Testing pulmonary physiology in ventilated non-human primates.

BACKGROUND: Animal models of respiratory viral infections are essential for investigating disease pathogenesis and the efficacy of antivirals and vaccine candidates. A major limitation in the research of respiratory diseases in animal models is correlating clinically relevant changes in pulmonary physiology with cellular and molecular mechanistic studies. Few animal models have captured and correlated physiologic changes in lung function and immune response within same experiment, which is critical given the heterogeneous nature of lung disease due to viral infections. In ventilated human patients, pulmonary physiology testing can be used to not only capture oxygenation, ventilation, but also pulmonary mechanics to yield quantitative measures of lung function and scalar tracings of flow-volume and pressure-volume loops. Application of this protocol during mechanical ventilation in non-human (NHP) models would represent a major advance in respiratory viral disease research. METHODS: We have applied and optimized a human pulmonary physiology testing protocol to ventilated pigtail macaques (Macaca nemestrina) at baseline and 5 days after influenza A (IAV) viral inoculation. RESULTS: The NHPs manifested clinical disease with hypothermia and loss of body weight. Declines in lung function were striking with a 66%-81% decline in P/F ratio, a measure of oxygenation reflecting the ratio of partial pressure of oxygen in arterial blood (PaO2 ) to the fraction of inspiratory oxygen concentration (FiO2 ). There was also a 16%-45% decline in lung compliance. CONCLUSION: We describe a new approach to performing pulmonary physiology testing protocol in non-human primates to better capture quantitative correlates of respiratory disease and demonstrate protection by therapeutics and vaccines.

Australian medical radiation practitioners perspectives of continuing professional development: An online cross-sectional study.

INTRODUCTION: Continuing professional development (CPD) is mandatory for registered Australian medical radiation practitioners (MRPs) to maintain competence in their respective scopes of practice. The aim of this study was to explore MRPs attitudes, opinions and satisfaction towards CPD activities offered by the Australian Society of Medical Imaging and Radiation Therapy (ASMIRT). METHODS: An online cross-sectional survey was emailed to 6398 ASMIRT members and included questions on: demographics, ASMIRT CPD activities, learning mode preferences, barriers and perceptions of CPD outcomes. Data were analysed using descriptive statistics and chi-square tests. RESULTS: The survey was completed by 1018 MRPs. While MRPs were satisfied with face-to-face CPD quality (n = 540, 58.1%) and provision (n = 492, 55.3%), they were dissatisfied with the quantity of online CPD activities (n = 577, 65.1%) delivered by ASMIRT. Online learning was the most preferred mode of CPD delivery (n = 749, 74.2%), followed by face-to-face (n = 643, 64.0%) and collaborative learning (n = 539, 53.4%). Younger participants (19-35 years) had positive opinions regarding ASMIRT CPD activities and outcomes. Access to professional development leave (PDL) supported achievement of mandatory CPD requirements (P < 0.001). Lack of time, lack of access and workload were the highest ranked barriers preventing CPD participation. Rural/remote MRPs were dissatisfied with availability (P = 0.023), access (P < 0.001) and adequacy of ASMIRT provided CPD (P < 0.01) and were more likely to encounter barriers to CPD participation (P < 0.001). CONCLUSIONS: Many MRPs experienced barriers which prevented them from participating in CPD. Provision of more online CPD activities by ASMIRT and access to PDL can assist. Future improvements will ensure MRPs remain motivated to engage in CPD to improve clinical skills, patient safety and health outcomes.

Determining the Research Priorities for Adult Primary Brain Tumours in Australia and New Zealand: A Delphi Study with Consumers, Health Professionals, and Researchers.

The aim of this project was to determine research priorities, barriers, and enablers for adult primary brain tumour research in Australia and New Zealand. Consumers, health professionals, and researchers were invited to participate in a two-phase modified Delphi study. Phase 1 comprised an initial online survey (n = 91) and then focus groups (n = 29) which identified 60 key research topics, 26 barriers, and 32 enablers. Phase 2 comprised two online surveys to (1) reduce the list to 37 research priorities which achieved consensus (>75% 2-point agreement) and had high mean importance ratings (n = 116 participants) and (2) determine the most important priorities, barriers, and enablers (n = 90 participants). The top ten ranked research priorities for the overall sample and sub-groups (consumers, health professionals, and researchers) were identified. Priorities focused on: tumour biology, pre-clinical research, clinical and translational research, and supportive care. Variations were seen between sub-groups. The top ten barriers to conducting brain tumour research related to funding and resources, accessibility and awareness of research, collaboration, and process. The top ten research enablers were funding and resources, collaboration, and workforce. The broad list of research priorities identified by this Delphi study, together with how consumers, health professionals, and researchers prioritised items differently, and provides an evidence-based research agenda for brain tumour research that is needed across a wide range of areas.

Supportive care of patients diagnosed with high grade glioma and their carers in Australia.

PURPOSE: This study aimed to: determine the supportive care available for Australian patients with High Grade Glioma (HGG) and their carers; identify service gaps; and inform changes needed to implement guidelines and Optimal Care Pathways. METHODS: This cross-sectional online survey recruited multidisciplinary health professionals (HPs) who were members of the Cooperative Trials Group for Neuro-Oncology involved in management of patients diagnosed with HGG in Australian hospitals. Descriptive statistics were calculated. Fisher's exact test was used to explore differences between groups. RESULTS: 42 complete responses were received. A majority of MDT meetings were attended by a: neurosurgeon, radiation oncologist, medical oncologist, radiologist, and care coordinator. Less than 10% reported attendance by a palliative care nurse; physiotherapist; neuropsychologist; or speech therapist. Most could access referral pathways to a cancer care coordinator (76%), neuropsychologist (78%), radiation oncology nurse (77%), or psycho-oncologist (73%), palliative care (93-100%) and mental health professionals (60-85%). However, few routinely referred to an exercise physiologist (10%), rehabilitation physician (22%), dietitian (22%) or speech therapist (28%). Similarly, routine referrals to specialist mental health services were not standard practice. Nearly all HPs (94%) reported HGG patients were advised to present to their GP for pre-existing conditions/comorbidities; however, most HPs took responsibility (≤ 36% referred to GP) for social issues, mental health, symptoms, cancer complications, and treatment side-effects. CONCLUSIONS: While certain services are accessible to HGG patients nationally, improvements are needed. Psychosocial support, specialist allied health, and primary care providers are not yet routinely integrated into the care of HGG patients and their carers despite these services being considered essential in clinical practice guidelines and optimal care pathways.

Effectiveness of online communication skills training for cancer and palliative care health professionals: A systematic review.

OBJECTIVE: To determine the reported effect of online communication skills training (CST) on health professional (HP) communication skills and patient care outcomes in cancer and palliative care. METHODS: Primary research published in English between January 2003 and April 2019 was identified in bibliographic databases including Medline, Embase and Proquest (Prospero: CRD42018088681). An integrated mixed-method approach included studies describing a CST intervention and its effect, for cancer or palliative care HPs, delivered online or blended with an online component. Included studies' outcomes were categorised then findings were stratified by an evaluation framework and synthesised in an effect direction plot. Risk of bias was assessed using Joanna Briggs Institute's tools. RESULTS: Nineteen included studies (five randomised controlled trials, 11 pre-post, two post-test and one qualitative study) evaluated a CST intervention (median duration = 3.75 h; range 0.66-96 h) involving 1116 HPs, 422 students and 732 patients. Most interventions taught communication skills for specific scenarios and approximately half were delivered solely online and did not involve role plays. Online CST improved HPs' self-assessed communication skills (three studies, 215 participants), confidence (four studies, 533 participants), and objective knowledge (five studies, 753 participants). While few studies evaluated patient outcomes, CST may benefit observed communication skills in care settings (two studies, 595 participants). CONCLUSIONS: Online CST benefits oncology HPs' subjectively-reported communication skills and confidence, and objective knowledge. Translation to patient outcomes requires further investigation. The quality of research varied and few studies had a control group. We recommend improvements to study design, evaluation and implementation.

Oxytocin and pair compatibility in adult male rhesus macaques (Macaca mulatta).

Pair housing is considered one of the best ways of promoting psychological wellbeing for caged macaques. However, incompatible partnerships can result in stress or aggression. Though previous studies have analyzed the role of variables such as age, weight, gender, and temperament on pair compatibility, few have examined the relationship between physiological parameters and pair compatibility. Oxytocin is known to promote prosocial nonsexual behavior in various primate species and may serve as an indicator of pair compatibility. In this study, we examined the association between peripheral oxytocin levels and prosocial behaviors in isosexual pairs of male rhesus macaques. We hypothesized that animals that demonstrated high levels of prosocial behaviors would have higher oxytocin levels than those showing low levels of the behavior. In addition, to elucidate the relationship between oxytocin and compatibility, we compared peripheral oxytocin between the highly affiliative animals and single-housed males identified as having multiple unsuccessful pair attempts with multiple partners. We collected plasma oxytocin on 40 pairs of monkeys that had lived together for at least 1 month and 20 single-housed animals. Further, we simultaneously collected behavioral data on the pairs, recording prosocial interactions (e.g., groom, play). Oxytocin varied among individuals, but was highly correlated between members of a pair (r = 0.58, p < .001). Additionally, prosocial behavior was positively correlated with plasma oxytocin (r = 0.38, p < .02). However, contrary to our expectations, oxytocin did not differ between single and highly affiliative pair-housed animals (F(1,38) = 0.71, p = .40). Our results suggest that oxytocin may be associated with the quality of isosexual pairs of male macaques. More work is needed to determine the nature of this relationship.

Candida albicans-associated sepsis in a pre-term neonatal rhesus macaque (Macaca mulatta).

Invasive Candida infections (ICI) have been associated with neurodevelopmental impairment or death in human pre-term neonates. Candidiasis in nonhuman primates is seen mostly in immunosuppressed animals, and ICI is not commonly reported. Here, we report a case of Candida albicans-associated ICI in a pre-term neonatal rhesus macaque.

Systematic review and meta-analysis of patient reported outcomes for nurse-led models of survivorship care for adult cancer patients.

PURPOSE: This systematic review aimed to determine the effectiveness of nurse-led cancer survivorship care, compared with existing models of care, on patient reported outcomes for cancer survivors. METHODS: Randomised and non-randomised controlled trials and controlled before-after studies published in English between 1 January 2007 and 28 July 2017 were identified in bibliographic databases including Medline, Pubmed and PsychINFO. Included studies described nurse-led cancer care after treatment to adults (age ≥18 years) <2 years post treatment completion. Risk of bias was assessed using Joanna Briggs Institute's tools and meta-analysis was undertaken. RESULTS: Twenty one publications were included describing 15 tumour-specific trials involving 3278 survivors of breast (n = 5), gynecological (n = 3), head and neck (n = 2), colorectal (n = 2), upper gastrointestinal (n = 2) and prostate (n = 1) cancers. Seven trials reported quality of life (QoL) using the EORTC QLQ-C30; participants receiving nurse-led care (4-6 months) had better cognitive (4 trials, 463 participants; mean difference [MD] = 4.04 [95% CI, 0.59-7.50]; p = 0.02) and social functioning (4 trials, 463 participants; MD = 3.06 [0.14-5.97]; p = 0.04) but worse appetite loss (3 trials, 354 participants; MD = 4.43 [0.08-8.78]; p = 0.05). After intervention completion, intervention participants had reduced fatigue (4 trials, 647 participants; MD = -4.45 [-7.93 to -0.97]; p = 0.01). CONCLUSION: This systematic review synthesised outcomes of models of nurse-led survivorship care and contributes a meta-analysis of patient QoL to survivorship evidence. This review was limited by the risk of bias in many included studies for blinding of treatment personnel and outcome assessors. Nurse-led care appears beneficial for cancer survivors for some QoL domains.

Inhibition of CYP2E1 attenuates myocardial dysfunction in a murine model of insulin resistance through NLRP3-mediated regulation of mitophagy.

Insulin resistance leads to myocardial contractile dysfunction and deranged autophagy although the underlying mechanism or targeted therapeutic strategy is still lacking. This study was designed to examine the impact of inhibition of the cytochrome P450 2E1 (CYP2E1) enzyme on myocardial function and mitochondrial autophagy (mitophagy) in an Akt2 knockout model of insulin resistance. Adult wild-type (WT) and Akt2-/- mice were treated with the CYP2E1 inhibitor diallyl sulfide (100 mg/kg/d, i.p.) for 4 weeks. Cardiac geometry and function were assessed using echocardiographic and IonOptix systems. Western blot analysis was used to evaluate autophagy, mitophagy, inducible NOS (iNOS), and the NLRP3 inflammasome, a multi-protein intracellular pattern recognition receptor complex. Akt2 deletion triggered insulin resistance, compromised cardiac contractile and intracellular Ca2+ property, mitochondrial ultrastructural damage, elevated O2- production, as well as suppressed autophagy and mitophagy, accompanied with elevated levels of NLRP3 and iNOS, the effects of which were significantly attenuated or ablated by diallyl sulfide. In vitro studies revealed that the NLRP3 activator nigericin nullified diallyl sulfide-offered benefit against Akt2 knockout on cardiomyocyte mechanical function and mitophagy (using Western blot and colocalization of GFP-LC3 and MitoTracker Red). Moreover, inhibition of iNOS but not mitochondrial ROS production attenuated Akt2 deletion-induced activation of NLRP3, substantiating a role for iNOS-mediated NLRP3 in insulin resistance-induced changes in mitophagy and cardiac dysfunction. In conclusion, these data depict that insulin resistance through CYP2E1 may contribute to the pathogenesis of myopathic changes including myocardial contractile dysfunction, oxidative stress and mitochondrial injury, possibly through activation of iNOS and NLRP3 signaling.

Sustainability of the Australian radiation oncology workforce: A survey of radiation therapists and radiation oncology medical physicists.

This study aimed to determine and compare Radiation Therapists' (RTs') and Radiation Oncology Medical Physicists' (ROMPs') perspectives about their profession and workplace, satisfaction with career progression opportunities, and leaving the current workplace. RTs and ROMPs who were currently or had previously worked in Australia were invited to complete an online survey. Univariate and multivariate methods were used for analysis. Participants were 342 RTs and 112 ROMPs with estimated response rates of 14% and 26% respectively. Both professions rated workload poorly and identified the need for improvement in: communication between professions' members, support for junior staff/new graduates, staff morale, on-site training and multidisciplinary communication. RTs, more than ROMPs, perceived their profession was recognised and respected, but RTs were less likely to be satisfied with career progression/advancement, job promotion prospects and opportunities to specialise. At least 20% of RTs and ROMPs were thinking about leaving their workplace and 13% of RTs and 8% of ROMPs were thinking about leaving their profession. Different factors contributed to workforce satisfaction and retention within each profession. Staff satisfaction and career progression are critical to retain RTs and ROMPs. Further research is required to explore strategies to address workplace dissatisfaction, recruitment and retention.

Nonreducible Inguinal Hernia Containing the Uterus and Bilateral Adnexa in a Rhesus Macaque (Macaca mulatta).

Inguinal herniation of abdominal viscera is a relatively common condition in both humans and domestic animal species. In captive rhesus macaques (Macaca mulatta), the highest incidence occurs in overweight, aged males. However, inguinal herniation of the uterus with bilateral adnexa is extremely rare in both human and veterinary medicine. Here we report a previously undescribed uterine inguinal herniation with bilateral adnexa in a 3-y-old female rhesus macaque. Although uterine herniation remains a rare condition in rhesus macaques, it should be considered as a differential diagnosis in animals with unilateral subcutaneous enlargements in the inguinal region.

Does one workshop on respecting cultural differences increase health professionals' confidence to improve the care of Australian Aboriginal patients with cancer? An evaluation.

BACKGROUND: Aboriginal Australians have worse cancer survival rates than other Australians. Reasons include fear of a cancer diagnosis, reluctance to attend mainstream health services and discrimination from health professionals. Offering health professionals education in care focusing on Aboriginal patients' needs is important. The aim of this paper was to evaluate whether participating in a workshop improved the confidence of radiation oncology health professionals in their knowledge, communication and ability to offer culturally safe healthcare to Aboriginal Australians with cancer. METHODS: Mixed methods using pre and post workshop online surveys, and one delivered 2 months later, were evaluated. Statistical analysis determined the relative proportion of participants who changed from not at all/a little confident at baseline to fairly/extremely confident immediately and 2 months after the workshop. Factor analysis identified underlying dimensions in the items and nonparametric tests recorded changes in mean dimension scores over and between times. Qualitative data was analysed for emerging themes. RESULTS: Fifty-nine participants attended the workshops, 39 (66% response rate) completed pre-workshop surveys, 32 (82% of study participants) completed post-workshop surveys and 25 (64% of study participants) completed surveys 2 months later. A significant increase in the proportion of attendees who reported fair/extreme confidence within 2 days of the workshop was found in nine of 14 items, which was sustained for all but one item 2 months later. Two additional items had a significant increase in the proportion of fair/extremely confident attendees 2 months post workshop compared to baseline. An exploratory factor analysis identified three dimensions: communication; relationships; and awareness. All dimensions' mean scores significantly improved within 2 days (p < 0.005) and persisted to 2 months. The workshop raised awareness about barriers and enablers to delivering services respectful of cultural differences, led to a willingness to reflect on pre-existing beliefs and assumptions about Aboriginal Australians that in some cases resulted in improved care. CONCLUSION: Single workshops co-delivered by an Aboriginal and non-Aboriginal presenter can be effective in building health professionals' confidence and translating into practice knowledge of respectful care of Aboriginal patients with cancer. Sustaining improvements may require integrating this approach into ongoing professional development.

Radiation therapists' perspectives on participating in research.

INTRODUCTION: The objectives of this research were to: (1) determine the extent of Australian radiation therapists (RTs) research participation; (2) evaluate the impact of research involvement on career perceptions (3) explore which research topics require investigation and (4) identify benefits and barriers to research participation. METHODS: This study used mixed methods to collect qualitative and quantitative data using an online survey from a larger workforce study of RTs and radiation oncology medical physicists. Participants practising in Australia completed questions about their research involvement. Chi-square tests and logistic regression were used to analyse quantitative data and content analysis was used to explore qualitative data. RESULTS: Two hundred and ninety-six RTs answered the research questions. Forty-six percent had been involved in research. Of these, 91% had been involved in departmental, 28% in national, 14% in international and 29% in informal or self-directed research studies. Eleven RTs (8%) had received funding as a chief/principal investigator. Involvement in research was associated with a desire to make a career change. However, it also appeared to be associated with greater satisfaction with career progression and staying in the career. Respondents identified a range of potential research topics, benefits of participating in research and barriers which included lack of time, support and cost. CONCLUSION: Almost half of the RT participants identified that they were participating in research. Our data suggest that continued involvement in research, and opportunities to participate, improve RT job satisfaction. RTs' research activities are likely to be extended through provision of additional time and support.

Cytomegaloviral hypophysitis in a simian immunodeficiency virus-infected rhesus macaque (Macacca mulatta).

Rhesus macaques experimentally infected with Simian Immunodeficiency Virus (SIV) experience immunosuppression and often opportunistic infection. Among the most common opportunistic infections are rhesus cytomegalovirus (RhCMV), a ubiquitous betaherpesvirus that undergoes continuous low-level replication in immunocompetent monkeys. Upon SIV-mediated immunodeficiency, RhCMV reactivates and results in lesions in numerous organ systems including the nervous and reproductive systems. We report the first case of cytomegaloviral hypophysitis in a SIV-immunocompromised rhesus macaque.

An assessment of radiation oncology medical physicists' perspectives on undertaking research.

As part of a study of the radiation oncology workforce, radiation oncology medical physicists (ROMPs) who had worked in Australia were surveyed regarding their attitudes to participating in research. Responses from 88 ROMPs were available for analysis, representing a broad mix of employment situations and research experience. Greater than 70% of ROMPs described their involvement in research as "liking it" or "loving it", with associated identified benefits including skills development, job satisfaction and career progression. Over half of respondents agreed that involvement in research inspired them to stay in their profession. However, lack of time, support and motivation were all identified as barriers to participation in research. Areas of research interest were identified. This study highlights the importance of a research culture for job satisfaction and staff retention.

Obesity increases the risk of failure of noninvasive prenatal screening regardless of gestational age.

BACKGROUND: Noninvasive prenatal screening has become an increasingly prevalent choice for women who desire aneuploidy screening. Although the test characteristics are impressive, some women are at increased risk for noninvasive prenatal screen failure. The risk of test failure increases with maternal weight; thus, obese women may be at elevated risk for failure. This risk of failure may be mitigated by the addition of a paternal cheek swab and screening at a later gestational age. OBJECTIVE: The purpose of this study was to evaluate the association among obesity, gestational age, and paternal cheek swab in the prevention of screening failure. STUDY DESIGN: A retrospective cohort study was performed for women who were ≥35 years old at delivery who underwent screening at NorthShore University HealthSystem, Evanston, IL. Maternal weight, body mass index, gestational age, and a paternal cheek swab were evaluated in univariate and multivariable logistic regression analyses to assess the association with failed screening. RESULTS: Five hundred sixty-five women met inclusion criteria for our study. The mean body mass index was 25.9 ± 5.1 kg/m(2); 111 women (20%) were obese (body mass index, ≥30 kg/m(2)). Forty-four women (7.8%) had a failed screen. Obese women had a failure rate of 24.3% compared with 3.8% in nonobese women (P < .01). Gestational age was not associated with failure rate (mean ± standard deviation, 13 ± 3 weeks for both screen failure and nonfailure; P = .76). The addition of a paternal cheek swab reduced the failure rate from 10.2% in women with no swab to 3.8% in women with a swab (P < .01). In multivariable analysis, obesity and lack of a paternal cheek swab were independent predictors of screen failure (odds ratio, 9.75; 95% confidence interval, 4.85-19.61; P < .01; and odds ratio, 3.61; 95% confidence interval, 1.56-8.33; P < .01, respectively). CONCLUSION: The addition of a paternal cheek swab significantly improved noninvasive prenatal screen success rates in obese women. However, delaying testing to a later gestational age did not.

Rating general practitioner consultation performance in cancer care: does the specialty of assessors matter? A simulated patient study.

BACKGROUND: Patients treated for prostate cancer may present to general practitioners (GPs) for treatment follow up, but may be reticent to have their consultations recorded. Therefore the use of simulated patients allows practitioner consultations to be rated. The aim of this study was to determine whether the speciality of the assessor has an impact on how GP consultation performance is rated. METHODS: Six pairs of scenarios were developed for professional actors in two series of consultations by GPs. The scenarios included: chronic radiation proctitis, Prostate Specific Antigen (PSA) 'bounce', recurrence of cancer, urethral stricture, erectile dysfunction and depression or anxiety. Participating GPs were furnished with the patient's past medical history, current medication, prostate cancer details and treatment, details of physical examinations. Consultations were video recorded and assessed for quality by two sets of assessors- a team of two GPs and two Radiation Oncologists deploying the Leicester Assessment Package (LAP). LAP scores by the GPs and Radiation Oncologists were compared. RESULTS: Eight GPs participated. In Series 1 the range of LAP scores by GP assessors was 61%-80%, and 67%-86% for Radiation Oncologist assessors. The range for GP LAP scores in Series 2 was 51%- 82%, and 56%-89% for Radiation Oncologist assessors. Within GP assessor correlations for LAP scores were 0.31 and 0.87 in Series 1 and 2 respectively. Within Radiation Oncologist assessor correlations were 0.50 and 0.72 in Series 1 and 2 respectively. Radiation Oncologist and GP assessor scores were significantly different for 4 doctors and for some scenarios. Anticipatory care was the only domain where GPs scored participants higher than Radiation Oncologist assessors. CONCLUSION: The assessment of GP consultation performance is not consistent across assessors from different disciplines even when they deploy the same assessment tool.

Supporting patients treated for prostate cancer: a video vignette study with an email-based educational program in general practice.

BACKGROUND: Men who have been treated for prostate cancer in Australia can consult their general practitioner (GP) for advice about symptoms or side effects at any time following treatment. However, there is no evidence that such men are consistently advised by GPs and patients experience substantial unmet need for reassurance and advice. OBJECTIVE: The intent of the study was to evaluate a brief, email-based educational program for GPs to manage standardized patients presenting with symptoms or side effects months or years after prostate cancer treatment. METHODS: GPs viewed six pairs of video vignettes of actor-patients depicting men who had been treated for prostate cancer. The actor-patients presented problems that were attributable to the treatment of cancer. In Phase 1, GPs indicated their diagnosis and stated if they would prescribe, refer, or order tests based on that diagnosis. These responses were compared to the management decisions for those vignettes as recommended by a team of experts in prostate cancer. After Phase 1, all the GPs were invited to participate in an email-based education program (Spaced Education) focused on prostate cancer. Participants received feedback and could compare their progress and their performance with other participants in the study. In Phase 2, all GPs, regardless of whether they had completed the program, were invited to view another set of six video vignettes with men presenting similar problems to Phase 1. They again offered a diagnosis and stated if they would prescribe, refer, or order tests based on that diagnosis. RESULTS: In total, 64 general practitioners participated in the project, 57 GPs participated in Phase 1, and 45 in Phase 2. The Phase 1 education program was completed by 38 of the 57 (59%) participants. There were no significant differences in demographics between those who completed the program and those who did not. Factors determining whether management of cases was consistent with expert opinion were number of sessions worked per week (OR 0.78, 95% CI 0.67-0.90), site of clinical practice (remote practice, OR 2.25, 95% CI 1.01-5.03), number of patients seen per week (150 patients or more per week, OR 10.66, 95% CI 3.40-33.48), and type of case viewed. Completion of the Spaced Education did impact whether patient management was consistent with expert opinion (not completed, OR 0.88, 95% CI 0.5-1.56). CONCLUSIONS: The management of standardized patients by GPs was particularly unlikely to be consistent with expert opinion in the management of impotence and bony metastasis. There was no evidence from this standardized patient study that Spaced Education had an impact on the management of patients in this context. However, the program was not completed by all participants. Practitioners with a greater clinical load were more likely to manage cases as per expert opinion.