhage (ICH) in the paediatric population.

METHODS

The literature was searched using Medline, Embase, Experts, and the grey literature. Reference lists of major guidelines were crosschecked. Control or nested case-control studies of children with head injury who had skull radiography, recording of common symptoms and signs, and head computed tomography (CT) were selected.

OUTCOME VARIABLE

CT presence or absence of ICH.

RESULTS

Sixteen papers were identified as satisfying criteria for inclusion in the meta-analysis, although not every paper contained data on every correlate. Available evidence gave pooled patient numbers from 1136 to 22 420. Skull fracture gave a relative risk ratio of 6.13 (95% CI 3.35 to 11.2), headache 1.02 (95% CI 0.62 to 1.69), vomiting 0.88 (95% CI 0.67 to 1.15), focal neurology 9.43 (2.89 to 30.8), seizures 2.82 (95% CI 0.89 to 9.00), LOC 2.23 (95% CI 1.20 to 4.16), and Glasgow Coma Scale (GCS) <15 of 5.51 (95% CI 1.59 to 19.0).

CONCLUSIONS

There was a statistically significant correlation between intracranial haemorrhage and skull fracture, focal neurology, loss of consciousness, and GCS abnormality. Headache and vomiting were not found to be predictive and there was great variability in the predictive ability of seizures. More information is required about the current predictor variables so that more refined guidelines can be developed. Further research is currently underway by three large study groups.

Waste management models and their application to sustainable waste management

The purpose of this paper is to review the types of models that are currently being used in the area of municipal waste management and to highlight some major shortcomings of these models. Most of the municipal waste models identified in the literature are decision support models and for the purposes of this research, are divided into three categories-those based on cost benefit analysis, those based on life cycle assessment and those based on multicriteria decision making. Shortcomings of current waste management models include that they are concerned with refinements of the evaluation steps (e.g. stage four of AHP or the improvement of weight allocations in ELECTRE) rather than addressing the decision making process itself. In addition, while many models recognise that for a waste management model to be sustainable, it must consider environmental, economic and social aspects, no model examined considered all three aspects together in the application of the model.

Facet joint injection: a rare form cause of epidural abscess formation

The posterior zygo-apophyseal joints (facet joints) may be a significant source of back pain. Invasive treatment typically consists of injecting the joints with local anaesthetic and steroid or by radiofrequency ablation of the nerve supply to the joint. Facet joint injection is generally considered to be a very safe procedure with few significant side effects reported. Epidural abscess is a rare but potentially very serious occurrence. Most cases occur spontaneously but the condition may complicate epidural anaesthesia, spinal anaesthesia or epidural steroid injection. We report a case in which facet joint injections resulted in epidural abscess formation. To our knowledge this has not previously been reported.