Difference in general practice telehealth utilisation associated with birth country during COVID-19 from two Australian states

Objective

Telehealth has been an integral part of ensuring continued general practice access during the COVID-19 pandemic. Whether telehealth was similarly adopted across different ethnic, cultural, and linguistic groups in Australia is unknown. In this study, we assessed how telehealth utilisation differed by birth country.

Methods

In this retrospective observational study, electronic health record data from 799 general practices across Victoria and New South Wales, Australia between March 2020 to November 2021 were extracted (12,403,592 encounters from 1,307,192 patients). Multivariate generalised estimating equation models were used to assess the likelihood of a telehealth consultation (against face-to-face consultation) by birth country (relative to Australia or New Zealand born patients), education index, and native language (English versus others).

Results

Patients born in Southeastern Asia (aOR: 0.54; 95% CI: 0.52-0.55), Eastern Asia (aOR: 0.63; 95% CI: 0.60-0.66), and India (aOR: 0.64; 95% CI: 0.63-0.66) had a lower likelihood of having a telehealth consultation compared to those born in Australia or New Zealand. Northern America, British Isles, and most European countries did not present with a statistically significant difference. Additionally, higher education levels (aOR: 1.34; 95% CI: 1.26-1.42) was associated with an increase in the likelihood of a telehealth consultation, while being from a non-English-speaking country was associated with a reduced likelihood (aOR: 0.83; 95% CI: 0.81-0.84).

Conclusions

This study provides evidence showing differences in telehealth use associated with birth country. Strategies to ensure continued healthcare access for patients, whose native language is not English, such as providing interpreter services for telehealth consultations, would be beneficial.

Perspectives

Understanding cultural and linguistic differences may reduce health disparities in telehealth access in Australia and could present an opportunity to promote healthcare access in diverse communities.

Identifying and managing psoriasis-associated comorbidities: the IMPACT research programme

Background

Psoriasis is a common, lifelong inflammatory skin disease, the severity of which can range from limited disease involving a small body surface area to extensive skin involvement. It is associated with high levels of physical and psychosocial disability and a range of comorbidities, including cardiovascular disease, and it is currently incurable.

Objectives

To (1) confirm which patients with psoriasis are at highest risk of developing additional long-term conditions and identify service use and costs to patient, (2) apply knowledge about risk of comorbid disease to the development of targeted screening services to reduce risk of further disease, (3) learn how patients with psoriasis cope with their condition and about their views of service provision, (4) identify the barriers to provision of best care for patients with psoriasis and (5) develop patient self-management resources and staff training packages to improve the lives of people with psoriasis.

Design

Mixed methods including two systematic reviews, one population cohort study, one primary care screening study, one discrete choice study, four qualitative studies and three mixed-methodology studies.

Setting

Primary care, secondary care and online surveys.

Participants

People with psoriasis and health-care professionals who manage patients with psoriasis.

Results

Prevalence rates for psoriasis vary by geographical location. Incidence in the UK was estimated to be between 1.30% and 2.60%. Knowledge about the cost-effectiveness of therapies is limited because high-quality clinical comparisons of interventions have not been done or involve short-term follow-up. After adjusting for known cardiovascular risk factors, psoriasis (including severe forms) was not found to be an independent risk factor for major cardiovascular events; however, co-occurrence of inflammatory arthritis was a risk factor. Traditional risk factors were high in patients with psoriasis. Large numbers of patients with suboptimal management of known risk factors were found by screening patients in primary care. Risk information was seldom discussed with patients as part of screening consultations, meaning that a traditional screening approach may not be effective in reducing comorbidities associated with psoriasis. Gaps in training of health-care practitioners to manage psoriasis effectively were identified, including knowledge about risk factors for comorbidities and methods of facilitating behavioural change. Theory-based, high-design-quality patient materials broadened patient understanding of psoriasis and self-management. A 1-day training course based on motivational interviewing principles was effective in increasing practitioner knowledge and changing consultation styles. The primary economic analysis indicated a high level of uncertainty. Sensitivity analysis indicated some situations when the interventions may be cost-effective. The interventions need to be assessed for long-term (cost-)effectiveness.

Limitations

The duration of patient follow-up in the study of cardiovascular disease was relatively short; as a result, future studies with longer follow-up are recommended.

Conclusions

Recognition of the nature of the psoriasis and its impact, knowledge of best practice and guideline use are all limited in those most likely to provide care for the majority of patients. Patients and practitioners are likely to benefit from the provision of appropriate support and/or training that broadens understanding of psoriasis as a complex condition and incorporates support for appropriate health behaviour change. Both interventions were feasible and acceptable to patients and practitioners. Cost-effectiveness remains to be explored.

Future work

Patient support materials have been created for patients and NHS providers. A 1-day training programme with training materials for dermatologists, specialist nurses and primary care practitioners has been designed. Spin-off research projects include a national study of responses to psoriasis therapy and a global study of the prevalence and incidence of psoriasis. A new clinical service is being developed locally based on the key findings of the Identification and Management of Psoriasis Associated ComorbidiTy (IMPACT) programme.

Funding

This project was funded by the National Institute for Health Research (NIHR) Programme Grants for Applied Research programme and will be published in full in Programme Grants for Applied Research; Vol. 10, No. 3. See the NIHR Journals Library website for further project information.

Novel electronic adherence monitoring devices in children with asthma: a mixed-methods study

Introduction

Adherence monitoring to inhaled corticosteroids is an essential component of asthma management. Electronic monitoring devices (EMD) provide objective data on date, time and number of actuations. However, most give no information on inhalation. Novel EMD (NEMD) platforms have the potential to monitor both activation and inhalation.

Aim

To assess the feasibility of NEMDs, in terms of usability, acceptability to patients and healthcare professionals and accuracy.

Methods

This was an open-label, prospective, mixed-methods, pragmatic randomised study. Children with asthma attending specialist tertiary care were randomised to one of four NEMD: Remote Directly Observed Therapy (R-DOT), Hailie Smartinhaler, INhaler Compliance Assessment device (INCA) and the Rafi-tone App. Following monitoring, participants were invited to focus groups or one-to-one interviews. Usability and acceptability were evaluated using themes identified from the focus groups and interviews. Adherence accuracy was determined using adherence data from each NEMD.

Results

Thirty-five children were recruited; 18 (51%), (11 males, median age 13.5 (7–16) years) completed monitoring, 14 (78%) provided feedback. Participants identified various features such as ease of use and minimal effort as desirable criteria for an NEMD. The Hailie and INCA fulfilled these criteria and were able to record both actuation and inhalation. Negative themes included a ‘Big Brother’ effect and costs.

Conclusion

There was no ‘one size fits all’, as participants identified advantages and disadvantages for each NEMD. Devices that can easily calculate adherence to activation and inhalation have the potential to have greatest utility in clinical practice. Each NEMD has different functionality and therefore choice of platform should be determined by the needs of the patient and healthcare professional.

A queueing system with non-recurrent input and batch servicing

We consider a queueing system in which arrivals occur at times , and after every kth arrival a servicing of k arrivals is begun. We assume that the number of servers is infinite. Initially, at t0= 0, the system is empty and the arrival process {tn} is about to start. The batch service times are independently and identically distributed with distribution function No assumption is made about the process {tn}.

Queues with moving average service times

A model for the service time structure in the single server queue is given embodying correlations between contiguous and near-contiguous service times. A number of results are derived in the case of Poisson arrivals both for equilibrium and the transient state. In particular, Kendall's (equilibrium) result P (a departure leaves the queue empty) = 1 — (mean service time)/(mean inter-arrival time) is found still to hold good. The effect of the correlation on the mean and variance of the equilibrium queue length distribution is examined in a simple case.

Comparison of conventional testing to polymerase chain reaction in detection of Trichomonas vaginalis in indigenous women living in remote areas

There are high rates of Trichomonas vaginalis in remote areas of Central Australia. Conventional tests for T. vaginalis have low sensitivity in this setting. Aims of the study were to estimate the prevalence of T. vaginalis, to assess the presence of clinical signs and symptoms, to compare a T. vaginalis polymerase chain reaction (PCR) test with conventional methods of diagnosis, and to compare the PCR from different samples, including self-collected swabs (SCS). Of 205 women recruited, the prevalence of T. vaginalis was 24%. The prevalence of T. vaginalis was higher in women under 25 years (33%), compared with those who were 25–34 years (26%) and those over 35 years (15%, P < 0.05). The sensitivity of T. vaginalis PCR detection from SCS (94%) was not statistically different from a practitioner-collected HVS (96%), but was superior to urine PCR (74%) and conventional methods. After multivariate analysis, those women with high pH were almost three times more likely to be positive for T. vaginalis (odds ratio = 2.71 with 95% confidence interval 1.06–6.93, P = 0.037). Superior assays such as PCR should be a diagnostic option to adequately screen and treat women with T. vaginalis, in order to reduce complications, including the increased risk of HIV transmission.

Osteosarcoma of the talus misdiagnosed as ankle arthritis: a case report

We present a 65-year-old man with osteosarcoma of the talus that was misdiagnosed as osteoarthritis. The patient eventually underwent below-knee amputation and adjuvant chemotherapy.

Reporting Observational Studies of the Use of Information Technology in the Clinical Consultation

To develop a classification system to improve the reporting of observational studies of the use of information technology (IT) in clinical consultations.

Literature review, workshops, and development of a position statement. We grouped the important aspects for consistent reporting into a “faceted classification”; the components relevant to a particular study to be used independently.

The eightfacetsof ourclassification are: (1) Theoretical and methodological approach: e.g. dramaturgical, cognitive; (2) Data collection: Type and method of observation; (3) Room layout and environment: How this affects interaction between clinician, patient and computer. (4) Initiation and Interaction: Who starts the consultation, and how the participants interact; (5) Information and knowledge utilisation: What sources of information or decision support are used or provided; (6) Timing and type of consultation variables: Standard descriptors that can be used to allow comparison of duration and description of continuous activities (e.g. speech, eye contact) and episodic ones, such as prescribing; (7) Post-consultation impact measures: Satisfaction surveys and health economic assessment based on the perceived quality of the clinician-patient interaction; and (8) Data capture, storage, and export formats: How to archive and curate data to facilitate further analysis.

Adoption of this classification should make it easier to interpret research findings and facilitate the synthesis of evidence across studies. Those engaged in IT-consultation research shouldconsider adopting this reporting guide.

Reporting observational studies of the use of information technology in the clinical consultation. A position statement from the IMIA Primary Health Care Informatics Working Group (IMIA PCI WG)

OBJECTIVES

To develop a classification system to improve the reporting of observational studies of the use of information technology (IT) in clinical consultations.

METHODS

Literature review, workshops, and development of a position statement. We grouped the important aspects for consistent reporting into a "faceted classification"; the components relevant to a particular study to be used independently.

RESULTS

The eight facets of our classification are: (1) Theoretical and methodological approach: e.g. dramaturgical, cognitive; (2) DATA COLLECTION: Type and method of observation; (3) Room layout and environment: How this affects interaction between clinician, patient and computer. (4) Initiation and Interaction: Who starts the consultation, and how the participants interact; (5) Information and knowledge utilisation: What sources of information or decision support are used or provided; (6) Timing and type of consultation variables: Standard descriptors that can be used to allow comparison of duration and description of continuous activities (e.g. speech, eye contact) and episodic ones, such as prescribing; (7) Post-consultation impact measures: Satisfaction surveys and health economic assessment based on the perceived quality of the clinician-patient interaction; and (8) Data capture, storage, and export formats: How to archive and curate data to facilitate further analysis.

CONCLUSIONS

Adoption of this classification should make it easier to interpret research findings and facilitate the synthesis of evidence across studies. Those engaged in IT-consultation research shouldconsider adopting this reporting guide.

Munchausen's syndrome by Google

A case is discussed of the use of medical images from the internet to support claims of injury. There were several inconsistencies in both history and examination even prior to the presentation of the specimen radiograph from the internet. Clinicians are advised to be vigilant, to question histories that do not match with examination findings, to ensure that all radiographs are adequately labelled with patient-specific information and to look for radiographic inconsistencies such as the presence or absence of accessory ossicles.

The misuse of 'no significant difference' in British orthopaedic literature

INTRODUCTION

Many studies published in medical journals do not consider the statistical power required to detect a meaningful difference between study groups. As a result, these studies are often underpowered: the sample size may not be large enough to pick up a statistically significant difference (or other effect of interest) of a given size between the study groups. Therefore, the conclusion that there is no statistically significant difference between groups cannot be made unless a study has been shown to have sufficient power. The aim of this study was to establish the prevalence of negative studies with inadequate statistical power in British journals to which orthopaedic surgeons regularly submit.

MATERIALS AND METHODS

We assessed all papers in the last consecutive six issues prior to the start of the study (April 2005) in The Journal of Bone and Joint Surgery (British), Injury, and Annals of the Royal College of Surgeons of England. We sought published evidence that a power analysis had been performed in association with the main hypothesis of the paper.

RESULTS

There were a total of 170 papers in which a statistical comparison of two or more groups was undertaken. Of these 170 papers, 49 (28.8%) stated as their primary conclusion that there was no statistically significant difference between the groups studied. Of these 49 papers, only 3 (6.1%) had performed a power analysis demonstrating adequate sample size.

CONCLUSIONS

These results demonstrate that the majority of negative studies in the British orthopaedic literature that we have looked at have not performed the statistical analysis necessary to reach their stated conclusions. In order to remedy this, we recommend that the journals sampled include the following guidance in their instructions to authors: the statement 'no statistically significant difference was found between study groups' should be accompanied by the results of a power analysis.

Quantification of t-tubule area and protein distribution in rat cardiac ventricular myocytes

The transverse (t-) tubules of cardiac ventricular myocytes are invaginations of the surface membrane that form a complex network within the cell. Many of the key proteins involved in excitation-contraction coupling appear to be located predominantly at the t-tubule membrane. Despite their importance, the fraction of cell membrane within the t-tubules remains unclear: measurement of cell capacitance following detubulation suggests approximately 32%, whereas optical measurements suggest up to approximately 65%. We have, therefore, investigated the factors that may account for this discrepancy. Calculation of the combinations of t-tubule radius, length and density that produce t-tubular membrane fractions of 32% or 56% suggest that the true fraction is at the upper end of this range. Assessment of detubulation using confocal and electron microscopy suggests that incomplete detubulation can account for some, but not all of the difference. High cholesterol, and a consequent decrease in specific capacitance, in the t-tubule membrane, may also cause the t-tubule fraction calculated from the loss of capacitance following detubulation to be underestimated. Correcting for both of these factors results in an estimate that is still lower than that obtained from optical measurements suggesting either that optical methods overestimate the fraction of membrane in the t-tubules, or that other, unknown, factors, reduce the apparent fraction obtained by detubulation. A biophysically realistic computer model of a rat ventricular myocyte, incorporating a t-tubule network, is used to assess the effect of the altered estimates of t-tubular membrane fraction on the calculated distribution of ion flux pathways.

Coagulase-negative staphylococci in very-low-birth-weight infants: inability of genetic markers to distinguish invasive strains from blood culture contaminants

Selected coagulase-negative staphylococci from the blood of very-low-birth-weight infants in the Neonatal Intensive Care Unit at the Royal Women's Hospital, Melbourne, collected over a 5-year period were examined. Isolates were classified as invasive or contaminants, speciated, typed by pulsed-field gel electrophoresis, and examined for biofilm genes (icaA, icaC, and icaD), adhesion genes (atlE, fbe), and the number of copies of IS256. Of the 24 isolates studied, there were 13 contaminants and 11 invasive isolates. The collection included 15 Staphylococcus epidermidis, eight Staphylococcus capitis, and one each of Staphylococcus warneri and Staphylococcus haemolyticus. Two small clusters of S. epidermidis that belonged to the same molecular type were identified. All S. capitis isolates belonged to the same molecular type or subtype, suggesting that a particular clone was circulating in the unit. There was no significant difference in the species found, the presence of icaA, icaC, icaD, atlE, or fbe, or the number of copies of IS256 between invasive isolates and contaminants. A series of nasal isolates from nonhospitalized adults differed from hospital isolates in the absence of IS256 and the low prevalence of icaC. There was no evidence of IS256-mediated insertion into ica genes as a mechanism of phase variation. These findings suggest that contaminants and invasive isolates derived from the same pool of hospital strains capable of causing sepsis in compromised hosts and that other mechanisms of phase variation exist, apart from IS256 insertion into ica genes.

Screening for intestinal parasites in recently arrived children from East Africa

BACKGROUND

Intestinal parasitic carriage is common in East African populations with a wide spectrum of clinical severity. There are scant data on the rates of carriage in East African immigrants to Australia. This study describes the prevalence of and risk factors for intestinal parasite carriage among children recently arrived from East African countries.

METHODS

Children aged 0-17 years, who attended an outpatient clinic, were born in East Africa and had immigrated since 1998 were eligible to participate. A single preserved stool specimen was collected for faecal microscopy, and blood tests were conducted for Strongyloides and Schistosoma serology, full blood examination and serum ferritin.

RESULTS

One hundred and thirty-five children (median age 8.1 years, range 1.0-17.5) participated, of whom 133 (99%) provided a stool specimen. Parasites were detected in 50% of samples, and 18% of children carried a possibly pathogenic species. No child was symptomatic at diagnosis. Positive or equivocal serology occurred in 11% of children for Strongyloides and 2% for Schistosoma. Anaemia and iron deficiency were detected in 16% of all children. Those carrying an intestinal parasite were older (mean age 9.8 vs 7.4 years, P= 0.002) and less likely to be anaemic (odds ratio 0.37, 95% confidence interval 0.14-0.96) than those who were not carriers.

CONCLUSIONS

Carriage of intestinal parasites is common among children from East Africa. Those carrying pathogenic organisms require treatment and follow up to ensure eradication. The results of this survey support the need for routine assessment of newly arrived immigrants from East Africa for intestinal parasites, anaemia and iron deficiency.

Australian doctors and their postgraduate qualifications

BACKGROUND

A key activity for doctors is lifelong learning. This may be as part of professional development, vocational registration, formal postgraduate study, e.g. university diplomas and degrees, or vocational training which leads to fellowship of a professional college. However, there are significant barriers of time and cost that prevent many doctors from participating in lifelong learning.

METHOD

We examined the range of basic and postgraduate qualifications held by a representative sample of 1198 doctors provided by the HIC of Australian doctors.

DISCUSSION

Significant numbers of general practitioners practise without a formal postgraduate qualification in general practice, unlike our specialist colleagues. However, postgraduate studies are undertaken in a variety of other formats and qualifications.

Anticoagulant therapy. Will computer use improve outcomes?

BACKGROUND

Anticoagulant therapy has been steadily increasing in clinical practice. With its narrow therapeutic range for efficacy and adverse events, this trend can lead to greater morbidity and mortality, making it an increasingly significant clinical, economic, medicolegal and public health issue.

OBJECTIVE

To examine issues and challenges arising from the increasing use of anticoagulants in general practice.

DISCUSSION

Adherence and regular monitoring by an effective multidisciplinary health care team is critical to optimise anticoagulant therapy. Clinicians, carers and patients need good information, training and support. Adherence to anticoagulation therapy is influenced by clinician interest, skills and involvement in shared decision making and risk counselling. Computerised decision support, based on relevant and comprehensive guidelines for anticoagulant therapy, can improve the way patients and clinicians manage anticoagulant therapy.

Pregnant women's perceptions of abuse

OBJECTIVE

To determine whether pregnant women's perceptions of abuse severity and danger, and their ability to control the abuse, are significantly correlated with the acts of abuse they experience, and to find out whether relationships exist among women's appraisals of abuse severity, danger, and their perceived ability to stop the abuse.

DESIGN

A correlational design was used to compare the abusive acts experienced by the women and their perceptions of that abuse.

SETTING

Nine prenatal clinics in urban areas of the northeastern United States.

PARTICIPANTS

Sixty-one ethnically diverse, pregnant abused women were interviewed.

MAIN OUTCOME MEASURE

Pearson's product-moment correlations were used to examine relationships between abusive experiences and women's perceptions of abuse.

RESULTS

Women's perceptions of abuse severity were modestly correlated with threatened (r = .25) and actual violence (r = .36). Perceptions of abuse severity and danger were correlated (r = .41).

CONCLUSIONS

Women's beliefs about abuse severity, danger, and their ability to control abuse cannot be fully comprehended by exploring the discrete acts they experience. Further research is needed to identify additional factors that influence those beliefs.

Mechanics of an educational exchange

Rural general practitioners occasionally exchange practices internationally. The process of exchanging is a complicated one, which involves multiple bureaucarcies. Exchanging is not for the anxious or impatient. We exchanged with a family physician in Canada and had to arrange registration, provider numbers and immigration for our Canadian colleague, as well as for ourselves in Canada. In addition, there are many personal details (cars, house, etc.) that must also be sorted out.

8-methyl-pyridoxatin: A novel N-hydroxy pyridone from fungus OS-F61800 that induces erythropoietin in human cells

In the course of screening for small-molecule modulators of erythropoietin gene expression, a novel N-hydroxy pyridone was isolated from a culture of OS-F61800. Its structure was elucidated by extensive 1H and 13C NMR spectroscopic and chemical studies. This compound induced erythropoietin gene expression fivefold at a concentration of 0.3 microM, which is about threefold greater potency than our previously identified erythropoietin inducers.

Epolones: novel sesquiterpene-tropolones from fungus OS-F69284 that induce erythropoietin in human cells

In the course of our screening for small molecule modulators of erythropoietin gene expression, two novel sesquiterpene tropolones and pycnidone were isolated from a culture of OS-F69284 (ATCC 74390). Their structures were elucidated by extensive 1H and 13C NMR spectroscopic studies and chemical reactions. These compounds induced erythropoietin gene expression 5-fold at a concentration of 1-1.6 microM.

Cell wall active antifungal compounds produced by the marine fungus hypoxylon oceanicum LL-15G256. I. Taxonomy and fermentation

The cell wall targeted antifungal activity of Hypoxylon oceanicum LL-15G256 extracts resulted from the production of novel lipodepsipeptides and previously reported macrocyclic polylactones. In an optimized medium, titers of the lipodepsipeptide and the polylactones reached approximately 200-400 mg/liter and 25-50 mg/liter, respectively. The optimum fermentation temperature for production of 15G256 gamma was 28 degrees C. Seawater appeared to have an inhibitory effect on metabolite accumulation at lower fermentation temperatures.

Isolation and characterization of the fungal metabolite 3-O-methylviridicatin as an inhibitor of tumour necrosis factor alpha-induced human immunodeficiency virus replication

The cytokine tumour necrosis factor alpha (TNF-alpha) has been shown to play a role in human immunodeficiency virus (HIV) replication by activating transcription of the provirus in both T cells and macrophages. Therefore, agents that block TNF-alpha-induced HIV expression could have therapeutic value in the treatment of AIDS. We have sought to identify antiviral agents that block TNF-alpha induction of HIV LTR-directed transcription, using a cell-based, virus-free assay system in automated high-throughput screening. HeLa cells were transfected with an HIV LTR-luciferase reporter plasmid and a stable line was isolated in which TNF-alpha increased luciferase production by two- to threefold. This cell line was used to screen approximately 15,000 fungal extracts. An inhibitory activity specific for TNF-alpha-induced HIV LTR transcription was observed in culture OS-F67406. The active component was isolated and identified as a known metabolite, 3-O-methylviridicatin, by NMR and mass spectrometry. No biological activity has been associated with this compound previously. This compound blocks TNF-alpha activation of the HIV LTR in the HeLa-based system, with an IC50 of 5 microM, and inhibited virus production in the OM-10.1 cell line, a model of chronic infection responsive to induction by TNF-alpha, with an IC50 of 2.5 microM.

Destruxin-A4 chlorohydrin, a novel destruxin from fungus OS-F68576: isolation, structure determination, and biological activity as an inducer of erythropoietin

In the course of screening for small-molecule modulators of erythropoietin gene expression, five destruxins were isolated from the fungal culture of OS-F68576. The structures were elucidated by extensive 1H and 13C NMR spectroscopy and by hydrolytic modification. One compound (destruxin-A4 chlorohydrin, 1) is a novel destruxin. All these compounds induced erythropoietin gene expression 5-fold at concentration of 0.2-2 microM.

Effects of diethylamine/nitric oxide on blood perfusion and oxygenation in the R3230Ac mammary carcinoma

The effects of intravenous diethylamine/nitric oxide (DEA/NO), a short-acting nitric oxide (NO) donor, on systemic haemodynamics, muscle and tumour blood flow (MBF and TBF) and tumour oxygenation were examined in rats bearing subcutaneous R3230Ac carcinoma in the leg. The effects of DEA/NO on the diameters of tumour-feeding and normal arterioles were evaluated in window chambers with and without implanted tumours. DEA/NO reduced mean arterial pressure (MAP) when given at doses > or = 100 nmol kg(-1), with maximal suppression at 0.5-1 min followed by return to baseline within 20 min. DEA/NO did not affect MBF except at the highest doses (500 and 1000 nmol kg(-1)). In contrast, DEA/NO reduced TBF and constricted tumour arterioles at doses > or = 100 nmol kg(-1). Tumour arteriolar vasomotion occurred in more than half the animals during hypotension and with a significantly higher frequency than in normal granulating tissue at a dose of 500 nmol kg(-1). Normal arterioles rapidly and significantly vasodilated for about 3 min and then returned to baseline. The reductions in TBF and MAP were accompanied by synchronous reduction in tumour pO2. Our findings suggest that DEA/NO decreases TBF in two ways. In the window chamber model, vascular steal occurs as normal arterioles adjacent to tumour dilate more than tumour arterioles during the initial period of hypotension. In leg tumours, the predominant mechanism is attributable to reduced perfusion pressure induced by lowered MAP, which decreases flow to the tumour, probably because of relatively higher flow resistance. The vasoconstriction and vasomotion in tumour arterioles during DEA/NO-induced hypotension may reflect differences in regulatory metabolism of NO between neoplastic and normal arterioles. Thus, intravenous injection of a short-acting NO donor, DEA/NO, decreases MAP and heart rate, leading to subsequent decreases in tumour blood flow and oxygenation.

Clonal diversity of Streptococcus mitis biovar 1 isolates from the oral cavity of human neonates

The clonal diversity of 101 isolates of the pioneer bacterium Streptococcus mitis biovar 1 obtained from the oral cavities of 40 human neonates 1 to 3 days, 2 weeks, and 1 month postpartum was examined by using rRNA gene restriction patterns. There was a high degree of genetic diversity, with the 101 isolates comprising 93 unique PvuII ribotypes. There were eight identical pairs of ribotype patterns, and seven of the eight pairs were obtained from individual neonates. Only one identical pair comprised isolates obtained from different neonates. In all but two cases, isolates with matching ribotypes were obtained at one visit. Two pairs of isolates with matching ribotype patterns were obtained from neonates on successive visits. The ribotype patterns of the isolates were examined by cluster analysis. The isolates forming each cluster were very similar, yet each cluster was well separated from its neighbors. When several isolates were obtained from individual neonates at a particular visit, in some instances they were contained in a single cluster, whereas in other cases each isolate was contained in a separate cluster. Isolates obtained from individual neonates on successive visits tended to be contained in different clusters. This high degree of diversity, which has been observed in other mucosal commensal bacteria, may serve as a mechanism for avoiding immune elimination of these bacteria.

Continuing medical education in marital and family therapy: a survey of South Australian psychiatrists

OBJECTIVE

South Australian psychiatrists were surveyed to determine their impressions of the usefulness of marital and family therapy (MFT) in the management of serious psychiatric conditions and to ascertain their previous experience with Continuing Medical Education (CME) about family therapy. It was expected that psychiatrists' preferences regarding CME would be related to their clinical experience of the usefulness of MFT.

METHOD

One hundred and twenty psychiatrists returned a questionnaire about their training, clinical and research interests, with ratings of the usefulness of MFT and CME preferences. This represented 65% of those eligible for the CME programme.

RESULTS

Thirteen percent of the respondents found MFT to be extremely useful and a further 47% found it moderately useful in their current practice. There was evidence of a possible training effect: respondents who had previous CME rated MFT as more useful, especially for mood disorders. Furthermore, the treatment of mood disorders seemed to have a particular relevance in family psychiatry, making a statistically unique contribution to ratings of MFT usefulness in the respondents' total practice. Sixty-nine percent of the respondents requested further CME in family therapy. This represented 45% of all South Australian psychiatrists. Respondents who rated MFT as more useful in practice were significantly more likely to be interested in CME.

CONCLUSIONS

There seems to be sufficient interest and clinical experience among psychiatrists for MFT to be included in CME courses. It is recommended that further training focus on major mental disorders, especially mood disorders and schizophrenia.

Adolescent suicide, depression and family dysfunction

This study investigated associations between adolescents' perceptions of their family dynamics (McMaster Family Assessment Device, FAD) and depression, suicide thoughts and attempts. High school students (mean age 15.2 years) completed self-report questionnaires including the Beck Depression Inventory (BDI), the FAD, questions about suicidal thoughts, plans and attempts, deliberate self harm, and selected life experiences. Univariate analysis showed that family dysfunction measured on the FAD is associated with thinking and planning suicide, deliberate self harm, suicide attempts, as well as severe depression (BDI > or = 22). Despite this, stepwise regression indicated that family dysfunction influences suicide behaviors indirectly through other variables such as depression. The FAD is recommended as a useful addition to questionnaires seeking to identify vulnerability to both depression and adolescent attempted suicide in early detection studies.

Identification of pioneer viridans streptococci in the oral cavity of human neonates

Three hundred and sixty-seven strains of pioneer streptococci isolated from the mouths of 40 healthy, full-term infants during the first month of life were examined by two taxonomic schemes that incorporated biochemical and physiological characteristics, IgA1 protease production and glycosidase activities. Streptococcus mitis biovar 1 and S. oralis comprised 55.0% of the pioneer streptococci isolated from neonates. S. salivarius constituted 25.3% of the isolates, while S. anginosus, S. mitis biovar 2, S. sanguis and S. gordonii accounted collectively for 11.4%. Difficulties in identifying streptococci were encountered and 8.4% of the 367 isolates could not be assigned to a recognised species.

RN to BS in Nursing: Historical Review Leads to Articulation Agreement

Historically, registered nurses who have graduated from associate degree or diploma programs and who wish to obtain a baccalaureate degree in nursing have been required to pass challenge examinations to obtain credit for their previous nursing knowledge. A review of this university's policy regarding challenge examinations convinced faculty to establish a transition course and to actively pursue articulation agreements with local community colleges. Through these agreements, RN students would be granted 29 credits and bypass the junior year. This article is written to encourage others to review their policies to facilitate educational mobility for the RN/BS student.

Pioneer oral streptococci produce immunoglobulin A1 protease

As part of a longitudinal study of the relationship between bacterial colonization and the secretory immune response, 367 isolates of pioneer viridans streptococci collected from 40 breast- and bottle-fed neonates within the first month postpartum were tested for the production of immunoglobulin A1 (IgA1) protease and glycosidases. Fifty percent of the streptococci isolated produced IgA1 protease, including all isolates of Streptococcus oralis and S. sanguis, 60.7% of S. mitis biovar 1 isolates, and some isolates that could not be identified. Three cleavage patterns of alpha 1 heavy chains were observed. Six isolates of S. mitis biovar 1 that did not produce IgA1 protease attacked the alpha 1 chain. Incubation of IgA1 protease-negative S. mitis biovar 1 isolates with IgA1, either prior to or together with S. sanguis, rendered the IgA1 paraprotein resistant to cleavage by the IgA1 protease of S. sanguis. The ability of some pioneer streptococci in the human oral cavity to produce IgA1 protease and of others to modify the susceptibility of IgA1 to cleavage by IgA1 protease perhaps enhances their ability to survive in this habitat.

Adolescent suicide: music preference as an indicator of vulnerability

OBJECTIVE

This preliminary study investigated possible relationships between adolescents' music preference and aspects of their psychological health and lifestyle.

METHOD

Students (mean age 14.76 years) from two randomly chosen high schools completed self-report questionnaires on preferred music types and messages in the music. In addition the Youth Self-Report provided information about suicide ideation, deliberate self-harm, "depression," and "delinquency." Brief risk taking and drug taking scales were administered in addition to questions about family environment.

RESULTS

A marked gender bias was shown to exist with 74% of girls preferring pop music compared with 70.7% of boys preferring rock/metal. Significant associations appear to exist between a preference for rock/metal and suicidal thoughts, acts of deliberate self-harm, "depression," "delinquency," drug taking, and family dysfunction. This was all particularly true for girls. In addition, feeling sadder after listening to the preferred music appeared to distinguish the most disturbed group.

CONCLUSIONS

The authors recommend that further academic study of these associations is warranted. Both preference for rock/metal music, particularly in girls, and feeling worse after listening to the music may be indicators in adolescents of vulnerability to suicidal thoughts and actions.

Formal measurement of pain by nurses

How often have we heard nurses complain because doctors have not prescribed adequate pain relief for patients? Nurses, however, are just as guilty as doctors of not managing patients with acute and chronic pain adequately. Concern that nurses in her district were not using, or were using inappropriately, pain assessment tools prompted the author to undertake a small survey of current practice. The results confirmed her suspicions, but subsequent continuing education programmes on pain management seem to be helping to raise nurses' awareness of their responsibilities in this crucial area of care.