Early psychological interventions for posttraumatic stress, depression and anxiety after traumatic injury: A systematic review and meta-analysis.

The psychological impacts of injury have significant long-term implications on injury recovery. This review examined the effectiveness of interventions delivered within three months of injury on reducing the severity of posttraumatic stress disorder (PTSD), anxiety and depression symptoms. A systematic search of seven databases (PsycINFO, Medline, Web of Science, CINAHL, Embase, Scopus and Cochrane Library) identified 15,224 records. 212 full-text articles were retrieved, 26 studies were included in narrative synthesis, and 12 studies with lower risk of bias were included in meta-analyses. Prolonged exposure, and cognitive and behavioural interventions elicited improvements in PTSD, anxiety and depression symptoms; multidisciplinary interventions improved PTSD and depression symptoms; and education-based interventions had little impact on any psychological symptoms. Studies comprising risk stratified or stepped care methods showed markedly greater population impact through better reach, implementation and adoption. Meta-analyses revealed small-medium reductions in PTSD symptoms over the first 12 months postinjury (SMD = 0.32 to 0.49) with clinically meaningful effects in 64% of studies; reduced depression symptoms at 0-3 (small effect; SMD = 0.34) and 6-12 months postinjury (medium effect; SMD = 0.60), with clinically meaningful effects in 40% of studies; but no pooled effects on anxiety symptoms at any time. Altogether, exposure- and CBT-based psychological interventions had the greatest impact on PTSD and depression symptoms postinjury when delivered within three months of injury, with risk-stratified, stepped care having the greatest population impact potential.

Informing Intervention Strategies to Reduce Energy Drink Consumption in Young People: Findings From Qualitative Research.

OBJECTIVE: To determine young people's knowledge of energy drinks (EDs), factors influencing ED consumption, and intervention strategies to decrease ED consumption in young people. DESIGN: Eight group interviews with young people (aged 12-25 years). SETTING: Community groups and secondary schools in Perth, Western Australia. PARTICIPANTS: Forty-one young people, 41% of whom were male and 73% of whom consumed EDs. PHENOMENON OF INTEREST: Factors influencing ED consumption and intervention strategies informed by young people to reduce ED consumption. ANALYSIS: Two researchers conducted a qualitative content analysis on the data using NVivo software. RESULTS: Facilitators of ED consumption included enhanced energy, pleasant taste, low cost, peer pressure, easy availability, and ED promotions. Barriers included negative health effects, unpleasant taste, high cost, and parents' disapproval. Strategies to reduce ED consumption included ED restrictions, changing ED packaging, increasing ED prices, reducing visibility in retail outlets, and research and education. CONCLUSION AND IMPLICATIONS: Because many countries allow the sale of EDs to people aged <18 years, identifying ways to minimize potential harm from EDs is critical. This study provided unique insights into intervention strategies suggested by young people to reduce ED consumption. In addition to more research and education, these strategies included policy changes targeting ED sales, packaging, price, and visibility. Future research might examine the feasibility of implementing such interventions.

Transition into the workplace: comparing health graduates' and organisational perspectives.

BACKGROUND: Health graduates face personal and work-related stressors during the graduate year. The extent to which employers and health graduates have a shared understanding of graduate stressors is unclear but may impact graduate support and transition into the health profession. Aim and design: The aim of this exploratory qualitative study was to identify factors that impact health graduates' transition and integration into the workplace, comparing the perspectives of health graduates and organisational representatives. METHOD: Individual and small group semi-structured interviews were conducted with 15 medical and 26 nursing graduates and five organisational representatives from a regional health organisation in Victoria, Australia. A thematic analysis was undertaken on the data. FINDINGS: Five main categories were identified: dealing with change, dealing with conflict, workload, taking responsibility and factors that influence performance. CONCLUSION: Similarities and differences in the perspectives of health graduates and organisational representatives were identified. These findings have implications for current graduate support programs.

Adolescent energy drink consumption: An Australian perspective.

Caffeinated Energy Drinks (EDs) are not recommended for consumption by children, yet there is a lack of age-specific recommendations and restrictions on the marketing and sale of EDs. EDs are increasingly popular among adolescents despite growing evidence of their negative health effects. In the current study we examined ED consumption patterns among 399 Australian adolescents aged 12-18 years. Participants completed a self-report survey of consumption patterns, physiological symptoms, and awareness of current ED consumption guidelines. Results indicated that ED consumption was common among the sample; 56% reported lifetime ED consumption, with initial consumption at mean age 10 (SD = 2.97). Twenty-eight percent of the sample consumed EDs at least monthly, 36% had exceeded the recommended two standard EDs/day, and 56% of consumers had experienced negative physiological health effects following ED consumption. The maximum number of EDs/day considered appropriate for children, adolescents, and adults varied, indicating a lack of awareness of current consumption recommendations. These findings add to the growing body of international evidence of adolescent ED consumption, and the detrimental impact of EDs to adolescent health. Enforced regulation and restriction of EDs for children's and adolescents' consumption is urgently needed in addition to greater visibility of ED consumption recommendations.

Refinement and validation of the Work Readiness Scale for graduate nurses.

The transition from student to registered nurse is often stressful and has been attributed to a lack of work readiness. Understanding what comprises work readiness for newly registered nurses, or graduate nurses as they are referred to in Australia, may reduce attrition and improve transition into the workplace. The 64-item Work Readiness Scale (WRS), developed with a generic population of graduates, has yet to be validated against specific disciplines to confirm applicability as a measure of work readiness. This study adapted the original WRS for use with a graduate nurse population (WRS-GN). The aim was to refine and validate the WRS-GN and determine whether the original four factor construct was supported. The WRS-GN was completed by 450 graduate nurses. Exploratory factor analyses supported the original four-factor solution (social intelligence, personal work characteristics, organizational acumen, and work competence). The final WRS-GN consisted of 46 items, showed excellent reliability, and explained 73.55% of the variance.

Young adolescents' perceptions, patterns, and contexts of energy drink use. A focus group study.

Caffeinated energy drinks (EDs) are purported to increase energy and improve performance, but have been associated with adverse health effects and death. EDs are popular among adolescents and young adults, yet little is known about their use among young adolescents. This study explored perceptions, patterns, and contexts of ED use in six focus groups with 40 adolescents aged 12-15 years from two regional Australian schools. A thematic analysis of the data was used to investigate knowledge about ED brands and content, ED use, reasons for ED use, physiological effects, and influences on ED use. Participants were familiar with EDs and most had used them at least once but had limited knowledge of ED ingredients, and some had difficulty differentiating them from soft and sports drinks. EDs were used as an alternative to other drinks, to provide energy, and in social contexts, and their use was associated with short-term physiological symptoms. Parents and advertising influenced participants' perceptions and use of EDs. These findings suggest young adolescents use EDs without knowing what they are drinking and how they are contributing to their personal risk of harm. The advertising, appeal, and use of EDs by adolescents appear to share similarities with alcohol and tobacco. Further research is needed to replicate and extend the current findings, informed by the lessons learned in alcohol research.

Work readiness of graduate health professionals.

BACKGROUND AND AIM: The current exploratory study investigated work readiness among graduate health professionals. DESIGN AND PARTICIPANTS: A critical incident technique was used to elicit perceptions regarding: strategies and skills that constitute work readiness among health professionals and the work readiness factors that help or hinder health graduates' transition and integration into the workplace. Fifteen medical graduates, 26 nursing graduates and five organisational representatives from a regional hospital in Victoria, Australia participated. METHOD: Data were collected via qualitative interviews. RESULTS: Participants discussed a total of 92 critical incidents; 52 related to helping and 40 to hindering work readiness factors that impacted graduates' transition and integration experiences. A follow-up thematic analysis indentified four critical work readiness factors: social intelligence, organisational acumen, work competence and personal characteristics. While graduates and organisational representatives considered each factor important, some differences between the groups emerged. Organisational representative's perceived social intelligence and clinical skills critical graduate competencies, yet graduates were unprepared in these areas. CONCLUSION: The identified work readiness factors were consistent with past research and warrant further investigation of work readiness among a larger group of graduate health professionals in a range of contexts.

Graduate nurses' transition and integration into the workplace: a qualitative comparison of graduate nurses' and Nurse Unit Managers' perspectives.

A three-year longitudinal qualitative study was undertaken to compare graduate nurses' (GNs') and Nurse Unit Managers' (NUMs') perceptions regarding the workplace factors that affect GNs' during the first year of clinical practice in a regional context in Victoria, Australia. In the first year a pilot study was used to develop a qualitative survey seeking information about GNs' transition experiences. Over the next two years 69 GNs and 25 NUMs from one health organisation completed the qualitative survey. Based on the literature and a pilot study, a directed content analysis was used to code the qualitative survey data into two initial categories: job-related and personal stressors. Themes within the two categories were subsequently identified and refined. GNs' and NUMs' perspectives were compared in relation to the categories and themes identified. GNs and NUMs differed with respect to perceptions of unprofessional workplace behaviour and coping with death and dying. GNs were more likely to report unprofessional workplace behaviour than NUMs and this was identified as a main factor affecting workforce integration. Alternatively, NUMs were more likely than GNs to report that coping with death and dying was a major issue. GNs and NUMs were found to hold similar perceptions in relation to shift work and the importance of emotional support. These findings suggest that NUMs and GNs do not always have a shared understanding of the stressors that GNs face in the first year of clinical practice. Further research in other contexts is necessary before any conclusions can be drawn.

The CDM-Net Project: The Development, Implementation and Evaluation of a Broadband-Based Network for Managing Chronic Disease.

Background. In Australia most chronic disease management is funded by Medicare Australia through General Practitioner Management Plans (GPMPs) and Team Care Arrangements (TCAs). Identified barriers may be reduced effectively using a broadband-based network known as the Chronic Disease Management Service (CDMS). Aims. To measure the uptake and adherence to CDMS, test CDMS, and assess the adherence of health providers and patients to GPMPs and TCAs generated through CDMS. Methods. A single cohort before and after study. Results. GPMPs and TCAs increased. There was no change to prescribed medicines or psychological quality of life. Attendance at allied health professionals increased, but decreased at pharmacies. Overall satisfaction with CDMS was high among GPs, allied health professionals, and patients. Conclusion. This study demonstrates proof of concept, but replication or continuation of the study is desirable to enable the impact of CDMS on diabetes outcomes to be determined.

Effectiveness of IT-based diabetes management interventions: a review of the literature.

BACKGROUND: Information technology (IT) is increasingly being used in general practice to manage health care including type 2 diabetes. However, there is conflicting evidence about whether IT improves diabetes outcomes. This review of the literature about IT-based diabetes management interventions explores whether methodological issues such as sample characteristics, outcome measures, and mechanisms causing change in the outcome measures could explain some of the inconsistent findings evident in IT-based diabetes management studies. METHODS: Databases were searched using terms related to IT and diabetes management. Articles eligible for review evaluated an IT-based diabetes management intervention in general practice and were published between 1999 and 2009 inclusive in English. Studies that did not include outcome measures were excluded. RESULTS: Four hundred and twenty-five articles were identified, sixteen met the inclusion criteria: eleven GP focussed and five patient focused interventions were evaluated. Nine were RCTs, five non-randomised control trials, and two single-sample before and after designs. Important sample characteristics such as diabetes type, familiarity with IT, and baseline diabetes knowledge were not addressed in any of the studies reviewed. All studies used HbA1c as a primary outcome measure, and nine reported a significant improvement in mean HbA1c over the study period; only two studies reported the HbA1c assay method. Five studies measured diabetes medications and two measured psychological outcomes. Patient lifestyle variables were not included in any of the studies reviewed. IT was the intervention method considered to effect changes in the outcome measures. Only two studies mentioned alternative possible causal mechanisms. CONCLUSION: Several limitations could affect the outcomes of IT-based diabetes management interventions to an unknown degree. These limitations make it difficult to attribute changes solely to such interventions.

Assessment of functional limitation after necrotizing soft tissue infection.

Previous literature on necrotizing soft tissue infections (NSTIs) has focused on its diagnosis and high mortality, but to our knowledge, none have reported on the functional outcomes of patients surviving this devastating disease. The purpose of this study was to evaluate the management and assess factors associated with decreased physical function in patients who survived this life-threatening infection. A retrospective review was conducted on patients treated for NSTI in whom an evaluation of functional status was performed between 2002 and 2006. Measurements were based on the American Medical Association Guides of impairment rating, and categorized into a functional class from "minimal or no limitation" to "severe limitation." Multivariate analyses were performed to discern independent factors associated with functional limitation. Final disposition status after discharge was also recorded. A total of 297 patients were treated for NSTI during this time. Of these, 119 (41%) patients met inclusion criteria for review. Mean number of débridements and coverage procedures were 3.4 and 2.0, respectively. Although mean percent functional limitation was 7.1, which is classified as "minimal or no limitation," 30% of patients had "mild" to "severe" functional limitation. Extremity involvement was independently associated with a higher functional limitation class (P < .01). Functional limitation may challenge recovery from NSTI in many survivors. In this series, the involvement of an extremity predicted a higher functional limitation class at the time of discharge. Development of validated functional assessment tools and accurate longitudinal follow-up are necessary to measure the functional impact of NSTI.

Pediatric palm contact burns: a ten-year review.

Management and proper approach to pediatric palm burns remains unclear. Our burn center's approach includes early, aggressive range of motion therapy, combined with a period of watchful waiting, reserving grafting only for those palms that do not heal in a timely manner. We reviewed our experience using this approach over a 10-year period. We performed a retrospective review of all pediatric patients with palm burns admitted to our burn center from 1994 to 2004. A total of 168 patients (194 palms) were included in the study. The average patient was 1.3 years old. A total of 168 of the injured palms (87%) healed without need for surgery. The average time to healing was 13 days (range 5-34). The 19 patients (26 palms, 13.4%) who underwent excision and grafting were managed with thick split thickness skin grafts. Of these, four patients (five palms, 19.2%) underwent secondary reconstruction, at an average of 166 days after the initial surgery. Of the 168 (87%) palms managed without surgery, only three patients (four palms) required late reconstruction (2.4%). Reconstructive procedures consisted of full-thickness skin grafts (n = 7) and z-plasty (n = 2). We have found that the majority of patients in this study healed without need for acute or reconstructive surgery. We therefore recommend aggressive hand therapy and conservative surgical management of palm burns in children.

Qualitative exploration of the nature of grief-related beliefs and expectations.

Societal expectations of grief impact the experience of bereavement. The congruence of societal expectations with current scientific understanding of grief is unknown. Therefore two qualitative studies explored community perceptions of grief. In study one, three small focus groups (N = 9) examined grief-related expectations associated with hypothetical scenarios of bereavement. In study two, the impact of grief-related perceptions on the lived experience of bereavement for 11 individuals was explored through semi-structured interviews. Across both studies, elements of a traditional stage model view of grief were evident, with participants viewing emotional expression of grief as important. An avoidant coping style in the bereaved was considered problematic. Findings of study two suggested that grief-related beliefs may impact the bereavement experience via appraisal of the grief response and willingness to support bereaved individuals. The studies suggested that stage model assumptions in the beliefs of the general population persist, although there was a recognition of diversity in the grief response.

Extended time to wound closure is associated with increased risk of heterotopic ossification of the elbow.

Heterotopic ossification (HO) is a well-recognized complication of burn injury that can result in significantly compromised limb function. The etiology and optimal treatment strategy for HO remain elusive. The purpose of this study was to examine the relationship between delay in elbow wound closure and the development of HO. We performed a case-control study to examine the relationship between delay in wound closure and development of HO. Cases (HO patients) were identified using our patient registry and matched with patients of similar age, burn size, and sex who did not develop HO. Time to wound closure was compared using bivariate statistics and the odds for developing HO based on time to wound closure was modeled using multivariate logistic regression. During the study period, a total of 45 patients developed elbow HO. When compared with controls matched for age, burn size, and sex, elbow wounds were open significantly longer in the cases than in the controls (48.7 days vs 24.2 days, P < .01). On multivariate logistic regression, the adjusted odds ratio was 1.08 (95% CI 1.04-1.12, P < .01). Time to elbow wound closure significantly impacts the risk of development of heterotopic ossification. Therefore, to minimize risk of HO formation, increased attention is warranted to optimize time to wound closure over joints. In addition, consideration of other soft tissue coverage options such as local flaps, including fascia or muscle flaps, may be warranted in cases of very deep elbow buns with high risk of skin graft failure.

Management of facial burns with a collagen/glycosaminoglycan skin substitute-prospective experience with 12 consecutive patients with large, deep facial burns.

Management of deep facial burns remains one of the greatest challenges in burn care. We have developed a protocol over the past 20 years for management of facial burns that includes excision and coverage with thick autograft. However, the results were not perfect. Deformities of the eyelids, nose and mouth as well as the prominence of skin graft junctures demonstrated the need to explore novel approaches. Integra has been used with success in the management of burns of the trunk and extremities. The purpose of this study was to prospectively evaluate the aesthetic outcome of the use of Integra for deep facial burns. Twelve consecutive patients underwent excision of large, deep facial burns and placement of Integra. Integra provides excellent color and minimally visible skin graft junctures. The texture is good but not as supple as thick autograft. Integra is not well suited for use in the coverage of eyelid burns due to the need to wait 2 weeks for adequate vascularization. In summary, thick autograft remains the gold standard for deep facial burns. However, for patients with extensive burns and limited donor sites, Integra provides an acceptable alternative.

What is the prevalence of hypertrophic scarring following burns?

Hypertrophic scarring after burns remains a major problem and is considered to be "common". Pressure garments are commonly used as treatment even though there is little sound data that they reduce the prevalence or magnitude of the scarring. In 1999 we began a study of the efficacy of pressure garments on forearm burns. After studying 30 patients, mainly white adults, we found no hypertrophic scar in either those treated with pressure or without. This prompted us to review the literature on the prevalence of hypertrophic scarring after burns and found only four articles with a relatively small number of patients and only three geographical locations. It became clear that the prevalence of hypertrophic scarring is really unknown. We then did a retrospective study of 110 burn survivors and counted all hypertrophic scars of all sizes and locations in all races and found the prevalence hypertrophic scarring to be 67% which conflicts with the published reports and our prospective study and suggests that further research is necessary. We concluded that a worldwide, prospective survey is necessary to establish the prevalence of hypertrophic scarring after burns. In this article we are calling for and offering to organize this survey.

Early excision and grafting of face and neck burns in patients over 20 years.

Although excision and grafting of burns has become common and standard, many surgeons have been reluctant to excise and graft face burns. In fact, we could find photographic results at 1 year after grafting of only eight patients in the English literature. We began excision and grafting of face burns in 1979 and presented our first 16 patients in 1986 in this journal. With encouragement from Janzekovic and Jackson, we continued and have now used essentially the same procedure for more than 20 years in approximately 100 patients and, from this large series, are able to present outcomes. From January of 1979 to May of 1999, we performed excision and grafting on 91 patients with deep face burns. Data were recorded and 35-mm photographs were obtained throughout the 20-year period. We reviewed that database and the slide files of these patients. We found 45 patients with complete photographic sets including 1-year follow-up. Since, in our opinion, there is no useful, objective measure of appearance, we decided to simply publish all 45 sets of complete photographs, permitting the reader to subjectively form an opinion of the outcome of this procedure. The results are all shown as "full" face burns and two "partial" face burns. We continue to believe that early excision and grafting is indicated for face burns that will not heal within 3 weeks and that the procedure yields results that permit the burn victims to return to society and minimizes the time off work or out of school.