A qualitative evaluation of the hot debrief/follow-up initiative: Implications of readily identifying positive outcomes in an Australian emergency department.

AIM: To gain insight into how emergency department nurses and doctors perceive the experience of being offered the opportunity to request a patient follow-up as part of a structured debrief initiative. BACKGROUND: An increased prevalence of burnout and compassion fatigue amongst emergency clinicians is being recognized globally. A wellbeing initiative has been implemented within a large public hospital emergency department to combat these phenomena. METHOD: A qualitative research approach using semi-structured interviews was carried out to explore the participants' views relating to the debrief/follow-up initiative. RESULTS: A total of 17 face-to-face semi-structured interviews were conducted. This research highlighted a number of common themes including the participants understanding and perception of the follow up initiative, the barriers and enablers of effective implementation, and the perceived benefits of following up on patient outcomes in the emergency setting. This research identified unanimous support for the initiative. No negative implications relating to the initiative were identified. CONCLUSIONS: This study indicates the positive impacts of employing a deliberate and formalized approach to enabling staff to access follow-up information about the patients for whom they provide life-giving care. IMPLICATIONS FOR NURSING MANAGEMENT: Nurse Unit Managers should consider the findings of this research and understand the crucial role that nursing leadership can play in fostering the design and implementation of similar initiatives.

Assessment of in-shoe pressure: Development of a clinical user guide based on a DELPHI-derived consensus.

BACKGROUND: The F-Scan (F-Scan System by Tekscan, Boston, USA) is an in-shoe pressure measurement device used to provide dynamic pressure, force and timing information to guide appropriate offloading of plantar foot ulcers. Despite the clinical utility of an in-shoe pressure measuring device there are some limitations in the validity and reliability of the output of the F-Scan. The aim of this study was to develop a consensus-based guideline following information provided by experienced clinicians, synthesis of research evidence and manufacturer's guidelines on the most appropriate use and interpretation of the data generated by the F-Scan to manage plantar foot ulceration. METHODS: Using the Delphi method a series of sixteen consensus statements were developed following a two-step questionnaire utilising clinicians feedback, a review of evidence and the manufacturer's guidelines. FINDINGS: Seventeen clinicians responded to the first questionnaire and 11 to the second, that included 8 podiatrists and 9 pedorthists working in the public and private sectors. Of the sixteen statements there was strong consensus for ten and moderate consensus for a further four. Only two statements failed to reach consensus and the feedback from the respondents was of great value providing sound clinical rationale for their rejection. INTERPRETATION: The objective of this study has been achieved in developing a clear and concise set of guiding statements (Table 1) to standardise use of the F-Scan. The application of the guiding statements will encourage standardisation of practice with the aim of highlighting the limitations of the system and reducing potential systematic error in measurement from output produced.

Personality, staff attitudes and their association with absenteeism and presenteeism in Australian public sector hospital-based nurses: A cross-sectional study.

AIM: To examine how personality and attitudes to sick leave influence nurses self-reported rates of absenteeism and presenteeism. BACKGROUND: Despite the significant economic cost and negative impact of absenteeism and presenteeism in health care, there has been limited research looking at personality (using the five-factor model) and absenteeism and presenteeism in nurses. METHODS: A cross-sectional online survey of 320 nurses. RESULTS: Low emotional stability was significantly associated with higher presenteeism. Shift work predicted more absenteeism, whereas those who believed that a culture of entitlement to sick leave existed in the health service were less likely to be absent from work. Increased work-related stress was also a significant predictor of presenteeism. CONCLUSION: The results of this study highlight the role of personality, stress and attitudes in nurses' decision to be absent or present at work when they are sick. IMPLICATIONS FOR NURSING MANAGEMENT: Nurses are the largest workforce in health care settings. Reducing absenteeism and presenteeism in nursing through a greater understanding of the influencing factors will limit the economic impacts of this behaviour and improve patient safety.

Trust, Connection and Equity: Can Understanding Context Help to Establish Successful Campus Community Gardens?

Campus community gardens (CCGs) can potentially improve student health and wellbeing, mitigate social and ecological problems, and nurture university-community relationships. However, CCGs are located in complex socio-political and ecological settings and many community gardens struggle or fail. However, few studies have assessed the socio-political/ecological context of a garden setting prior to its development to understand the potential barriers and enablers of success. Our study assessed the socio-spatial context of a proposed CCG at a student university accommodation site. We engaged diverse university and community stakeholders through interviews, focus groups and a survey to explore their perceptions of the space generally and the proposed garden specifically. Visual observations and public life surveying were used to determine patterns of behavior. Results confirmed known problems associated with an underutilized site that provides little opportunity for lingering or contact with nature; and unknown barriers, including socially disconnected stakeholders and community distrust of the university. The research also uncovered positive enablers, such as stakeholder appreciation of the social, wellbeing and ecological benefits that a CCG could deliver. Our findings suggest that an in-depth exploration of a proposed garden context can be an important enabler of its success.

Employing positive psychology to improve radiation therapy workplace culture.

The Australian radiotherapy profession is challenged by job dissatisfaction, stress, burnout and unfavourable attrition. This paper will use psychological models to discuss the confluence of job demands, resources and personal characteristics that contribute to these challenges. Factors contributing to burnout and attrition amongst Australian Radiation Therapists will be explored, and a number of leadership strategies will be introduced to improve workplace culture. These strategies - aligned with positive psychology - seek to address staff engagement, emotional needs, and job stressors.

Perception of social support in individuals living with a diabetic foot: A qualitative study.

AIM: To explore the perception of social support in individuals living with a diabetic foot in order to influence future service delivery in management of similar individuals. METHOD: A purposive sample of eight participants with a diabetic foot were recruited from a public podiatry service in Tasmania, Australia. A hermeneutic phenomenology qualitative approach was used with individual semi-structured interviews conducted using an interview guide designed to gain insight into five pre-determined measures of social support. Hybrid thematic analysis was used to produce the final results. RESULTS: Five clusters of themes emerged; emotional self-efficacy, isolation and stress; transport needs linked to physical or social functioning; perception of social support from health professionals; reciprocal support including health professionals facilitating support and financial support. CONCLUSION: The findings have major implications for three broad areas; recognition and management of psychosocial well-being, the need for patient centred care approaches and inclusion and equity in health care and society. Adopting measures that are informed by these findings in current day management practices will complement the existing body of evidence on addressing factors for developing and treating ulceration.

Depression symptoms in people with diabetes attending outpatient podiatry clinics for the treatment of foot ulcers.

BACKGROUND: The purpose of this study was to examine the prevalence of depressive symptoms, diabetes self-management, and quality of life in people with diabetes and foot ulcers. Ulcer status, mortality and amputations were also assessed at six months follow-up. METHODS: This was a cross-sectional survey of people attending outpatient podiatry clinics at a major tertiary referral hospital. Depressive symptoms were measured using the Patient Health Questionnaire (PHQ). Diabetes self-care was assessed using the Summary of Diabetes Self Care Activities (SDSCA) measure. Health-related quality of life was measured using the physical component summary score (PCS) and the mental component summary score (MCS) of the SF-12. RESULTS: Of the 60 participants in the study 14 (23.3%) reported mild symptoms of depression (PHQ score 5-9) and 17 (28.3%) moderate to severe depressive symptoms (PHQ score > 9). Twenty-one (35%) met the criteria for previously recognized depression (on antidepressants and/or a diagnosis of depression in the last 12 months) and 17 (28.3%) for depression not previously recognized (PHQ > 4). Seventeen (28%) participants had been receiving antidepressant treatment for a median duration of 104 weeks (IQR 20, 494 weeks). Despite antidepressant treatment 12 participants (70.6% of those taking antidepressants) still reported moderate to severe depressive symptoms at the time of the study. Patients with PHQ scores > 4 reported poorer adherence to diabetes self-care activities including general diet, exercise, blood sugar monitoring and foot care when compared to those participants with PHQ scores < 5. No association was found between physical functioning (PCS) and depressive symptoms. Decreasing mental wellbeing (MCS) was associated with increasing depressive symptoms. At six months follow-up, there were three deaths and three amputations in participants with PHQ scores > 4 compared with no deaths and 2 amputations in participants with PHQ scores < 5. There was no association between depressive symptoms and ulcer healing or ulcer recurrence at the six-month follow-up. CONCLUSIONS: This study found a high prevalence of depressive symptoms both recognized and unrecognized in people with diabetes and foot ulcers. Depressive symptoms were associated with overall poorer diabetes self-management and health-related quality of life (HRQoL). There was no association between depressive symptoms and ulcer outcomes at six-months follow-up.

MR1-restricted MAIT cells display ligand discrimination and pathogen selectivity through distinct T cell receptor usage.

Mucosal-associated invariant T (MAIT) cells express a semi-invariant T cell receptor (TCR) that detects microbial metabolites presented by the nonpolymorphic major histocompatibility complex (MHC)-like molecule MR1. The highly conserved nature of MR1 in conjunction with biased MAIT TCRα chain usage is widely thought to indicate limited ligand presentation and discrimination within a pattern-like recognition system. Here, we evaluated the TCR repertoire of MAIT cells responsive to three classes of microbes. Substantial diversity and heterogeneity were apparent across the functional MAIT cell repertoire as a whole, especially for TCRß chain sequences. Moreover, different pathogen-specific responses were characterized by distinct TCR usage, both between and within individuals, suggesting that MAIT cell adaptation was a direct consequence of exposure to various exogenous MR1-restricted epitopes. In line with this interpretation, MAIT cell clones with distinct TCRs responded differentially to a riboflavin metabolite. These results suggest that MAIT cells can discriminate between pathogen-derived ligands in a clonotype-dependent manner, providing a basis for adaptive memory via recruitment of specific repertoires shaped by microbial exposure.

Methylglyoxal, cognitive function and cerebral atrophy in older people.

BACKGROUND: The effects of advanced glycation endproducts on cognition and brain structure are poorly understood. We studied associations of the advanced glycation endproduct precursor methylglyoxal (MGO) with cognitive function and brain volumes in older people. METHODS: Nondemented participants in the Tasmanian Study of Cognition and Gait underwent cognitive testing and brain magnetic resonance imaging scans. Brain volumes were obtained by magnetic resonance imaging scan segmentation and statistical parametric mapping procedures. Serum MGO was measured after derivatization to methylquinoxaline by high pressure liquid chromatography and UV detection. Linear regression was used to examine associations of log-transformed MGO with cognitive scores and brain volumes adjusting for potential confounding by age, sex, education, mood, insulin resistance, history of stroke, vascular risk factors, alcohol intake, and psychoactive medication use. RESULTS: There were 378 participants, mean age 72.1 years (SD 7.1), 55% male. Greater MGO was associated with poorer memory (ß = -.12, 95% confidence interval: -0.22, -0.02, p = .02) and executive function, the latter being greater among those with a history of stroke (MGO × stroke ß = .48, 95% confidence interval: 0.17, 0.79, p = .002). Greater MGO was associated with lower grey matter volume (ß = -6.42, 95% confidence interval -11.82, -1.11, p = .02) but not with white matter volume, white matter lesion volume, or hippocampal volume. CONCLUSIONS: These results support the investigation of the role of the advanced glycation endproduct precursor methylglyoxal in cognitive decline and neurodegeneration in older people.

Depression and insulin resistance: cross-sectional associations in young adults.

OBJECTIVE: To examine the association between depressive disorder and insulin resistance in a sample of young adults using the Composite International Diagnostic Interview to ascertain depression status. RESEARCH DESIGN AND METHODS: Cross-sectional data were collected from 1,732 participants aged between 26 and 36 years. Insulin resistance was derived from blood chemistry measures of fasting insulin and glucose using the homeostasis model assessment method. Those identified with mild, moderate, or severe depression were classified as having depressive disorder. RESULTS: The 12-month prevalence of depressive disorder was 5.4% among men and 11.7% among women. In unadjusted models mean insulin resistance was 17.2% (95% CI 0.7-36.0%, P = 0.04) higher in men and 11.4% (1.5-22.0%, P = 0.02) higher in women with depressive disorder. After adjustment for behavioral and dietary factors, the increased level of insulin resistance associated with depressive disorder was 13.2% (-3.1 to 32.3%, P = 0.12) in men and 6.1% (-4.1 to 17.4%, P = 0.25) in women. Waist circumference was identified as a mediator in the relationship between depression and insulin resistance, reducing the beta coefficient in the fully adjusted models in men by 38% and in women by 42%. CONCLUSIONS: A positive association was found between depressive disorder and insulin resistance in this population-based sample of young adult men and women. The association seemed to be mediated partially by waist circumference.

Prospective analysis of effector and regulatory CD4+ T cells in chronic HCV patients undergoing combination antiviral therapy.

BACKGROUND/AIMS: The role of HCV-specific CD4(+) T cells and regulatory T cells in influencing the outcome of antiviral therapy is incompletely defined. METHODS: CD4(+) IFN-gamma ELISPOT assays (n=58) and flow cytometric analysis of FoxP3-expressing T regulatory cells (n=62) were performed on patients from the Virahep-C study at baseline, during and after cessation of antiviral therapy. RESULTS: Total HCV-specific IFN-gamma CD4(+) T cell ELISPOT responses did not increase with therapy, but rather decreased by 8 weeks and remained below baseline 24 weeks after cessation of therapy. There were no statistically significant differences with respect to viral kinetics, race and virologic outcome. In contrast, viral relapse after treatment was associated with a three-fold increase in HCV-specific responses. The frequency and phenotype of regulatory T cells during therapy were not significantly different in terms of race, viral kinetic groups or virologic outcome. CONCLUSIONS: A contraction of HCV-specific CD4(+) T cell responses was found during treatment with recovery of responses in patients experiencing virologic relapse after treatment. The levels of FoxP3-expressing regulatory T cells did not vary by race and were not predictive of virologic outcome. Work is ongoing to explore the contribution of mechanisms independent of CD4(+) T cells in therapy-induced viral clearance.

Extending the horizon in chronic heart failure: effects of multidisciplinary, home-based intervention relative to usual care.

BACKGROUND: The long-term impact of chronic heart failure management programs over the typical life span of affected individuals is unknown. METHODS AND RESULTS: The effects of a nurse-led, multidisciplinary, home-based intervention (HBI) in a typically elderly cohort of patients with chronic heart failure initially randomized to either HBI (n=149) or usual postdischarge care (UC) (n=148) after a short-term hospitalization were studied for up to 10 years of follow-up (minimum 7.5 years of follow-up). Study end points were all-cause mortality, event-free survival (event was defined as death or unplanned hospitalization), recurrent hospital stay, and cost per life-year gained. Median survival in the HBI cohort was almost twice that of UC (40 versus 22 months; P<0.001), with fewer deaths overall (HBI, 77% versus 89%; adjusted relative risk, 0.74; 95% CI, 0.53 to 0.80; P<0.001). HBI was associated with prolonged event-free survival (median, 7 versus 4 months; P<0.01). HBI patients had more unplanned readmissions (560 versus 550) but took 7 years to overtake UC; the rates of readmission (2.04+/-3.23 versus 3.66+/-7.62 admissions; P<0.05) and related hospital stay (14.8+/-23.0 versus 28.4+/-53.4 days per patient per year; P<0.05) were significantly lower in the HBI group. HBI was associated with 120 more life-years per 100 patients treated compared with UC (405 versus 285 years) at a cost of 1729 dollars per additional life-year gained when we accounted for healthcare costs including the HBI. CONCLUSIONS: In altering the natural history of chronic heart failure relative to UC (via prolonged survival and reduced frequency of recurrent hospitalization), HBI is a remarkably cost- and time-effective strategy over the longer term.

Prognostic importance of cognitive impairment in chronic heart failure patients: does specialist management make a difference?

BACKGROUND: Cognitive impairment is common among chronic heart failure (CHF) patients. AIMS: To determine the prognostic significance of cognitive impairment in patients participating in a randomized study of a CHF management program (CHF-MP). METHODS: CHF patients were randomized to a CHF-MP (n=100) or usual care (n=100). Baseline cognition was assessed using the Mini Mental Status Examination (MMSE). Five-year all-cause mortality, and combined death-or-readmission, were compared on the basis of the presence (MMSE 19-26) or absence (MMSE >26) of cognitive impairment. RESULTS: 27 patients (13.5%) had cognitive impairment and, on an adjusted basis, were more likely to die (96.3% versus 68.2%. RR 2.19, 95% CI 1.41 to 3.39: P<0.001) and/or experience an unplanned hospitalization (100% versus 94%. RR 1.44, 95% CI 1.06 to 1.95: P=0.019). Cognitively impaired patients had a similar (non-significant) adjusted risk of death-or-readmission in both the CHF-MP (RR 1.40, 95% CI 0.63 to 3.11: P=0.403) and in usual care (RR 1.38, 95% CI 0.75 to 2.53: P=0.305). In the usual care cohort, cognitive impairment was associated with a greater (non-significant), adjusted risk of death (RR 1.61, 95% CI 1.10 to 4.92: P=0.122). In the CHF-MP, adjusted risk of death was significantly higher for cognitively impaired patients (RR 2.33, 95% CI 1.10 to 4.92: P=0.027). CONCLUSION: These data suggest that "mild" cognitive impairment is of prognostic importance in CHF: even when a CHF-MP has been applied.

Prolonged effects of a home-based intervention in patients with chronic illness.

BACKGROUND: Data on the long-term benefits of nonspecific disease management programs are limited. We performed a long-term follow-up of a previously published randomized trial. METHODS: We compared all-cause mortality and recurrent hospitalization during median follow-up of 7.5 years in a heterogeneous cohort of patients with chronic illness initially exposed to a multidisciplinary, home-based intervention (HBI) (n = 260) or to usual postdischarge care (n = 268). RESULTS: During follow-up, HBI had no impact on all-cause mortality (relative risk, 1.04; 95% confidence interval, 0.80-1.35) or event-free survival from death or unplanned hospitalization (relative risk, 1.03; 95% confidence interval, 0.86-1.24). Initial analysis suggested that HBI had only a marginal impact in reducing unplanned hospitalization, with 677 readmissions vs 824 for the usual care group (mean +/- SD rate, 0.72 +/- 0.96 vs 0.84 +/- 1.20 readmissions/patient per year; P = .08). When accounting for increased hospital activity in HBI patients with chronic obstructive pulmonary disease during follow-up for 2 years, post hoc analyses showed that HBI reduced readmissions by 14% within 2 years in patients without this condition (mean +/- SD rate, 0.54 +/- 0.72 vs 0.63 +/- 0.88 readmission/patient per year; P = .04) and by 21% in all surviving patients within 3 to 8 years (mean +/- SD rate, 0.64 +/- 1.26 vs 0.81 +/- 1.61 readmissions/patient per year; P = .03). Overall, recurrent hospital costs were significantly lower (14%) in the HBI group (mean +/- SD, 823 dollars +/- 1642 dollars vs 960 dollars +/- 1376 dollars per patient per year; P = .045). CONCLUSION: This unique study suggests that a nonspecific HBI provides long-term cost benefits in a range of chronic illnesses, except for chronic obstructive pulmonary disease.

Interacting effects of preoperative information and patient choice in adaptation to colonoscopy.

PURPOSE: The aim of this study was to match patient information requirements by determining whether giving patients a choice for additional preprocedural audiovisual information modifies the effectiveness of this information on anxiety, worry, knowledge, and patient satisfaction. METHODS: Patients scheduled to undergo colonoscopy were approached one week before their procedure. All patients received an information leaflet during their standard preanesthetic clinic visit. Patients were randomly assigned to a choice or no-choice condition. Patients in the choice condition were free to watch or not watch the video, people in the no-choice condition were further randomized to watch or not watch the video. Measures of anxiety and worry were completed before watching the video. Anxiety, worry, knowledge, and satisfaction were measured one week later just before the colonoscopy. RESULTS: One hundred sixty-six patients completed the study. Of those patients randomized to the choice condition, 69 percent wanted to watch the video. Those who chose not to watch the video were significantly more worried on the day of their procedure. Consistent with current evidence, watching the video was associated with improvements in short-term knowledge (F(1,161) = 4.8, P = 0.03). There was, however, no significant effect of the choice or video conditions on anxiety or patient satisfaction. CONCLUSIONS: There appears to be no additional benefits in terms of patient outcomes by allowing patients to choose whether they want additional audiovisual information. We suggest that all patients undergoing colonoscopy would benefit from watching such an educational video in the week before their procedure.

The role of pre-operative state-anxiety in the determination of intra-operative neuroendocrine responses and recovery.

OBJECTIVES: The psychophysiological model of adjustment to surgery predicts associations between (1) heightened pre-operative state-anxiety and intra-operative neuroendocrine responses, (2) neuroendocrine responses and complications; and (3) heightened pre-operative state-anxiety and post-operative recovery. The present study examined these associations. METHODS: Participants were 39 patients (mean age 71.9+/-6.1 years) undergoing elective carotid endarterectomy surgery under local anaesthesia. In the week prior to surgery, patients completed baseline measures of physical and mental functioning using the MOS 36-item Short-Form Health Survey (SF-36). In addition to this, they undertook a 24-hour urine save to measure cortisol and catecholamines. Measures of state-anxiety were completed on the evening prior to surgery. A second 24-hour urine save was started at the time of anaesthetic induction. Follow-up measures of physical and mental functioning were completed 1 month following surgery. All complications were recorded during hospitalization. RESULTS: There was a significant negative association between pre-operative state-anxiety and intra-operative cortisol (r=-.52, p

Endovascular repair of abdominal aortic aneurysm reduces intraoperative cortisol and perioperative morbidity.

BACKGROUND: The release of catabolic stress hormones because of surgical trauma leads to a breakdown of fats, proteins, and carbohydrate stores and interference with immune function. This can delay wound healing and may increase the risk of systemic inflammatory response syndrome (SIRS)/sepsis and postoperative complications. Minimally invasive surgery can attenuate this response. Our purpose was (1) to compare neuroendocrine responses in patients undergoing open abdominal aneurysm repair with those in patients undergoing endovascular aneurysm repair (EVAR), (2) to compare the incidence of SIRS/sepsis and all complications in these two groups, and (3) to look at the relationship between procedure type, neuroendocrine response, and incidence of SIRS/sepsis and complications. METHODS: Forty-six patients who underwent open repair and 19 who underwent EVAR were studied. A baseline (T1) 24-hour urine save was undertaken in the week before admission, and a second 24-hour save (T2) commenced at anesthetic induction to measure cortisol and catecholamines. The incidences of SIRS/sepsis and complications were recorded. RESULTS: Significant ( P