Referral practices of recent graduate and experienced physiotherapists working in Australian primary care for people with musculoskeletal conditions.

BACKGROUND: People with musculoskeletal conditions often seek care from physiotherapists. Some, particularly those at risk of poor outcomes, may benefit from referral to physiotherapists with expertise in managing musculoskeletal conditions and/or multidisciplinary care. Understanding referral practices of physiotherapists, and how experience influences those practices, may assist in implementing optimal care pathways in primary care. AIMS: Explore (i) current referral practices of recent graduate and experienced physiotherapists who manage musculoskeletal conditions; (ii) opinions about referral to specialist physiotherapists for people at risk of poor outcomes. METHODS: This qualitative study consisted of 23 semi-structured interviews with recent graduate (n = 9) and experienced physiotherapists (n = 14) working in primary care. Perspectives of participants' current referral practices (to whom, when and why they are referred) and referral to specialist physiotherapists were sought. Interviews were recorded and transcribed verbatim prior to analysis. RESULTS: Referral practices for both groups were influenced by specific diagnoses, complexity of presentations, confidence, self-awareness, the clinical environment and system-related factors. Experienced physiotherapists were more confident and specific in their referrals and had established trusted networks compared with new graduates. Early referral to specialist physiotherapists was more likely when therapists were co-located. Barriers to early referral were lack of awareness, health system factors and impact on the patient (e.g., financial, time, continuity of care). CONCLUSION: Understanding factors influencing referral decisions may improve both intra- and interprofessional care for people with musculoskeletal conditions. Referral of people at risk of poor outcomes to specialist physiotherapists may be improved by greater intraprofessional awareness and clarity of roles.

Developing a spinal cord injury research strategy using a structured process of evidence review and stakeholder dialogue. Part III: outcomes.

STUDY DESIGN: Focus Group. OBJECTIVES: To develop a unified, regional spinal cord injury (SCI) research strategy for Australia and New Zealand. SETTING: Australia. METHODS: A 1-day structured stakeholder dialogue was convened in 2013 in Melbourne, Australia, by the National Trauma Research Institute in collaboration with the SCI Network of Australia and New Zealand. Twenty-three experts participated, representing local and international research, clinical, consumer, advocacy, government policy and funding perspectives. Preparatory work synthesised evidence and articulated draft principles and options as a starting point for discussion. RESULTS: A regional SCI research strategy was proposed, whose objectives can be summarised under four themes. (1) Collaborative networks and strategic partnerships to increase efficiency, reduce duplication, build capacity and optimise research funding. (2) Research priority setting and coordination to manage competing studies. (3) Mechanisms for greater consumer engagement in research. (4) Resources and infrastructure to further develop SCI data registries, evaluate research translation and assess alignment of research strategy with stakeholder interests. These are consistent with contemporary international SCI research strategy development activities. CONCLUSION: This first step in a regional SCI research strategy has articulated objectives for further development by the wider SCI research community. The initiative has also reinforced the importance of coordinated, collective action in optimising outcomes following SCI.

The AuSpinal: a test of hand function for people with tetraplegia.

STUDY DESIGN: Five-phased reliability and validity study. OBJECTIVES: To develop and test an assessment tool designed to quantify unilateral hand function in people with tetraplegia. SETTING: Seven spinal injury units in Australia. METHODS: The AuSpinal is a new assessment tool comprising seven tasks designed to quantify unilateral hand function in people with tetraplegia. There were five phases in this study: (1) development of the AuSpinal; (2) testing the test-retest and intrarater reliability of repeat ratings of 84 videos as determined by 13 therapists; (3) testing the interrater reliability and internal consistency of simultaneous real-life ratings of eight hands as determined by six therapists; (4) testing the range of scores from cross-sectional data obtained from 50 hands; and (5) quantifying sensitivity to change from longitudinal data collected over the course of rehabilitation from 16 hands. RESULTS: The test-retest, intrarater and interrater reliabilities were high (intraclass correlation coefficients ranged from 0.79 to 0.98, 95% CI ranged from 0.72 to 1.0) with a Cronbach α-value of 0.93. There was a reasonable range in the scores obtained from the cross-sectional data of the 50 hands (interquartile range extended from 6 to 14). There was an obvious and marked change in AuSpinal scores over the course of patients' rehabilitation in 8 of the 16 hands. CONCLUSION: The AuSpinal provides a quick and reliable instrument to test hand function in people with tetraplegia. It is useful for people with poor hand function but requires the addition of more complex tasks for those with good hand function.

Dissolved oxygen as a physico-chemical supporting element in the Water Framework Directive.

For transitional and coastal waters the Water Framework Directive identifies 5 "General chemical and physiochemical elements supporting the biological elements". The five elements are transparency, thermal conditions, oxygenation conditions, salinity and nutrient conditions. "Supporting" in the context of the directive means that the values of the physicochemical quality elements are such as to support a biological community of a certain ecological status, recognising the fact that biological communities are products of their physical and chemical environment. Physicochemical and hydromophological aspects fundamentally determine the type of water body and habitat, and hence the type specific biological community. The directive does not intended that these supporting elements should be used as surrogates for the biological elements in monitoring. The monitoring and assessment of the physical and physicochemical quality elements will support the interpretation, assessment and classification of the results arising from the monitoring of the biological quality elements. This paper considers the challenges involved in the development of oxygen standards for the directive, their relationship to the biological elements and normative conditions of the directive and to regulatory requirements.

The strength-duration curve and its importance in pacing efficiency: a study of 325 pacing leads in 229 patients.

Pacemaker battery life is dependent on programmable parameters, principally pulse amplitude and pulse duration. High factory default settings cause excessive current drain. The strength-duration curve relates pacing threshold to pulse duration. The most energy efficient pacing occurs at chronaxie, a value of pulse duration derived from the curve. Strength-duration curves were calculated for 325 acutely implanted pacing leads. Chronaxie and rheobase were compared for atrial and ventricular leads. Chronaxie was compared with actual programmed pulse duration. There were 101 atrial and 224 ventricular leads, all passive fixation. The curve fit was good, (mean error +/- SD) 0.024 +/- 0.06 V for atrial curves and 0.008 +/- 0.034 V for ventricular curves. Mean (+/- SD) atrial and ventricular chronaxies were 0.24 +/- 0.07 ms and 0.25 +/- 0.07 ms, respectively. A "Z" value of 1.4 indicated that chronaxies might have been from the same population. Mean (+/- SD) atrial and ventricular rheobases were 0.51 +/- 0.2 V and 0.35 +/- 0.13 V, respectively. A "Z" value of 7.1 (P < 0.001) suggested atrial and ventricular rheobases were from differing populations. All patients had factory default pulse durations of 0.45 ms or 0.5 ms, exceeding acute chronaxie by a factor of two, thus, demonstrating suboptimal pacing. We conclude that understanding the strength-duration curve is critical. Sensible programming of other pacing functions optimizes longevity. Battery drain is reduced by programming pulse duration to chronaxie with a doubling of voltage threshold at this point to achieve a safety margin. Further study of chronaxie drift with time is required.

Evaluation of hepatitis C virus glycoprotein E2 for vaccine design: an endoplasmic reticulum-retained recombinant protein is superior to secreted recombinant protein and DNA-based vaccine candidates.

Hepatitis C virus (HCV) is the leading causative agent of blood-borne chronic hepatitis and is the target of intensive vaccine research. The virus genome encodes a number of structural and nonstructural antigens which could be used in a subunit vaccine. The HCV envelope glycoprotein E2 has recently been shown to bind CD81 on human cells and therefore is a prime candidate for inclusion in any such vaccine. The experiments presented here assessed the optimal form of HCV E2 antigen from the perspective of antibody generation. The quality of recombinant E2 protein was evaluated by both the capacity to bind its putative receptor CD81 on human cells and the ability to elicit antibodies that inhibited this binding (NOB antibodies). We show that truncated E2 proteins expressed in mammalian cells bind with high efficiency to human cells and elicit NOB antibodies in guinea pigs only when purified from the core-glycosylated intracellular fraction, whereas the complex-glycosylated secreted fraction does not bind and elicits no NOB antibodies. We also show that carbohydrate moieties are not necessary for E2 binding to human cells and that only the monomeric nonaggregated fraction can bind to CD81. Moreover, comparing recombinant intracellular E2 protein to several E2-encoding DNA vaccines in mice, we found that protein immunization is superior to DNA in both the quantity and quality of the antibody response elicited. Together, our data suggest that to elicit antibodies aimed at blocking HCV binding to CD81 on human cells, the antigen of choice is a mammalian cell-expressed, monomeric E2 protein purified from the intracellular fraction.

Exposure of sows to Ascaris suum influences worm burden distributions in experimentally infected suckling piglets.

This paper reports on the influence of maternal exposure to Ascaris suum on worm burden distributions in experimentally infected piglets. In the first study, sows were inoculated before and during gestation (6 months, long-term exposure) with 10,000 A. suum eggs twice weekly. In a second study, sows were inoculated during gestation only (3 months, short-term exposure) with increasing doses of eggs (10,000-40,000 eggs twice weekly). Helminth-naive sows served as controls in both studies. The third study used the same design as the short-term exposure study, but piglets from exposed and control sows were cross-suckled within 4 h of birth before colostrum uptake. All piglets were inoculated 2 or 3 times with 50 A. suum eggs on days 4 and 7 (and 14) after birth, and left with the sows. At 10 weeks of age all piglets were necropsied, and liver lesions and worm burdens were recorded. Surprisingly, in piglets born to long-term exposed sows, the prevalence of A. suum infection and the mean worm burden were significantly higher than those in piglets from control sows. In contrast, neither worm burdens nor prevalence were significantly different between piglets from short-term exposed sows compared with their controls. In the cross-suckling experiment, 67% of piglets suckling control sows harboured worms at slaughter, compared with 15% of piglets suckling exposed sows. Maximum likelihood analysis of worm burden distribution and the degree of parasite aggregation showed 3 distinctly different types of overdispersed distributions: worm counts in piglets from control sows, in piglets from short-term exposed sows and in piglets from long-term exposed sows. When the worm burden data were analysed including the cross-suckled piglets by biological mother, it appeared that the control and short-term distributions converged and that only the long-term exposure was significantly different. Overall, the degree of parasite aggregation in piglets infected with A. suum decreased with exposure of the sows. A non-linear relationship was observed between prevalence of infection and mean worm burden, which was different for piglets from exposed and control sows, and similar to relationships of this type that previously have been found in human A. lumbricoides infections. It was concluded that in porcine A. suum infections maternal exposure alters the distribution of worms in their offspring, in which the duration of exposure appeared to be an important influence. The results of the cross-suckling further suggest that maternal factors, e.g. antibodies, are transferred via colostrum.

Performance tested method certification of BAX for Screening/Salmonella: a case study.

This report details the independent laboratory study of the BAX for Screening/Salmonella assay to complete AOAC Performance Tested Method certification. The performance of the BAX system was compared with those of BAM culture methods on food samples inoculated with Salmonella. This study validated product claims. Performance Tested Method status was granted for the screening assay.

A strategy for reducing the mortality rate from vasa previa using transvaginal sonography with color Doppler.

Vasa previa is a cause of sudden unanticipated fetal death, with a fetal mortality of 33-100%. Transvaginal sonography (TVS) and color Doppler may aid in making the diagnosis antenatally, allowing elective Cesarean delivery, thereby avoiding fetal death from exsanguination which would occur if the membranes were allowed to rupture in labor. Whilst it is not feasible to screen all pregnant women for vasa previa, antenatal examination with TVS and color Doppler of women at risk, specifically those with low-lying placentas, bi-lobed, multi-lobed and succenturiate-lobed placentas, multiple pregnancies and pregnancies resulting from in vitro fertilization may lead to antenatal diagnosis of the condition. We present the last three cases of vasa previa to have occurred in our institution, two of which were diagnosed antenatally using TVS and color Doppler. In all three cases, routine 20-week obstetric sonography revealed low-lying placentas; in only one of these did the placenta remain low at term. A low-lying placenta at 20 weeks may be a risk factor for vasa previa; we suggest that further studies be carried out to ascertain this. Judicious use of TVS and color Doppler in women considered at risk of vasa previa may help to reduce the mortality from this condition.

Inheritance of resistance to gray leaf spot in crosses involving selected resistant inbred lines of corn.

ABSTRACT Three populations derived from crosses of selected resistant inbreds (061, B37HtN, and DS:74:1071) with susceptible inbred FR1141 and a population derived from a cross of B37 x B37HtN were evaluated for gray leaf spot severity in 1992 and 1993 at Urbana, IL, and Andrews, NC. Populations included the susceptible parent (P(1)), the resistant parent (P(2)), F(1) and F(2) generations, backcrosses BCP(1) and BCP(2), and, when space and seed were available, one or more of the F(3), BCP(1)S(1), and BCP(2)S(1) generations. Plants at Urbana were inoculated, and naturally occurring disease was relied upon at Andrews. Individual plants were rated by visually estimating the percent leaf area blighted (necrotic). Generation mean analysis of data combined over years or locations indicated that a simple additive-dominance model was able to explain the inheritance of resistance for all populations. Dominance effects were detected in all population evaluated. For the FR1141 x 061 and FR1141 x B37HtN populations, dominance was significant at early ratings, but not at late ratings. Results from generation mean analysis for individual years, locations, and rating were variable.

Sibling sex ratio of boys with gender identity disorder.

Sibling sex ratio (the ratio of brothers to sisters) was calculated for 444 boys with gender identity disorder (or with behaviors consistent with this diagnosis). The probands were ascertained from several researchers with expertise with this disorder and from the English language case report literature between 1938 and 1995. Among the probands with at least one sibling (N = 333), the results showed that boys with gender identity disorder had a significant excess of brothers to sisters, 131.1:100, when compared with the expected secondary sex ratio of 106:100. The excess of brothers replicated a previous study by Blanchard, Zucker, Bradley, and Hume (1995), in which the sibling sex ratio was 140.6:100. Further analyses showed that the probands were born later relative to their brothers than they were relative to their sisters. These findings are amenable to several psychosocial and biological explanations, which require further investigation.

Phase II trial of tirapazamine combined with cisplatin in chemotherapy of advanced malignant melanoma.

PURPOSE: A phase II study was undertaken to determine the efficacy of tirapazamine (TPZ) combined with cisplatin (cDDP) in patients with metastatic melanoma. PATIENTS AND METHODS: Between June 1994 and November 1995, 48 patients with metastatic melanoma were treated with TPZ (260 mg/m2, administered intravenously over two hours) followed in one-hour by cDDP (75 mg/m2 over one hour) every 21 days. Sixteen patients had received prior chemotherapy, and 13 of these had failed to respond to prior cDDP. None of the patients had symptomatic brain metastasis. RESULTS: Nine patients had partial responses, with an overall response rate of 19% (95% confidence interval (95% CI) of 9%-33%). The median duration of response was six months. None of the responders had received prior chemotherapy. Responses were seen in 8 (33%, confidence interval of 16%-55%) of 24 patients with primary cutaneous melanoma who had received no prior chemotherapy and in the only patient with previously untreated conjunctival melanoma. There were no responders among the seven patients with choroidal melanoma and 16 patients with previously treated cutaneous melanoma. Two patients with partial responses were rendered free of gross disease surgically three months after completing eight courses of TPZ-cDDP; they remain free of tumor recurrence. Responses were seen in lymph nodes (27%), lung (26%), skin (20%), adrenal gland (20%), soft tissues (17%) and liver (17%). Common toxicities included muscle cramps, fatigue, gastrointestinal effects and peripheral neuropathy. Fatigue, nausea, vomiting, anorexia, and muscle cramps were grade 3 or 4 in less than 10% of the courses. Neutropenia and thrombocytopenia were rare. CONCLUSION: The TPZ-cDDP combination has definite activity against chemotherapy-naïve patients with cutaneous melanoma and warrant further studies in combination with other cytotoxic agents.

Compelling evidence for discretionary brain computed tomographic imaging in those patients with mild cognitive impairment after blunt trauma.

OBJECTIVE: To identify computed tomographic-detected intracranial hemorrhage (CTIH) risk factors and outcome in mild cognitive impairment (MCI) blunt trauma patients. METHODS: In 2,587 consecutive patients, 251 (9.7%) had CTIH. RESULTS: Analysis is on 2,252 direct transports with 163 CTIH, because transfers were different (7.2 vs. 26.3%, p < 0.0001). CTIH rates for patients age 14-60 and > 60 years were 6.3 and 15.9%, p = 0.001. In those 14-60 years (n = 2,032), CTIH (n = 128) was independently related to arrival Glasgow Coma Scale (GCS) score and cranial soft tissue injury (CSTI) (p = 0.0001). [table: see text] Craniotomy was < or = 0.6% in each group except GCS score of 13 with CSTI, 7.4%. Of those with CTIH, 98.4% survived. Of those at low risk (GCS score of 14 without CSTI and GCS score of 15), 1,504 had no CTIH. Of these, 64.4% were available for serial cognitive evaluation (noncranial injuries mandated hospitalization; tracheal intubation was not required). In those > 60 years (n = 220), CTIH (n = 35) was independently related to GCS and CSTI (p = 0.003). CTIH for GCS score of 15 without CSTI was 5.8%, but > or = 16% for others. One craniotomy was required. Of those with CTIH, 91.4% survived. CONCLUSIONS: In mild cognitive impairment patients triaged directly to a Level I trauma center, age, arrival GCS score, and cranial soft tissue injury are risk factors for CT-detected intracranial hemorrhage. Neurologic deterioration and death are infrequent. These data strongly suggest that observation and discretionary brain CT imaging are a rational approach for blunt-injury mild cognitive impairment.

Medication choices in juvenile rheumatoid arthritis.

This survey was performed to review medication usage by pediatric rheumatologists in the care of patients with juvenile rheumatoid arthritis (JRA). Prospective data from 50 patients per physician with JRA were recorded by six pediatric rheumatologists in the Fall of 1993. Naproxen was used most frequently-in 48% of all patients. Next in order of frequency were methotrexate (39%), prednisone (15%), tolmetin (12%), indomethacin (11%) and folic acid (10%). Salicylates (acetylsalicylic acid, trisalicylate and salsalate) were used in 7%, and myochrysine was used in 2% of patients. Overall, nonsteroidal anti-inflammatory drugs were used in 93% of all patients, slower-acting antirheumatic drugs (SAARDs) were used in 54% and prednisone in 15%.Medication usage varied by disease type in predictable ways but also varied by physician in ways that could not be accounted for by population differences. Methotrexate was the most-often used of all SAARDs and supplanted myochrysine in JRA. Naproxen was the most often used NSAID in the treatment of JRA and had largely supplanted salicylates. With the arrival of practice guidelines, reasons for and impact of these changes (as well as the interesting variations between physicians) will need to be examined.

Hydroxyl radical-mediated oxidation of serotonin: potential insights into the neurotoxicity of methamphetamine.

When incubated with a hydroxyl radical (HO.)-generating system (ascorbic acid/Fe(2+)-EDTA/O2/H2O2), 5-hydroxytryptamine (5-HT; serotonin) is rapidly oxidized initially to a mixture of 2,5-, 4,5-, and 5,6-dihydroxytryptamine (DHT). The major reaction product is 2,5-DHT, which at physiological pH exists as its keto tautomer, 5-hydroxy-3-ethylamino-2-oxindole (5-HEO). Rapid autoxidation of 4,5-DHT gives tryptamine-4,5-dione (T-4,5-D), which reacts with the C(3)-centered carbanion of 5-HEO to give 3,3'-bis(2-aminoethyl)-5-hydroxy-[3,7'-bi-1H-indole]-2,4',5'- 3H-trione (7). The latter slowly cyclizes to 3'-(2-aminoethyl)-1',6',7',8'-tetrahydro-5-hydroxy-spiro[3H-indole-3,9'- [9H]pyrrolo[2,3-f]quinoline]-2,4',5' (1H)-trione (9). A minor amount of T-4,5-D dimerizes to give 7,7'-bi-(5-hydroxytryptamine-4-one) (7,7'-D). In the presence of GSH, the reaction of T-4,5-D with 5-HEO is diverted and, in the presence of sufficient concentrations of this tripeptide, completely blocked. This is because GSH preferentially reacts with T-4,5-D to give 7-S-glutathionyltryptamine-4,5-dione (11). The results of this investigation suggest that 5,6-DHT, 5-HEO, 7, and 9 are products unique to the HO.-mediated oxidation of 5-HT. Thus, the observation of other investigators that 5,6-DHT is formed in the brains of rats following a large dose of methamphetamine (MA) suggests that this drug might evoke HO. formation. However, the present in vitro study indicates that 5,6-DHT is a rather minor, unstable product of the HO.-mediated oxidation of 5-HT and suggests that detection of 5-HEO, 7/9, and 11 in rat brain following MA administration could provide additional support for HO. formation. Furthermore, one or more of the intermediates and major products of oxidation of 5-HT by HO. might, in addition to 5,6-DHT, contribute to the MA-induced degeneration of serotonergic neurons.