Community pharmacists' perceptions of a hospital based virtual clinical pharmacy service: Findings from qualitative research

Background

A Virtual Clinical Pharmacy Service (VCPS) was introduced in selected rural and remote NSW hospitals in 2020 to address a gap in onsite clinical pharmacy services. Follow-up research determined hospital staff and patients at these locations perceived the service as a safe, effective and efficient system for delivering clinical pharmacy services. Community pharmacists are key stakeholders in medication safety and continuity of management in these regions, however, their insight on the VCPS had not yet been sought.

Objective

To understand perspectives of community pharmacists on the implementation of VCPS in rural and remote hospitals and impacts on medication management at transitions of care.

Methods

Semi-structured interviews were conducted via videoconference with seven community pharmacists with at least three months exposure to VCPS following service implementation. Thematic analysis of transcribed interviews was conducted influenced by Appreciative Inquiry.

Results

Participants identified that the VCPS had supported and enhanced their community pharmacy practice and acknowledged its future potential. Identified themes were interaction with VCPS, acceptability of VCPS, community pharmacy workflow, and involvement in patient care. Suggested improvements included involving community pharmacists early in the implementation of the service and establishing clear expectations and procedures.

Conclusions

The experiences of community pharmacists with VCPS were positive and there was a consensus that the introduction of the service had assisted interviewees in providing medication management to patients at transition of care. The ease of communication and efficiency of the service were recognised as key factors in the success of VCPS for community pharmacists.

Barriers and facilitators to adherence to Optimal Care Pathways for diagnosis and treatment of cancer for Aboriginal and Torres Strait Islander people

BACKGROUND

The Optimal Care Pathways (OCP) are a framework to promote high-quality and integrated cancer care for all Australians, from prevention through to end-of-life-care. Aboriginal and Torres Strait Islander people experience disproportionate cancer incidence and mortality, but little research has addressed whether cancer care for Aboriginal people meets the standards prescribed by the OCPs. This study aims to consider barriers and facilitators to quality cancer care for Aboriginal people.

METHODS

Semi-structured interviews were conducted with 30 health professionals who deliver care to Aboriginal people with cancer in primary care and hospital settings in New South Wales, Australia. Health professionals included Aboriginal Health Workers, nurses, general practitioners, and community workers. Interviews were conducted in 2019-2020 and explored participant perspectives of barriers and facilitators of optimal cancer care, particularly related to prevention, early detection, diagnosis, and treatment for Aboriginal people. Data were qualitatively analysed using framework analysis.

RESULTS

In general, participants perceived Aboriginal patients to have good access to preventive care. In terms of early detection and diagnosis, access to primary care, pathology, radiology, and some specialists (e.g. respiratory physicians) was seen as optimal. However, access to hospital-based gastroenterologists for colonoscopy was perceived to be poor due to long wait times. Access to optimal care for cancer treatment was perceived to be hindered due to the lack of bulk-billing for bowel cancer, breast cancer, and cardiothoracic surgery. Other barriers to care identified by participants included unclear referral pathways, poor communication between patient and the treating team, and a lack of timely provision of discharge summaries.

CONCLUSIONS

Facilitators of optimal care during treatment and survivorship included: the Integrated Team Care and Close the Gap programs, and presence of key health workers to help patients navigate the health system. The major barriers to quality cancer care for Aboriginal people appeared to be to specialist and procedural access, demonstrating that the 'Inverse Care' law applied in reducing access for populations at higher risk of cancer.

A retrospective observational study of vCare: a virtual emergency clinical advisory and transfer service in rural and remote Australia

BACKGROUND

Provision of critical care in rural areas is challenging due to geographic distance, smaller facilities, generalist skill mix and population characteristics. Internationally, the amalgamation telemedicine and retrieval medicine services are developing to overcome these challenges. Virtual emergency clinical advisory and transfer service (vCare) is one of these novel services based in New South Wales, Australia. We aim to describe patient encounters with vCare from call initiation at the referring site to definitive care at the accepting site.

METHODS

This retrospective observational study reviewed all patients using vCare in rural and remote Australia for clinical advice and/or inter-hospital transfer for higher level of care between February and March 2021. Data were extracted from electronic medical records and included remoteness of sites, presenting complaint, triage category, camera use, patient characteristics, transfer information, escalation of therapeutic intervention and outcomes. Data were summarised using cross tabulation.

RESULTS

1,678 critical care patients were supported by vCare, with children (12.5%), adults (50.6%) and older people (36.9%) evenly split between sexes. Clinicians mainly referred to vCare for trauma (15.1%), cardiac (16.1%) and gastroenterological (14.8%) presentations. A referral to vCare led to an escalation of invasive intervention, skill, and resources for patient care. vCare cameras were used in 19.8% of cases. Overall, 70.5% (n = 1,139) of patients required transfer. Of those, 95.1% were transferred to major regional hospitals and 11.7% required secondary transfer to higher acuity hospitals. Of high-urgency referrals, 42.6% did not receive high priority transport. Imaging most requested included CT and MRI scans (37.2%). Admissions were for physician (33.1%) and surgical care (23.3%). The survival rate was 98.6%.

CONCLUSION

vCare was used by staff in rural and remote facilities to support decision making and care of patients in a critical condition. Issues were identified including low utilisation of equipment, heavy reliance on regional sites and high rates of secondary transfer. However, these models are addressing a key gap in the health workforce and supporting rural and remote communities to receive care.

Experiential learning spaces and student wellbeing: a mixed-methods study of students at three research intensive UK universities

There is clear evidence that university students are experiencing significant mental health difficulties, further exacerbated by the temporary closure of university campuses during the height of the COVID-19 pandemic. Against this backdrop, our study - Student Wellbeing and Experiential Learning Spaces (SWELS) - explored the role of experiential learning spaces in supporting student wellbeing. We adopted a mixed-methods approach, consisting of an online survey and interviews with students from three research intensive UK Universities. The survey results revealed that compared to the national average of 16-25-year-olds from the UK Office for National Statistics' (ONS) wellbeing questionnaire, the sampled students exhibited significantly lower levels of life satisfaction, happiness, perceived worthwhileness and higher levels of anxiety. The qualitative results further confirmed that students perceived their wellbeing to be affected by their university experience and the COVID pandemic. However, the results also suggest that experiential learning spaces (such as museums, collections, libraries, and gardens) hold strong potential to support student mental health. Accordingly, the study indicates that diversifying module content and conscientiously considering both physical and digital learning spaces can positively impact students. In short, curricula that are cognisant of the physical learning environment and embed a focus on wellbeing into their content might help to bolster student wellbeing.

A Cross-Sequential Study of the Effect of the Coronavirus Disease 2019 Pandemic on the Risk of Anxiety and Depression of Royal Flying Doctors Staff, an Australian Air Medical Organization

OBJECTIVE

This cross-sequential study examines whether the coronavirus disease 2019 pandemic affected the mental health of staff working at an Australian air medical service, the Royal Flying Doctors Service South Eastern (RFDSSE) Section.

METHODS

The risk of anxiety and depression was measured using a prospective anonymized online survey using the Hospital Anxiety and Depression Scale, which was answered by 119 employees. This cross-sequential study was completed in December 2021 with reference to 2 time points: now and the beginning of the pandemic. A high risk of anxiety was defined using a Hospital Anxiety and Depression Scale score of 11 to 21 (low risk: 0-10). Chi-square testing was used to compare subgroups at single time points. McNemar testing was used to compare the risk of anxiety and depression between the beginning of the pandemic and December 2021.

RESULTS

Employees recalled a higher risk of anxiety at the beginning of the pandemic (29%) compared with December 2021 (16%) (P = .012). At the beginning of the pandemic, nonoperational staff members were more anxious than operational staff (P = .019). One third (31%) of operational staff members were concerned about dying at the beginning of the pandemic.

CONCLUSION

Our findings demonstrate that RFDSSE employees recalled higher levels of anxiety at the beginning of the pandemic compared with their risk in December 2021. Operational and nonoperational staff have different mental health needs; anxiety experienced by nonoperational staff during a pandemic should not be underestimated. The overall prevalence of anxiety and depression is high, suggesting health care staff in an air medical service may require extra psychological support. Other air medical organizations may reflect on our study findings and plan how to better support their own staff as a result.

Understanding and Improving Older People's Well-Being through Social Prescribing Involving the Cultural Sector: Interviews from a Realist Evaluation

Social prescribing is a non-clinical approach to addressing social, environmental, and economic factors affecting how people feel physical and/or emotionally. It involves connecting people to "community assets" (e.g., local groups, organizations, and charities) that can contribute to positive well-being. We sought to explain in what ways, for whom, and why the cultural sector can support social prescribing with older people. We conducted semi-structured interviews with 28 older people (aged 60+) and 25 cultural sector staff. The following nine concepts, developed from interview data, progressed the understanding of tailoring cultural offers, which came from our previous realist review-immersion, buddying, café culture, capacity, emotional involvement, perseverance, autonomy, elitism, and virtual cultural offers. Through tailoring, we propose that older people might experience one or more of the following benefits from engaging with a cultural offer as part of social prescribing-being immersed, psychological holding, connecting, and transforming through self-growth.

'The best thing since sliced bread': Patient experiences of teleoncology in western NSW

OBJECTIVE

This study explored experiences of rural cancer patients who were receiving treatments by remote video-assisted chemotherapy (RVAC) or participating in clinical trials remotely.

SETTING

Participants lived in Coonabarabran or Dubbo in western NSW.

PARTICIPANTS

Seven cancer patients undergoing treatment for breast, bladder or colon cancer, renal cell carcinoma or lymphoma.

DESIGN

Appreciative inquiry informed this qualitative study. Semi-structured interviews were conducted between July 2018 and January 2019 and thematically analysed.

RESULTS

The patient experience of teleoncology was overwhelmingly positive. Patients explained the value of relationships that developed with the local and virtual care team. Patients felt they received better care if they saw the same oncologist for the duration of their treatment and felt RVAC had accommodated this. Teleoncology allowed patients to remain independent because they were able to maintain their usual support mechanisms including family, friends and health care team. Patients described the reduced physical and emotional travel burden in addition to reduction in travel time and cost.

CONCLUSIONS

These findings highlight the acceptability of teleoncology for rural patients as chemotherapy can be added to the health care and social and emotional supports, which exist in their hometown. Expansion of teleoncology should be codesigned with local communities with a focus on establishing care teams with consistent staffing to build trust between the treating team and the patient. These relationships improve the patient experience and enhance patient independence, which is a desirable attribute of cancer survivorship. Recruitment to clinical trials using teleoncology is acceptable and should be factored into trial development.

Critical realist exploration of long-term outcomes, impacts and skill development from an Australian Rural Research Capacity Building Programme: a qualitative study

OBJECTIVES

Research capacity building programmes usually only examine short-term outcomes, following up participants after 1 or 2 years. Capacity building in health research requires a long-term view to understand the influence and impact of capacity building endeavours. This study examined long-term outcomes for individuals regarding the maintenance and use of research skills and the conduct of real-world research in a rural area. We also explored the changes individuals had seen in their career, work team or organisation as a result of this training.

DESIGN

A qualitative study underpinned by critical realism and based on interviews and focus groups with graduates of the Rural Research Capacity Building Programme (RRCBP), a researcher development programme that has been delivered since 2006.

SETTING

Rural and remote areas of New South Wales, Australia.

PARTICIPANTS

22 graduates of the RRCBP from the 2006 to 2015 cohorts (20 female, 2 male). All were experienced rural-based health workers at the time of training.

RESULTS

Focus groups and interviews yielded three themes about capacity building outcomes: (1) developed research capable individuals; (2) embedded research capability into teams and (3) real-world research that makes a difference within an organisation.

CONCLUSIONS

Research training improved graduates' skill, experience, confidence and employability. Research capable individuals enabled others, enhancing team research capacity and raising the profile of research within their organisation.Training in research, alongside tangible organisational support for research activity, creates real-world impacts for policy and clinical practice. Providing ongoing opportunities for researchers to undertake research would enhance return on investment and assist with retention of experienced staff.

Social prescribing for older people and the role of the cultural sector during the COVID-19 pandemic: What are link workers' views and experiences?

Older people's well-being can be bolstered by engaging with cultural activities and venues. They may be encouraged to try cultural offers by a link worker as part of social prescribing. However, the cultural sector, like all parts of life, was affected by the COVID-19 pandemic; this has had implications for cultural offers available to link workers. A study was conducted to explore the views and experiences of link workers in using the cultural sector within social prescribing, particularly for older people (aged 60+) during the pandemic. An online questionnaire was distributed to and completed by link workers in the UK. Data were analysed mainly using descriptive statistics. Open text responses were clustered into similar ideas to create key concepts. Useable responses were received from 148 link workers. They highlighted a general lack of interaction between link workers and the cultural sector about how the latter could support social prescribing. Results suggested that personal familiarity with cultural offers might prompt link workers to refer to them. Some respondents proposed that cultural offers were regarded as elitist, which deterred them from referring there. However, there was a general acknowledgement that the cultural sector could contribute to social prescribing. Link workers need to regard the cultural sector as accessible, appropriate, adequate, affordable and available before referring older people to cultural offers as part of social prescribing. Link workers may benefit from becoming more familiar with cultural sector staff and offers, including online resources, so they can then propose them to patients with confidence.

Tailoring cultural offers to meet the needs of older people during uncertain times: a rapid realist review

BACKGROUND

Non-medical issues (e.g. loneliness, financial concerns, housing problems) can shape how people feel physically and psychologically. This has been emphasised during the Covid-19 pandemic, especially for older people. Social prescribing is proposed as a means of addressing non-medical issues, which can include drawing on support offered by the cultural sector.

METHOD

A rapid realist review was conducted to explore how the cultural sector (in particular public/curated gardens, libraries and museums), as part of social prescribing, can support the holistic well-being of older people under conditions imposed by the pandemic. An initial programme theory was developed from our existing knowledge and discussions with cultural sector staff. It informed searches on databases and within the grey literature for relevant documents, which were screened against the review's inclusion criteria. Data were extracted from these documents to develop context-mechanism-outcome configurations (CMOCs). We used the CMOCs to refine our initial programme theory.

RESULTS

Data were extracted from 42 documents. CMOCs developed from these documents highlighted the importance of tailoring-shaping support available through the cultural sector to the needs and expectations of older people-through messaging, matching, monitoring and partnerships. Tailoring can help to secure benefits that older people may derive from engaging with a cultural offer-being distracted (absorbed in an activity) or psychologically held, making connections or transforming through self-growth. We explored the idea of tailoring in more detail by considering it in relation to Social Exchange Theory.

CONCLUSIONS

Tailoring cultural offers to the variety of conditions and circumstances encountered in later life, and to changes in social circumstances (e.g. a global pandemic), is central to social prescribing for older people involving the cultural sector. Adaptations should be directed towards achieving key benefits for older people who have reported feeling lonely, anxious and unwell during the pandemic and recovery from it.

Building cultural responsiveness in a mainstream health organisation with '8 Aboriginal Ways of Learning': a participatory action research study

OBJECTIVE

Despite much effort and goodwill, the gap in health status between Aboriginal and non-Aboriginal Australians persists. Bringing Aboriginal cultural protocols and teaching strategies into healthcare could improve the fit between healthcare services provided and Aboriginal peoples. This approach to making healthcare more accessible has not been tested in mainstream health settings. This study aimed to introduce '8 Aboriginal Ways of Learning' to a mainstream health organisation and observe how learning about Aboriginal perspectives and processes shaped work-related project or program design.

METHODS

Program and network coordinators (n=18) employed in a state-wide health organisation joined in-person workshops and virtual sessions. Participatory Action Research methods guided the process and framework analysis transformed data.

RESULTS

Introducing '8 Ways' generated conversations which went beyond deficits in Aboriginal health. Learning about cultural processes provided scaffolding to show how services and models of care can change.

CONCLUSIONS

This strategy demonstrated potential to improve approachability, acceptability and appropriateness of mainstream healthcare for Aboriginal peoples.

IMPLICATIONS FOR PUBLIC HEALTH

Introduction of Aboriginal pedagogies were welcomed by mainstream healthcare workers as they provided scaffolding and support to plan and work in new ways. Future studies could examine outcomes on program design and access to services for Aboriginal peoples.

Equipping medical students for ward round learning

Background

While ward rounds offer a rich opportunity for learning, the environment is chaotic, and medical students can struggle to maximise this potential. Few studies have focused on the best way to equip students for ward round learning. One proposed tool developed to orient students' learning on the ward round is called the Seek, Target, Inspect and reflect, Closure and clerk (STIC) model. This study examines the effect of using this model on the student experience of ward round learning.

Methods

Seven medical students with clinical attachments on medical wards in two rural hospitals in New South Wales, Australia, participated in three sequential focus groups over an 8‐week period. Students were asked about learning practices on ward rounds, what factors influenced their learning and how using the STIC model impacted on their experience. Thematic analysis was applied to focus group transcripts.

Findings

Students valued learning opportunities from ward rounds but felt the learning potential was largely dependent on the team to which they were attached. Students reported the STIC model promoted greater agency and enabled them to be more self‐directed and able to negotiate the chaotic context. Students also valued the focus group discussions about their learning as an avenue to share and better understand their experiences of learning on ward rounds.

Conclusion

Student experience of ward rounds can be influenced via (1) structured learning tools (STIC model) to better orient students and (2) facilitated discussions with peers to assist in developing skills of negotiating and directing one's own learning. Both should be more explicitly integrated in medical curricula.

"This is streets ahead of what we used to do": staff perceptions of virtual clinical pharmacy services in rural and remote Australian hospitals

BACKGROUND

The use of medications is the most common intervention in healthcare. However, unsafe medication practices and medication errors are a leading cause of injury and avoidable harm in healthcare systems across the world. A Virtual Clinical Pharmacy Service (VCPS) was introduced in rural and remote New South Wales public hospitals to support safe and effective use of medications. In this model clinical pharmacy services are delivered via a telehealth cart at the patient's bedside and through electronic medical and pharmaceutical record systems. The aim of this research was to understand healthcare staff perspectives of the VCPS and identify areas for improvement.

METHODS

A qualitative approach informed by Appreciative Inquiry was used to investigate healthcare staff perceptions of the VCPS. Focus group discussions (n = 15) with hospital staff and medical officers were conducted via videoconference at each study site. Focus groups explored issues, benefits and barriers 3 months after service implementation. Transcribed data were analysed using thematic analysis and team discussion to synthesise themes.

RESULTS

Focus group participants identified the value of the VCPS to patients, to the health service and to themselves. They also identified enhancements to increase value for each of these groups. Perceived benefits to patients included access to specialist medication advice and improved medication knowledge. Staff valued access to an additional, trusted workforce who provided back-up and guidance. Staff also reported confidence in improved patient safety and identification of medication errors. Enhanced compliance with antimicrobial stewardship and hospital accreditation standards were beneficial to the health service. Suggested improvements included extending virtual service hours and widening patient eligibility to include aged care patients.

CONCLUSIONS

The VCPS brought a positive, collegiate culture regarding medications. Healthcare staff perceived the VCPS was effective and an efficient way for the health service to supply pharmacy services to smaller hospitals. The ease of use, model of delivery, availability, local knowledge and responsiveness of highly skilled pharmacists was the key to user satisfaction.

TRIAL REGISTRATION

ANZCTR ACTRN12619001757101 , 11/12/2019.

What can primary care services do to help First Nations people with unhealthy alcohol use? A systematic review: Australia, New Zealand, USA and Canada

Background

First Nations peoples of Australia, New Zealand, the United States of America (USA) and Canada are more likely to be non-drinkers than other people in these countries. However, those who do drink may be at greater risk of alcohol-related harms (at a population level) due to the ongoing impacts from colonisation and associated oppression. Addressing unhealthy drinking (drinking above recommended limits including alcohol use disorders) in primary care settings is one important way to increase accessibility of treatment.

Methods

This systematic review identifies peer-reviewed studies of alcohol treatments delivered in primary care or other non-residential settings for First Nations peoples of Australia, New Zealand, USA and Canada. Literature searches were conducted in seven academic databases from their inception until March, 2020. We assessed evidence of treatment or implementation effectiveness, perceived acceptability or accessibility, and the study quality as assessed by the AXIS tool and by a measure of community participation in the research process.

Results

Twenty-eight studies were included, published between 1968 and 2018. Studies reported on a range of alcohol treatments, from brief intervention to ambulatory withdrawal management, relapse prevention medicines, and cultural therapies. Brief intervention was the most studied approach. Cultural healing practices and bicultural approaches were a key theme amongst several studies. Four studies measured treatment effectiveness, including one randomised controlled trial (naltrexone vs naltrexone plus sertraline vs placebo) and two uncontrolled trials of disulfiram. Of the six implementation studies, three were (hybrid) effectiveness-implementation designs. Most of the remaining studies (n = 21) focused on treatment accessibility or acceptability. Community participation in the research process was poorly reported in most studies.

Conclusions

Research evidence on how best to care for First Nations peoples with unhealthy alcohol use is limited. Trials of naltrexone and disulfiram presented promising results. Cultural and bicultural care were perceived as highly important to clinical staff and clients in several studies. More effectiveness studies on the full scope of alcohol treatments are needed. Greater community participation in research and more transparent reporting of this in study methods will be key to producing quality research that combines scientific rigour with cultural appropriateness.

Workplace-based health research training: a qualitative study of perceived needs in a rural setting

Background

The calls for increased numbers of researchers in rural health are growing. To meet this demand, training is needed. If training is to be effective, the value placed on research, the organisational need for research training and key targets for research skill development within a rural health organisation must be understood.

Methods

This qualitative study was underpinned by a critical realist perspective that allowed exploration of the organisational, cultural and structural contexts of research training and of the ability of individuals to act within these contexts. Individual interviews with purposively selected key informants from the organisation’s board, executive and facility management (n = 7) and two focus groups with a convenience sample of frontline health workers with interests in research (total n = 11) were held. Data were analysed using NVivo software and thematic analysis.

Results

The themes emerging from this study were the fragmentation of research activity, a need for systems that support research and collaboration for expertise.

Conclusions

This study has identified an overreliance on individual activity leading to a fragmented approach to research. There is a need for supportive structures, coordination and workplace leadership to overcome a longstanding culture that views research as out of the rural scope of practice. Identifying research training targets, partnering for educational expertise and planning for long-term sustainability are necessary steps toward increasing research activity in the longer term.

Building research experience: Impact of a novice researcher development program for rural health workers

OBJECTIVE

The objective of this study was to determine the effect of the Rural Research Capacity Building Program on self-reported research experience of rural health workers.

DESIGN

A repeat cross-sectional study design was used to assess self-reported research experience at the commencement and completion of a novice researcher development program.

SETTING

Candidates in the Rural Research Capacity Building Program are health workers employed in the rural NSW public health service who have not completed research higher degrees.

PARTICIPANTS

One hundred and thirty candidates of the Rural Research Capacity Building Program from the 2006 to 2013 cohorts were participated.

INTERVENTIONS

The Rural Research Capacity Building Program is an experiential learning program in which candidates gain research experience by undertaking a new, self-selected, local health service endorsed research project over a 2-year period, supported by 10 days face-to-face teaching, weekly teleconferencing and mentoring.

MAIN OUTCOME MEASURES

Change in self-assessed research experience using a validated 10-item measurement tool known as the Research Spider which measures 10 domains of research experience.

RESULTS

Reported research experience demonstrated statistically significant increases across all 10 domains of research experience. The largest change was 'writing and presenting a research report' and 'writing a research protocol'.

CONCLUSIONS

Significant increases in Research Spider results across all 10 domains demonstrated that completing the Rural Research Capacity Building Program significantly improves self-assessed research experience. Rural health workers who are experienced and confident to undertake research are more capable of studying health problems and finding solutions unique to the rural setting.

Lacosamide and sodium channel-blocking antiepileptic drug cross-titration against levetiracetam background therapy

OBJECTIVE

To assess prospectively the effectiveness of lacosamide (LCM) added to levetiracetam (LEV) after down-titration of a concomitant sodium channel blocker (SCB) among patients with focal epilepsy not adequately controlled on LEV and SCB.

METHODS

In this open-label trial, LCM was initiated at 100 mg/day and up-titrated to 200-600 mg/day over 9 weeks; SCB down-titration started when LCM dose reached 200 mg/day. Patients remained on stable LCM/LEV doses for 12 weeks' maintenance (21-week treatment period). The primary outcome was retention rate on LCM.

RESULTS

Due to recruitment challenges, fewer than the planned 300 patients participated in the trial, resulting in the trial being underpowered. Overall, 120 patients (mean age 39.7 years) started and 93 completed the trial. The most frequently used SCBs were lamotrigine (39.2%), carbamazepine (30.8%) and oxcarbazepine (27.5%). Eighty-four patients adhered to protocol and discontinued their SCB after cross-titration, but there was insufficient evidence for 36 patients. Retention rate was 73.3% (88/120) for all patients and 83.3% (70/84) for those with evidence of SCB discontinuation. Seizure freedom for patients completing maintenance was 14.0% (13/93). Discontinuation due to adverse events (6.7%) and lack of efficacy (3.3%) occurred primarily during cross-titration. Most frequently reported adverse events during treatment were dizziness (23.3%), headache (15.0%) and fatigue (8.3%).

CONCLUSIONS

In patients with uncontrolled seizures on LEV/SCB, the LCM/LEV combination appeared to be effective and well tolerated. A cross-titration schedule-flexible LCM up-titration, concomitant SCB down-titration and stable background LEV-could present a feasible and practical approach to initiating LCM while minimizing pharmacodynamic interactions with a SCB.

Theory that explains an Aboriginal perspective of learning to understand and manage diabetes

OBJECTIVE

To use grounded theory and participatory research methodology to explain how Aboriginal people learn to understand and manage type 2 diabetes.

METHODS

Aboriginal people with diabetes were invited to participate in one of five focus groups (n=25, male=12, female=13). Focus groups and education sessions were conducted by Aboriginal members of the research team. Focus groups were audio recorded and transcribed, with coding and first level analysis undertaken by all members of the research team.

RESULTS

Participants described colonisation and dislocation from Country and family members' experiences with diabetes as significant historical influences which, in conjunction with the model of care experienced and the type of interaction with health services, shaped how they came to understand and manage their diabetes.

CONCLUSIONS

Patient experience of a model of care alone is not what influences understanding and management of diabetes in Aboriginal people. Implications for Public Health: Health service improvements should focus on understanding past experiences of Aboriginal patients, improving interactions with health services and supporting holistic family centred models of care. Focusing on just the model of care in absence of other improvements is unlikely to deliver health benefits to Aboriginal people.

The evolution of compliance in the human lateral mid-foot

Fossil evidence for longitudinal arches in the foot is frequently used to constrain the origins of terrestrial bipedality in human ancestors. This approach rests on the prevailing concept that human feet are unique in functioning with a relatively stiff lateral mid-foot, lacking the significant flexion and high plantar pressures present in non-human apes. This paradigm has stood for more than 70 years but has yet to be tested objectively with quantitative data. Herein, we show that plantar pressure records with elevated lateral mid-foot pressures occur frequently in healthy, habitually shod humans, with magnitudes in some individuals approaching absolute maxima across the foot. Furthermore, the same astonishing pressure range is present in bonobos and the orangutan (the most arboreal great ape), yielding overlap with human pressures. Thus, while the mean tendency of habitual mechanics of the mid-foot in healthy humans is indeed consistent with the traditional concept of the lateral mid-foot as a relatively rigid or stabilized structure, it is clear that lateral arch stabilization in humans is not obligate and is often transient. These findings suggest a level of detachment between foot stiffness during gait and osteological structure, hence fossilized bone morphology by itself may only provide a crude indication of mid-foot function in extinct hominins. Evidence for thick plantar tissues in Ardipithecus ramidus suggests that a human-like combination of active and passive modulation of foot compliance by soft tissues extends back into an arboreal context, supporting an arboreal origin of hominin bipedalism in compressive orthogrady. We propose that the musculoskeletal conformation of the modern human mid-foot evolved under selection for a functionally tuneable, rather than obligatory stiff structure.

Does footprint depth correlate with foot motion and pressure?

Footprints are the most direct source of evidence about locomotor biomechanics in extinct vertebrates. One of the principal suppositions underpinning biomechanical inferences is that footprint geometry correlates with dynamic foot pressure, which, in turn, is linked with overall limb motion of the trackmaker. In this study, we perform the first quantitative test of this long-standing assumption, using topological statistical analysis of plantar pressures and experimental and computer-simulated footprints. In computer-simulated footprints, the relative distribution of depth differed from the distribution of both peak and pressure impulse in all simulations. Analysis of footprint samples with common loading inputs and similar depths reveals that only shallow footprints lack significant topological differences between depth and pressure distributions. Topological comparison of plantar pressures and experimental beach footprints demonstrates that geometry is highly dependent on overall print depth; deeper footprints are characterized by greater relative forefoot, and particularly toe, depth than shallow footprints. The highlighted difference between 'shallow' and 'deep' footprints clearly emphasizes the need to understand variation in foot mechanics across different degrees of substrate compliance. Overall, our results indicate that extreme caution is required when applying the 'depth equals pressure' paradigm to hominin footprints, and by extension, those of other extant and extinct tetrapods.

Rural research capacity building program: capacity building outcomes

The Rural Research Capacity Building Program commenced in 2006 with the aim of developing research skills in rural health workers. The program was based on the capacity building principles of workforce development, organisational development, resource allocation, partnership and leadership. Qualitative methods were used to assess capacity building outcomes. A sample of candidates from the 2006 and 2007 cohorts were selected for interview using stratified random sampling and supplemental purposive sampling. Twenty-five individual semi-structured interviews were conducted with candidates, their managers and mentors. Interviews were thematically analysed. The program components of teaching, mentoring and networking led to the development of research skills in candidates undertaking the program. This workforce development resulted in workplace change, particularly where the candidate's project was 'close to practice' and they had management support. The leadership shown and partnerships developed by the program managers enhanced the workforce development and organisational change outcomes. Resources, such as backfill and incidentals, were useful for candidates, but practicalities, such as availability of replacement staff, limited effectiveness. This study showed the value of using a capacity building framework and demonstrated that undertaking research on a topic close to practice positioned candidates to drive change within their organisation.

An observational study on the prevalence and impact of Isospora suis in suckling piglets in southwestern Ontario, and risk factors for shedding oocysts

An observational study was conducted to determine the prevalence of Isospora suis oocysts in fecal samples from suckling piglets in Ontario, and to evaluate the relationship between the presence of I. suis oocysts and diarrhea. Fifty farms and 709 litters of piglets were included in the study. Oocysts were detected on 70% of farms, with 187 litters infected. A litter of pigs that was positive for oocysts was significantly more likely to exhibit diarrhea than a litter that was negative [odds ratio (OR) = 4.0; 95% confidence interval (CI) = 2.8 to 5.8; P < 0.001]. Management and housing factors were examined with respect to risk factors for the presence of I. suis. Farms that did not use a detergent when cleaning farrowing crates were 10-times more likely to be positive for I. suis than those that used a detergent (P = 0.007). It was concluded that coccidiosis is a common problem on Ontario swine farms.

Integrating public health applications with commercial EMRs

At HIMSS 2007, we demonstrated how three processes of public health agencies could be facilitated through use of a prototype health information exchange, satisfying the AHIC biosurveillance use case.

Influencing population health performance: introduction of standards for area health services in New South Wales

Standards are a yardstick against which performance can be assessed and improved. Standards are well established in healthcare settings; however, population health standards have only recently been developed for area health services in NSW. This paper describes international and Australian population health standards, and presents the results of a pilot evaluation of the NSW Population Health Standards for Area Health Services against the Greater Western Area Health Service performance requirements. The findings revealed that the standards relating to the work of specialist population health staff feature in performance requirements; however the standards requiring the contribution of other health service staff do not. Population health standards have the potential to guide the health system towards population health goals.

A perspective on environmental models and QSARs

A general review is presented of the roles of QSARs and mass balance models as tools for assessing the environmental fate and effects of chemicals of commerce. It is argued that all such chemicals must be assessed using a consistent and transparent methodology that uses chemical property data derived from QSARs, or experimental determinations when possible and applies evaluative or region-specific environmental models. These data and models enable an assessment to be made of the key chemical features of persistence, bioaccumulation, potential for long-range transport and toxicity. The other key feature is quantity used or discharged to the environment. A taxonomy of environmental models is presented in which it is suggested that rather than develop a single comprehensive model, the aim should be to establish a set of coordinated and consistent models treating evaluative and real environmental systems at a variety of scales from local to global and including food web models, organism-specific models and human exposure and pharmacokinetic models. The concentrations derived from these models can then be compared with levels judged to be of toxic significance. A brief account is given of perceived QSAR needs in terms of partitioning, reactivity, transport and toxicity data to support these models.

Case report: Survival after deliberate strychnine self-poisoning, with toxicokinetic data

INTRODUCTION

Strychnine poisoning is uncommon, and in most severe cases, the patient dies before reaching hospital. The management of strychnine poisoning is well documented, although there are few data on the kinetics of elimination of strychnine after overdose.

CASE REPORT

A 42-year-old man presented shortly after ingestion of an unknown quantity of strychnine powder. After a respiratory arrest, with intensive supportive management requiring admission to an intensive care unit, he survived. Eight serum samples were taken over the first 5 days and analysed subsequently for strychnine concentrations.

RESULTS

The initial concentration at 1.5 hours after ingestion was 4.73 mg/l, falling to 0.38 mg/l at 74 hours postingestion. Serum concentrations followed a monoexponential elimination curve with a calculated elimination half-life of 12 hours.

DISCUSSION AND CONCLUSION

Strychnine poisoning presents with classical features, and with early diagnosis and supportive management, the patient can survive. The initial serum concentration of 4.73 mg/l is the highest reported concentration in a patient who has survived. Previous reports of the elimination half-life have suggested it is between 10 and 16 hours, which conforms to the elimination data in our case.

The impact of the nonpeptide corticotropin-releasing hormone antagonist antalarmin on behavioral and endocrine responses to stress

The nonpeptide CRH antagonist antalarmin has been shown to block both behavioral and endocrine responses to CRH. However, it's potential activity in blunting behavioral and endocrine sequelae of stressor exposure has not been assessed. Because antagonism of central CRH by alpha-helical CRH attenuates conditioned fear responses, we sought to test antalarmin in this regard. In addition, it remains unclear as to whether this is a result of receptor blockade during conditioning or during testing. Thus, we explored whether CRH mediates the induction or expression of conditioned fear (freezing in a context previously associated with 2 footshocks; 1.0 mA, 5 sec each). Furthermore, because rats previously exposed to inescapable shock (IS; 100 shocks, 1.6 mA, 5 sec each), demonstrate enhanced fear conditioning, we investigated whether this effect would be blocked by antalarmin. Antalarmin (20 mg/kg x 2 ml i.p.) impaired both the induction and expression of conditioned fear. In addition, antalarmin blocked the enhancement of fear conditioning produced by prior exposure to IS. Despite the marked behavioral effects observed in antalarmin-treated rats, antalarmin had no effect on IS-induced rises in ACTH or corticosterone. However, antalarmin did block the ACTH response produced by exposure to 2 footshocks.

Histamine potently suppresses human IL-12 and stimulates IL-10 production via H2 receptors

IL-12 and IL-10, respectively, stimulate Th1 and Th2 immune responses. The development of some allergic reactions, infections, and tumors are associated with excessive histamine production and a shift toward Th2 responses. Here we address the possibility that this association is causally linked, at least in part, to modulation of IL-12 and IL-10 production by histamine. We report that histamine dose-dependently inhibited the secretion of human IL-12 (p70) and increased the production of IL-10 in LPS-stimulated whole blood cultures. These effects of histamine were antagonized by cimetidine, an H2 receptor antagonist, but not by selective H1 and H3 receptor blockers, and were mimicked by an H2 receptor agonist. The effects of histamine on IL-12 and IL-10 secretion were independent of endogenous secretion of IL-10 or exogenous addition of IL-12, while Ro 20-1724, a phosphodiesterase inhibitor, potentiated the effects of histamine on IL-12 and IL-10 production, implicating cAMP in its actions. Similar modulatory effects of histamine on IL-12 and IL-10 production, which were reversed by the H2 antagonist cimetidine, were observed in PBMC and isolated monocytes stimulated by Staphylococcus aureus Cowan strain 1 and LPS, respectively. Thus, histamine, via stimulation of H2 receptors on peripheral monocytes and subsequent elevation of cAMP, suppresses IL-12 and stimulates IL-10 secretion, changes that may result in a shift of Th1/Th2 balance toward Th2-dominance. This may represent a novel mechanism by which excessive secretion of histamine potentiates Th2-mediated allergic reactions and contributes to the development of certain infections and tumors normally eliminated by Th1-dependent immune mechanisms.

Men and women holding hands: whose hand is uppermost?

This study explored the issue of whether status and power differences are expressed in the way men and women hold hands. It was hypothesized that men's hands would be upper in heterosexual handholding couples significantly more often than women's. Also, to explore the possibility that height differences of handholding partners might affect handholding position, all handholding couples observed in this study were classified as couples with men and women of equal height or couples where either the men or women were taller. A total of 1,006 handholing couples were observed, and men's hands were significantly more likely to be the upper one in couples when men were taller than women and in couples where men and women were of equal height, suggesting that, while height does matter, it is less important for this handholding pattern than sex differences.

Corticotropin-releasing hormone induces skin mast cell degranulation and increased vascular permeability, a possible explanation for its proinflammatory effects

Mast cells are involved in atopic disorders, often exacerbated by stress, and are located perivascularly close to sympathetic and sensory nerve endings. Mast cells are activated by electrical nerve stimulation and millimolar concentrations of neuropeptides, such as substance P (SP). Moreover, acute psychological stress induces CRH-dependent mast cell degranulation. Intradermal administration of rat/human CRH (0.1-10 microM) in the rat induced mast cell degranulation and increased capillary permeability in a dose-dependent fashion. The effect of CRH on Evans blue extravasation was stronger than equimolar concentrations of the mast cell secretagogue compound 48/80 or SP. The free acid analog of CRH, which does not interact with its receptors (CRHR), had no biological activity. Moreover, systemic administration of antalarmin, a nonpeptide CRHR1 antagonist, prevented vascular permeability only by CRH and not by compound 48/80 or SP. CRHR1 was also identified in cultured leukemic human mast cells using RT-PCR. The stimulatory effect of CRH, like that of compound 48/80 on skin vasodilation, could not be elicited in the mast cell deficient W/Wv mice but was present in their +/+ controls, as well as in C57BL/6J mice; histamine could still induce vasodilation in the W/Wv mice. Treatment of rats neonatally with capsaicin had no effect on either Evans blue extravasation or mast cell degranulation, indicating that the effect of exogenous CRH in the skin was not secondary to or dependent on the release of neuropeptides from sensory nerve endings. The effect of CRH on Evans blue extravasation and mast cell degranulation was inhibited by the mast cell stabilizer disodium cromoglycate (cromolyn), but not by the antisecretory molecule somatostatin. To investigate which vasodilatory molecules might be involved in the increase in vascular permeability, the CRH injection site was pretreated with the H1-receptor antagonist diphenhydramine, which largely inhibited the CRH effect, suggesting that histamine was involved in the CRH-induced vasodilation. The possibility that nitric oxide might also be involved was tested using pretreatment with a nitric oxide synthase inhibitor that, however, increased the effect of CRH. These findings indicate that CRH activates skin mast cells at least via a CRHR1-dependent mechanism leading to vasodilation and increased vascular permeability. The present results have implications for the pathophysiology and possible therapy of skin disorders, such as atopic dermatitis, eczema, psoriasis, and urticaria, which are exacerbated or precipitated by stress.

The hypothalamic-pituitary-adrenal axis and the female reproductive system

The hypothalamic-pituitary-adrenal (HPA) axis and the female reproductive system are intertwined and exhibit a complex relationship. Thus, the HPA axis exerts profound, mostly inhibitory effects, on the reproductive axis, with corticotropin-releasing hormone (CRH) and CRH-induced propiomelanocortin peptides inhibiting hypothalamic GnRH secretion, and with glucocorticoids inhibiting pituitary LH and ovarian estrogen and progesterone secretion and rendering estrogen-target tissues, such as the endometrium, resistant to the gonadal steroid. These effects of the HPA axis are responsible for the "hypothalamic" amenorrhea of stress, depression and eating disorders, and the hypogonadism of Cushing's syndrome. Conversely, estrogen directly stimulates the CRH gene, which may explain the slight hypercortisolism of females and the preponderance of depressive, anxiety, and eating disorders, as well as Cushing's disease in women. Interestingly, several components of the HPA axis and their receptors are present in reproductive tissues, as autocoid regulators of their various functions. These include ovarian and endometrial CRH, which may participate in the inflammatory processes of the ovary, that is, ovulation and luteolysis, and of the endometrium, that is, implantation and menstruation. Finally, the hypercortisolism of the latter half of pregnancy can be explained by high levels of placenta CRH in plasma. This hypercortisolism causes a transient adrenal suppression in the postpartum period, which may explain the postpartum blues/depression and autoimmune phenomena of this period.

The non-ligand binding beta-isoform of the human glucocorticoid receptor (hGR beta): tissue levels, mechanism of action, and potential physiologic role

BACKGROUND

Alternative splicing of the transcripts of the human glucocorticoid receptor gene results in two mutually exclusive products, the classic, ligand-binding glucocorticoid receptor (hGR alpha), and a dominant negative non-ligand-binding isoform, hGR beta.

MATERIALS AND METHODS

We examined the existence of and quantified both hGR alpha and hGR beta isoforms in a panel of human tissues, as well as in intact and fractionated HeLa cells, using specific quantitative Western blots and/or immunocytochemistry. We studied the potential interactions of hGR beta with heat shock protein (hsp) 90 and/or hGR alpha using cross-immunoadsorption/precipitation procedures followed by Western blots.

RESULTS

For the first time, we demonstrated the natural existence of the hGR beta protein, which was widely expressed in human tissues. The ratio of immunoreactive hGR alpha to hGR beta varied from 0.2 to 1.0 among different tissues, and was approximately 0.2 in HeLa cells. In the latter, both isoforms were distributed in the cytoplasm and nucleus in the absence of the hormonal ligand, and translocated into the nucleus after addition of dexamethasone. The cytosolic and nuclear hGR alpha-to-hGR beta ratio remained the same before and after dexamethasone exposure, suggesting that upon activation the two isoforms translocated into the nucleus in equal proportions. hGR alpha- and hGR beta-specific antibodies cross-adsorbed and precipitated cytosolic and nuclear glucocorticoid hGR alpha and hGR beta, respectively, as well as hsp90, suggesting that hGR alpha and hGR beta are in complex with hsp90 and/or each other.

CONCLUSIONS

The hGR beta protein is widely expressed throughout the human body and present mostly in the cytoplasm of human cells, in complex with hsp90 and other proteins. In the presence of glucocorticoid, hGR beta probably heterodimerizes with ligand-bound hGR alpha and translocates into the nucleus to act as a dominant negative inhibitor of the classic receptor.