The surgical care practitioner seeking consent: An appropriate delegate?

Surgical care practitioners (SCPs) have become recognised as integral members of the surgical team in many healthcare establishments. Seeking informed consent either as the operating practitioner or on behalf of the surgeon, as their delegate, has becoming routine for many SCPs. Informed consent is a critical step in the patient's care pathway and fundamental in fostering shared decision making and safer surgical practice. The relatively recent case of Montgomery v Lanarkshire Health Board has highlighted a need for those practitioners seeking informed consent to critically examine their practice and revisit the founding principles of the process.

Pain severity predicts depressive symptoms over and above individual illnesses and multimorbidity in older adults

BACKGROUND

Multi-morbidity in older adults is commonly associated with depressed mood. Similarly, subjective reports of pain are also associated with both physical illness and increased depressive symptoms. However, whether pain independently contributes to the experience of depression in older people with multi-morbidity has not been studied.

METHODS

In this study, participants were 1281 consecutive older adults presenting to one of 19 primary care services in Australia (recruitment rate = 75%). Participants were asked to indicate the presence of a number of common chronic illnesses, to rate their current pain severity and to complete the Geriatric Depression Scale.

RESULTS

Results confirmed that the number of medical illnesses reported was strongly associated with depressive symptoms. Twenty-six percent of participants with multi-morbidity scored in the clinical range for depressive symptoms in comparison to 15% of participants with no illnesses or a single illness. In regression analyses, the presence of chronic pain (t = 5.969, p < 0.0005), diabetes (t = 4.309, p < 0.0005), respiratory (t = 3.720, p < 0.0005) or neurological illness (t = 2.701, p = 0.007) were all independent contributors to depressive symptoms. Even when controlling for each individual illness, and the overall number of illnesses (t = 2.207, p = 0.028), pain severity remained an independent predictor of depressed mood (F change = 28.866, p < 0.0005, t = 5.373, p < 0.0005).

CONCLUSIONS

Physicians should consider screening for mood problems amongst those with multi-morbidity, particularly those who experience pain.

Can censoring of research outputs be automated to ensure robust data protection?

ABSTRACT BackgroundGuidance regarding research outputs recommends censoring so that even when aggregating anonymised linked data no cell should have less than 5 -10 units. This is recommended to decrease the likelihood of re- identification. Leaving those cells empty is not adequate if other cells can be used to identify the numerical value of that cell. Some outputs necessitate a large number of tables to be exported this will become more common. This was the case where the outputs from a research study involved several large tables which drove a front end interactive visualisation. As linked data outputs are used to make operational decisions which necessitates timely data outputs of large amount of aggregated data this issue will be more common. Human scanning of all tables may not be time or cost effective and can be subject to human error. ApproachMany methods of censoring were considered including Barnardisation (adding or subtracting 1 randomly to small numbers) suppression and a combination of methods. It was then necessary to code the methods to ensure that censoring was implemented in all cells in the output and that the output was still meaningful. It was then necessary to check the outputs for quality and introduce an ‘audit’ system to ensure that the quality was maintained but did not impact on the outputs of the findings. DiscussionSoftware engineers were able to develop an algorithm that performed safe censoring using a level of ‘10 or under’. It also ensured that the statistical tables were still functional. The presentation will describe how this was done and demonstrate some examples of the impact on the output. Some stakeholders felt that the censoring of the anonymised aggregated data went beyond the ‘reasonable effort’ required to re- identify individuals. Some expressed the opinion that the lack of detail and missing data that this method results in is excessive and has been sacrificed for the sake of minimal risk. Some stakeholders felt the risks had been allowed to outweigh the societal benefits. The team were assured that although the censoring may be considered excessive by some it did ensure safe censoring and offered as low a risk a possible for re-identification. However routine implementation of this method has not been agreed.

Health-related quality of life 24 months after sustaining a minor musculoskeletal injury in a road traffic crash: A prospective cohort study

OBJECTIVES

A better understanding of the long-term factors that independently predict poorer quality of life following mild to moderate musculoskeletal injuries is needed. We aimed to establish the predictors of quality of life (including sociodemographic, health, psychosocial, and pre-injury factors) 24 months after a noncatastrophic road traffic injury.

METHODS

In a prospective cohort study of 252 participants with mild/moderate injury sustained in a road traffic crash, quality of life was measured 24 months following the baseline survey. A telephone-administered questionnaire obtained information on various potential explanatory variables. Health-related quality of life was measured using the European Quality of Life-5 Dimensions (EQ-5D) and Medical Outcomes Survey Short Form-12 (SF-12). Multivariable linear regression analyses determined the associations between explanatory variables and quality of life measures.

RESULTS

Mean SF-12 physical component summary (PCS) and mental component summary (MCS) scores increased by 7.3 and 2.5 units, respectively, from baseline to 24-month follow-up. Each 10-year increase in baseline age was independently associated with 3.1-unit (P < .001) and 1.5-unit (P = .001) decrease in EQ Visual Analogue Scale (VAS) and SF-12 PCS scores at follow-up, respectively. Poor/fair compared to excellent pre-injury health was associated with a 0.16-, 21.3-, and 11.5-unit decrease in EQ-5D summary (P = .03), VAS scores (P = .001), and SF-12 PCS scores (P < .001), respectively. Baseline pain severity ratings and pain catastrophizing scores were inversely associated with 24-month EQ VAS scores (both P < .001). Each unit increase in baseline pain score (P = .001) and pain catastrophizing score (P = .02) was associated with a 1.0- and 4.6-unit decrease in SF-12 MCS scores at 24 months, respectively. Other observed predictors of quality of life measures (EQ-5D summary and/or VAS scores and/ or SF-12 MCS) included marital status, smoking, hospital admission, pre-injury health (anxiety/depression and chronic illness), and whiplash injury.

CONCLUSION

Sociodemographic indicators, pre-injury health, and biopsychosocial correlates were independently associated with health-related quality of life 24 months following a noncatastrophic road traffic crash injury.

The psychological impact of traffic injuries sustained in a road crash by bicyclists: A prospective study

OBJECTIVE

The objective of this study was to investigate the psychological impact of traffic injuries in bicyclists (cyclists) in comparison to car occupants who also sustained traffic injuries. Factors predictive of elevated psychological distress were also investigated.

METHODS

An inception cohort prospective design was used. Participants included cyclists aged ≥17 years (mean age 41.7 years) who sustained a physical injury (n = 238) assessed within 28 days of the crash, following medical examination by a registered health care practitioner. Injury included musculoskeletal and soft tissue injuries and minor/moderate traumatic brain injury (TBI), excluding severe TBI, spinal cord injury, and severe multiple fractures. Assessment also occurred 6 months postinjury. Telephone-administered interviews assessed a suite of measures including sociodemographic, preinjury health and injury factors. Psychological impact was measured by pain catastrophization, trauma-related distress, and general psychological distress. The psychological health of the cyclists was compared to that of the car occupants (n = 234; mean age 43.1 years). A mixed model repeated measures analysis, adjusted for confounding factors, was used to determine differences between groups and regression analyses were used to determine contributors to psychological health in the cyclists 6 months postinjury.

RESULTS

Cyclists had significantly better psychological health (e.g., lower pain catastrophizing, lower rates of probable posttraumatic stress disorder [PTSD], and lower general distress levels) compared to car occupants at baseline and 6 months postinjury. Factors predictive of cyclists' psychological distress included younger age, greater perceived danger of death, poorer preinjury health, and greater amount of time in hospital after the injury.

CONCLUSIONS

These data provide insight into how cyclists perceive and adjust to their traffic injuries compared to drivers and passengers who sustain traffic injuries, as well as direction for preventing the development of severe psychological injury. Future research should examine the utility of predictors of psychological health to improve recovery.

Early Workplace Communication and Problem Solving to Prevent Back Disability: Results of a Randomized Controlled Trial Among High-Risk Workers and Their Supervisors

Purpose There is a clear need for interventions that successfully prevent the development of disability due to back pain. We hypothesized that an intervention aimed at both the worker and the workplace could be effective. Hence, we tested the effects of a new early intervention, based on the misdirected problem solving model, aimed at both workers at risk of long-term impairments and their workplace. Methods Supervisors of volunteers with back pain, no red flags, and a high score on a screen (Örebro Musculoskeletal Screening Questionnaire) were randomized to either an evidence based treatment as usual (TAU) or to a worker and workplace package (WWP). The WWP intervention included communication and problem solving skills for the patient and their immediate supervisor. The key outcome variables of work absence due to pain, health-care utilization, perceived health, and pain intensity were collected before, after and at a 6 month follow up. Results The WWP showed significantly larger improvements relative to the TAU for work absence due to pain, perceived health, and health-care utilization. Both groups improved on pain ratings but there was no significant difference between the groups. The WWP not only had significantly fewer participants utilizing health care and work absence due to pain, but the number of health care visits and days absent were also significantly lower than the TAU. Conclusions The WWP with problem solving and communication skills resulted in fewer days off work, fewer health care visits and better perceived health. This supports the misdirected problem solving model and indicates that screening combined with an active intervention to enhance skills is quite successful and likely cost-effective. Future research should replicate and extend these findings with health-economic analyses.

Predictors of time to claim closure following a non-catastrophic injury sustained in a motor vehicle crash: a prospective cohort study

Background

Research suggests that exposure to the compensation system (including time to case closure) could adversely influence a persons’ recovery following injury. However, the long-term predictors of time to claim closure following minor road traffic injuries remain unclear. We aimed to assess a wide spectrum of factors that could influence time to claim closure (socio-demographic, compensation-related, health, psychosocial and pre-injury factors) over 24 months following a non-catastrophic injury.

Methods

Prospective cohort study of 364 participants involved in a compensation scheme following a motor vehicle crash. We used a telephone-administered questionnaire to obtain information on potential explanatory variables. Information on time to claim closure was obtained from an insurance regulatory authority maintained database, and was classified as the duration between the crash date and claim settlement date, and categorized into < 12 (early), > 12–24 (medium) and > 24 months (late).

Results

Just over half of claimants (54 %) had settled their claim by 12 months, while 17 % and 30 % took > 12–24 months and > 24 months for claim closure, respectively. Whiplash at baseline was associated with claim closure time of > 12–24 months versus < 12 months: multivariable-adjusted OR 2.38 (95 % CI 1.06–5.39). Claimants who were overweight/obese versus normal/underweight at the time of injury were ~3.0-fold more likely to settle their claim at > 12–24 months than < 12 months. Consulting a lawyer was associated with a 10.4- and 21.0-fold increased likelihood of settling a claim at > 12–24 months and > 24 months, respectively. Each 1-unit increase in Orebro Musculoskeletal Pain Screening Questionnaire scores at baseline was associated with greater odds of both medium (> 12–24 months) and delayed claim settlement date (> 24 months): multivariable-adjusted OR 1.04 (95 % CU 1.01–1.07) and 1.02 (95 % CI 1.00–1.05), respectively.

Conclusions

Around a third of claimants with a minor injury had not settled by 24 months. Health-related factors and lawyer involvement independently influenced time to claim closure.

Restriction in functioning and quality of life is common in people 2 months after compensable motor vehicle crashes: prospective cohort study

BACKGROUND

We sought to identify the role of pre-injury socio-demographic and health characteristics, and injury severity in determining health-related quality-of-life outcomes for mild to moderate injuries 2 months after a motor vehicle crash in a compensable setting.

METHODS

People aged 17 years and older, injured with a New Injury Severity Score of 8 or less, in a motor vehicle crash in New South Wales and who had registered a claim with the Compulsory Third Party Insurance scheme from March to December 2010 were contacted to participate in the study. Information for 364 eligible participants was primarily collected through telephone interview, approximately 2 months after injury.

RESULTS

Substantial proportions of participants continued to have adverse outcomes approximately 2 months after their injury with mean Short Form Health Survey (SF-12) physical component score of 36.7 (SD ±10.3), SF-12 mental component score of 46.6 (SD ±11), Euro Qol (EQ) analogue scale score of 65.8 (SD ±18) and Euro Qol five dimension (EQ-5D) summary score of 0.70 (SD ±10). Key factors predicting adverse outcomes were prior chronic illness, obesity, hospitalisation and self-perceived threat to life due to injury.

CONCLUSIONS

This study highlights the substantial impact of apparently "minor" motor vehicle crash injuries in a compensable setting and suggests targets for studies of tertiary prevention to improve health-related quality-of-life outcomes.

Comparison of health outcomes between hospitalised and non-hospitalised persons with minor injuries sustained in a road traffic crash in Australia: a prospective cohort study

OBJECTIVES

This prospective cohort study aimed to investigate whether there are differences in health outcomes among persons with mild or moderate injuries who were hospitalised compared with those not hospitalised following a road traffic crash.

SETTING

Sydney Metropolitan, New South Wales, Australia.

PARTICIPANTS

Persons aged ≥18 years involved in a motor vehicle crash were surveyed at baseline (n=364), and at 12 (n=284) and 24 months (n=252). A telephone-administered questionnaire obtained information on a range of socioeconomic, and preinjury and postinjury psychological and heath characteristics of all participants.

PRIMARY OUTCOME MEASURE

Participants who reported admission to hospital for 24 h or more (but less than 7 days) after the crash were classified as being hospitalised; those admitted for less than 24 h were classified as non-hospitalised.

RESULTS

Around 1 in 5 participants (19.0%) were hospitalised for ≥24 h after the crash. After adjusting for age and sex, hospitalised participants compared with those not hospitalised had approximately 2.6 units (p=0.01) lower Short Form-12 Physical Component Summary (SF-12 PCS) scores (poorer physical well-being) and approximately 4.9 units lower European Quality of Life visual analogue scale (EQ-VAS) scores (p=0.05), 12 months later. After further adjusting for education level, whiplash, fracture and injury severity score, participants who were hospitalised had approximately 3.3 units lower SF-12 PCS (p=0.04), 12 months later. The association with EQ-VAS did not persist after multivariable adjustment. No significant differences were observed between the 2 groups in health outcomes at 24-month follow-up.

CONCLUSIONS

These findings indicate that long-term health status is unlikely to be influenced by hospitalisation status after sustaining a mild/moderate injury in a vehicle-related crash.

A highly directional transducer for multipath mitigation in high-frequency underwater acoustic communications

This paper presents a transducer design of the hollow cylinder type designed to minimize transmission multipath and the need for channel equalization over short acoustic communication distances in shallow water. Operating at 750 kHz, the half-maximum envelope of the main lobe is approximately 3°. The transducer was incorporated into a low-complexity modem system in which it acted as both transmitter and receiver. At-sea testing indicated that the system is capable of operating over horizontal distances of 5 m without evidence of multipath distortion. The system was also found to be effective as an omnidirectional transmitter/receiver in the 10-60 kHz band.

A comparison of health outcomes in older versus younger adults following a road traffic crash injury: a cohort study

Background

Given the aging demographics of most developed countries, understanding the public health impact of mild/moderate road traffic crash injuries in older adults is important. We aimed to determine whether health outcomes (pain severity and quality of life measures) over 24 months differ significantly between older (65+) and younger adults (18–64).

Methods

Prospective cohort study of 364, 284 and 252 participants with mild/moderate injury following a vehicle collision at baseline, 12 and 24 months, respectively. A telephone-administered questionnaire obtained information on socio-economic, pre- and post-injury psychological and heath characteristics.

Results

At baseline, there were 55 (15.1%) and 309 (84.9%) participants aged ≥65 and 18–64 years, respectively. At 12- and 24-month follow-up, older compared to younger participants who had sustained a mild/moderate musculoskeletal injury had lower physical functioning (3.9-units lower Short Form-12 Physical Composite Score, multivariable-adjusted p = 0.03 at both examinations). After multivariable adjustment, older (n = 45) versus younger (n = 207) participants had lower self-perceived health status (8.1-units lower European Quality of Life-5 Dimensions Visual Acuity Scale scores at 24 months, p = 0.03), 24 months later.

Conclusions

Older compared to younger participants who sustained a mild/moderate injury following a road-traffic crash demonstrated poorer physical functioning and general health at 24 months.

Presence and predictors of persistent pain among persons who sustained an injury in a road traffic crash

BACKGROUND

There is a paucity of prospective studies with long follow-up that have examined a wide range of correlates associated with persistent pain outcomes in persons who sustained a mild or moderate injury in a road traffic crash. This study aimed to establish the independent predictors of pain severity over 24 months.

METHODS

A total of 364, 284 and 252 persons with mild/moderate musculoskeletal injuries sustained in a vehicle-related crash participated in telephone interviews in the subacute phase, and at 12 and 24 months, respectively. The numeric rating scale (NRS) assessed pain severity. Pain-Related Self-Statements Scale-Catastrophizing (PRSS-Catastrophizing) and the Short Form Orebro Musculoskeletal Pain Screening Questionnaire (OMPSQ) were also administered.

RESULTS

After multivariable adjustment, each 1 SD increase in Short Form-12 Physical Component Score (SF-12 PCS) in the subacute phase was associated with 0.73 (p = 0.002) and 1.11 (p < 0.0001) decrease in NRS scores after 12 and 24 months, respectively. Each unit increase in the PRSS-Catastrophizing score in the subacute phase was associated with 0.54 (p = 0.001) and 0.43 (p = 0.03) increase in NRS scores 12 and 24 months later, respectively. Subacute phase OMPSQ scores were positively associated with NRS scores at 12- and 24-month follow-ups (p < 0.0001).

CONCLUSIONS

Self-perceived physical well-being, pain-related work disability and pain catastrophizing could play a role in determining long-term pain-related outcomes following traffic-related injuries.

Factors influencing social and health outcomes after motor vehicle crash injury: an inception cohort study protocol

Background

There is growing evidence that health and social outcomes following motor vehicle crash injury are related to cognitive and emotional responses of the injured individual, as well as relationships between the injured individual and the compensation systems with which they interact. As most of this evidence comes from other states in Australia or overseas, investigation is therefore warranted to identify the key determinants of health and social outcomes following injury in the context of the New South Wales motor accident insurance scheme.

Methods/Design

In this inception cohort study, 2400 participants, aged 17 years or more, injured in a motor vehicle crash in New South Wales will be identified though hospital emergency departments, general and physiotherapy practitioners, police records and a government insurance regulator database. Participants will be initially contacted through mail. Baseline interviews will be conducted by telephone within 28 days of the injury and participants will be followed up with interviews at 6, 12 and 24 months post-injury. Health insurance and pharmaceutical prescription data will also be collected.

Discussion

The study results will report short and long term health and social outcomes in the study sample. Identification of factors associated with health and social outcomes following injury, including related compensation factors will provide evidence for improved service delivery, post-injury management, and inform policy development and reforms.

Trial registration

Australia New Zealand Clinical trial registry identification number - ACTRN12613000889752. Available at: ANZCTR Registered FISH Study.

Experimental verification of enhanced sound transmission from water to air at low frequencies

Laboratory measurements of enhanced sound transmission from water to air at low frequencies are presented. The pressure at a monitoring hydrophone is found to decrease for shallow source depths in agreement with the classical theory of a monopole source in proximity to a pressure release interface. On the other hand, for source depths below 1/10 of an acoustic wavelength in water, the radiation pattern in the air measured by two microphones becomes progressively omnidirectional in contrast to the classical geometrical acoustics picture in which sound is contained within a cone of 13.4° half angle. The measured directivities agree with wavenumber integration results for a point source over a range of frequencies and source depths. The wider radiation pattern owes itself to the conversion of evanescent waves in the water into propagating waves in the air that fill the angular space outside the cone. A ratio of pressure measurements made using an on-axis microphone and a near-axis hydrophone are also reported and compared with theory. Collectively, these pressure measurements are consistent with the theory of anomalous transparency of the water-air interface in which a large fraction of acoustic power emitted by a shallow source is radiated into the air.