Five healthcare trajectories in the year before suicide and what they tell us about opportunities for prevention: a population-level case series study.

Background: Suicide prevention requires a shift from relying on an at-risk individual to engage with the healthcare system. Understanding patterns of healthcare engagement by people who have died by suicide may provide alternative directions for suicide prevention. Methods: This is a population-based case-series study of all suicide decedents (n = 3895) in New South Wales (NSW), Australia (2013-2019), with linked coronial, health services and medicine dispensing data. Healthcare trajectories were identified using a k-means longitudinal 3d analysis, based on the number and type of healthcare contacts in the year before death. Characteristics of each trajectory were described. Findings: Five trajectories of healthcare utilisation were identified: (A) none or low (n = 2598, 66.7%), (B) moderate, predominantly for physical health (n = 601, 15.4%), (C) moderate, with high mental health medicine use (n = 397, 10.2%), (D) high, predominantly for physical health (n = 206, 5.3%) and E) high, predominantly for mental health (n = 93, 2.4%). Given that most decedents belonged to Trajectory A this suggests a great need for suicide preventive interventions delivered in the community, workplace, schools or online. Trajectories B and D might benefit from opioid dispensing limits and access to psychological pain management. Trajectory C had high mental health medicine use, indicating that the time that medicines are prescribed or dispensed are important touchpoints. Trajectory E had high mental health service predominantly delivered by psychiatrists and community mental health, but limited psychologist use. Interpretation: Although most suicide decedents made at least one healthcare contact in the year before death, contact frequency was overall very low. Given the characteristics of this group, useful access points for such intervention could be delivered through schools and workplaces, with a focus on alcohol and drug intervention alongide suicide awareness. Funding: Australia's National Health and Medical Research Council.

Effect of receiving mobile text messages on cortisol concentrations in students at the University of the Free State.

Background: Texting has become central to social life, with adverse effects on physiological functioning. Research into the impact of texting on cortisol secretion is limited. Aim: Thus study aimed to determine how receiving mobile text messages affected salivary cortisol concentrations and investigate the moderating effects of stress, anxiety and depression on cortisol secretion. Setting: Undergraduate physiology students attending physiology lectures at the Faculty of Health Sciences, University of the Free State, 2016. Methods: An experimental, crossover, quantitative design was used. Participants were involved over two consecutive days, receiving mobile text messages (intervention) on one day and acting as their own control on the other. Self-reported data on stress, anxiety, depression and subjective experience of the study, and saliva samples were collected. Text frequency and wording (neutral, positive, negative) were varied among participants. Results: Forty-eight students participated in the study. Salivary cortisol concentrations did not differ significantly between the intervention and control days. High anxiety levels were associated with increased cortisol concentrations. No associations with cortisol concentrations were documented in low to moderate anxiety, stress, depression or how participants experienced the intervention. There were no significant differences between text frequency, text emotion and change in cortisol concentrations on the intervention day. Conclusion: Receiving mobile text messages did not elicit a significant cortisol response in participants. Contribution: Findings added to the body of knowledge about the effect of texting on student learning by measuring salivary cortisol concentrations in a lecture setting, with investigation into the moderating effects of stress, anxiety, depression and participants' subjective experience.

Effects of service-wide support on regularity of alcohol screening of clients in Australian Aboriginal and Torres Strait Islander Community Controlled Health Services: a cluster randomised trial.

BACKGROUND: We have previously shown that service-wide support can increase the odds of alcohol screening in any 2-month period in a cluster randomized trial of service-wide support to Aboriginal and Torres Strait Islander Community Controlled Health Services (ACCHS). Here we report an exploratory analysis on whether the resulting pattern of screening was appropriate. AIM: we assess whether that increase in screening was associated with: (i) increased first-time screening, (ii) increased annual screening, (iii) whether frequently screened clients fell into one of four risk categories as defined by national guidelines. METHODS: Setting and participants: 22 ACCHS; randomized to receive the support model in the treatment ('early-support') arm over 24-months or to the waitlist control arm. INTERVENTION: eight-component support, including training, sharing of experience, audit-and-feedback and resource support. ANALYSIS: records of clients with visits before and after start of implementation were included. Multilevel logistic modelling was used to compare (i) the odds of previously unscreened clients receiving an AUDIT-C screen, (ii) odds of clients being screened with AUDIT-C at least once annually. We describe the characteristics of a sub-cohort of clients who received four or more screens annually, including if they were in a high-risk category. RESULTS: Of the original trial sample, 43,054 met inclusion criteria, accounting for 81.7% of the screening events in the overall trial. The support did not significantly increase the odds of first-time screening (OR = 1.33, 95% CI 0.81-2.18, p = 0.25) or of annual screening (OR = 0.99, 95% CI 0.42-2.37, p = 0.98). Screening more than once annually occurred in 6240 clients. Of the 841 clients with four or more screens annually, over 50% did not fall into a high-risk category. Females were overrepresented. More males than females fell into high-risk categories. CONCLUSION: The significant increase in odds of screening observed in the main trial did not translate to significant improvement in first-time or annual screening following implementation of support. This appeared to be due to some clients being screened more frequently than annually, while more than half remained unscreened. Further strategies to improve alcohol screening should focus on appropriate screening regularity as well as overall rates, to ensure clinically useful information about alcohol consumption. Trial Registration ACTRN12618001892202, retrospectively registered 16 November 2018 https://anzctr.org.au/Trial/Registration/TrialReview.aspx?ACTRN=12618001892202 .

Just 'nanging' around - harmful nitrous oxide use: a retrospective case series and review of Internet searches, social media posts and the coroner's database.

BACKGROUND: The chronic recreational inhalation of nitrous oxide (N2 O) 'nanging', can have adverse neurological and psychiatric effects. AIM: To evaluate cases of chronic N2 O use presenting to two hospitals, as well as to evaluate nationally N2 O deaths reported to the coroner and trends in Internet searches and social media posts related to N2 O. METHODS: Retrospective review of two toxicology units, from July 2017 to October 2020, of patients presenting with chronic N2 O use and neurological and/or psychiatric symptoms. We evaluated 10 years (2010-2019) of Internet search and social media trends involving N2 O and the National Coronial Information System (NCIS) database for deaths across Australia. RESULTS: Twenty-two patients were identified: median age 22 years, half female, 17 Asian background and 15 students. Presentations included decreased mobility or unsteady gait (n = 15) and psychiatric symptoms (n = 5). The median reported bulb use/day was 300 (interquartile range (IQR): 200-370), for a median of 6 months (IQR: 3-24). On magnetic resonance imaging, 10/18 had subacute combined degeneration of the spinal cord and 7/7 sensorimotor neuropathy on nerve conduction studies. All received high-dose intramuscular vitamin B12 and 11 methionine. Despite prolonged rehabilitation, nine required walking aids on discharge. Since 2017, social media posts and Internet searches for N2 O increased rapidly, the latter mostly directed at obtaining N2 O canisters. From the NCIS, 36 deaths were identified, 12 unintentional (recreational drug use), 20 intentional self-harm and 4 traumatic. CONCLUSION: We report a case series of symptomatic chronic N2 O use, many with ongoing neurological sequelae. Furthermore, a sharp increase in Internet searches to obtain N2 O cannisters was noted. Education of high-risk student groups on the long-term sequelae is important.

Role of age-sex as underlying risk factors for death in acute pesticide self-poisoning: a prospective cohort study.

BACKGROUND: There is growing evidence in the literature that patients' age is associated with increased risk of death in acute pesticide poisoning. However, few studies have investigated whether the age effect differs between males and females. We aimed to examine the association between age-sex and risk of death in acute pesticide self-poisoning. METHODS: A prospective cohort of deliberate pesticide-poisoned patients admitted to ten rural Sri Lankan hospitals between March 2002 and December 2019. The pesticide ingested was identified based on identification of container or history. A mixed effects logistic regression was fitted to investigate the effect of age-sex on death in acute pesticide self-poisoning adjusting for clinical symptoms on admission, measured by Glasgow Coma Scale and Poison Severity Score, and controlling for clustering among hospital sites. RESULTS: In total, 201 different pesticides were ingested by patients. 6,643 patients ingested an unknown pesticide. A single pesticide was co-ingested with alcohol by 4,603 patients. Of the 28,303 patients enrolled, 2,028 patients died, resulting in case fatality of 7.2% (95% CI 6.9-7.5). The effect of age on case fatality was stronger for males after 21 years of age. The odds of dying for each 5 years increase in age was 1.26 (95% CI 1.23-1.28) times higher for males versus 1.14 (95% CI 1.10-1.19) times higher for females. Missing data were handled by multiple imputation. CONCLUSION: Patient's age-sex are important risk factors for death in acute pesticide self-poisoning even after controlling for clinical effects. The age effect on the odds of dying was significantly different for males and females, with this effect being stronger for males. Given that patient's age and sex are very easy to collect on admission, our study highlights the need for incorporating these risk factors in policy and clinical decisions.

Referral practices of medical practitioners in central South Africa to physiotherapy services for patients living with musculoskeletal conditions.

BACKGROUND: Musculoskeletal diseases (MSDs) are a major cause of disability worldwide. It is essential to address effective MSD management, including appropriate referrals to physiotherapists and other healthcare professionals. Limited information is available regarding the referral practices of medical practitioners for patients with MSD. The doctors' referral practices to physiotherapists can impact the patient population and the South African health system. OBJECTIVES: To investigate or understand the referral practices of medical practitioners in Bloemfontein, South Africa, to physiotherapy services, for individuals living with MSD. METHOD: A quantitative study approach, implementing a semi-structured questionnaire, was used. Forty-nine participants completed the questionnaire. RESULTS: The referral of patients with MSDs by medical practitioners to physiotherapy services varied and multidimensional factors influenced their referral practices. Medical practitioners were unsure of the specific role played by physiotherapists in the management of individuals living with MSD. A need for improved relationships and communication between medical practitioners and physiotherapists was identified. CONCLUSIONS: Medical practitioners regularly referred individuals living with MSD to physiotherapists, but referral practices should be optimised in terms of evidence-based practice and the use of specialised physiotherapy services. In an attempt to decrease the burden of MSD, adequate awareness should be created for improved referral practices between medical practitioners and physiotherapists. CLINICAL IMPLICATIONS: Collaborative development of detailed guidelines for apt, evidence-based referrals should be developed, to ensure early detection and management of individuals living with MSD. Health care professionals should be educated and encouraged to refer individuals living with MSD to physiotherapists for appropriate management with clinical benefits including improvement of HRQOL and cost effectiveness of this management not only to the individual but also to the health system in South Africa. Physiotherapists should try to communicate their role in the treatment of individuals living with MSD to medical practitioners for the benefit of the patient.

Machine read frontal QRS-T angle and QTc is no substitute for manual measurement of QTc in pro-arrhythmic drug overdose.

INTRODUCTION: To investigate whether there is an association between the blocking of cardiac potassium channels, which is characterised by a prolonged QTc interval and the frontal QRS-T angle after overdose by QT prolonging drugs. METHODS: We obtained patient medical records associated with QT prolonging drugs from 3 different hospitals: the Calvary Mater Newcastle Hospital (CMNH), Royal Prince Alfred Hospital (RPAH) and Prince of Wales Hospital (POWH). RPAH and POWH admissions were taken between 4/01/2017 to 1/11/2019, and CMNH admissions were taken between 4/01/2013 to 24/06/2018. Demographic information and details of overdose were collected. All admission ECGs were manually measured. Linear regression was used to assess the relationship between various QTc formulas and the frontal QRS-T angle. A Bland-Altman plot was used to examine agreement between manual and machine QT intervals. RESULTS: 144 patients met the inclusion criteria for analysis. None of the patients developed torsades de pointes (TdP). There was no linear association between the QRS-T angle and the various QTc formulas (For QRS-T angle: QTcRTH: p = 0.76, QTcB: p = 0.83, QTcFri: p = 0.90, QTcFra: p = 0.13, QTcH: p = 0.97; For square root transformation of the QRS-T angle: QTcRTH: p = 0.18, QTcB: p = 0.33, QTcFri: p = 0.95, QTcFra: p = 0.47, QTcH: p = 0.33). Agreement between machine and manual QT measurements was low. CONCLUSIONS: The frontal QRS-T angle cannot substitute the QTc in assessing the blockage of cardiac potassium channels in drug induced long QT syndrome. We also support the consensus that despite the availability of machine measurements of the QT interval, manual measurements should also be performed.

Australian Suicide Prevention using Health-Linked Data (ASHLi): Protocol for a population-based case series study.

INTRODUCTION: In Australia, suicide is the leading cause of death for people aged 15-44 years. Health professionals deliver most of our key suicide prevention strategies via health services, but other efficacious population-level strategies include means restriction and public awareness campaigns. Currently, we have no population-level data allowing us to determine which individuals, in what parts of Australia, are likely to use our most promising interventions delivered by health services. The aims of this study are to describe: (1) health service utilisation rates in the year prior to death by suicide, and how this varies by individual case characteristics; (2) prescribed medicines use in the year prior to death by suicide, medicines used in suicide by poisoning and how this varies by individual case characteristics. METHODS AND ANALYSIS: This is a population-based case series study of all suicide cases in Australia identified through the National Coronial Information System (NCIS) from 2013 to 2019. Cases will be linked to administrative claims data detailing health service use and medicines dispensed in the year before death. We will also obtain findings from the coronial enquiry, including toxicology. Descriptive statistics will be produced to characterise health service and prescribed medicine use and how utilisation varies by age, sex, method of death and socioeconomic status. We will explore the geographical variability of health service and medicine use, highlighting regions in Australia associated with more limited access. ETHICS AND DISSEMINATION: This project involves the use of sensitive and confidential data. Data will be linked using a third-party privacy-preserving protocol meaning that investigators will not have access to identifiable information once the data have been linked. Statistical analyses will be carried out in a secure environment. This study has been approved by the following ethics committees: (1) the Justice Department Human Research Ethics Committee (REF: CF/17/23250), (2) the Western Australian Coroners Court (REF: EC 14/18 M0400), (3) the Australian Institute of Health and Welfare (REF: EO2017/4/366) and (4) NSW Population & Health Services Research Ethics Committee (REF: 2017/HRE1204). Findings will be published in peer-reviewed journals, presented at conferences and communicated to regulatory authorities, clinicians and policy-makers.

Learning osteology: what resources do undergraduate anatomy students prefer?

Several osteology-learning resources are helpful, but using human bones could optimise students' learning experience. Hence, the Department of Basic Medical Sciences, University of the Free State (UFS), South Africa, issues a complete set of unarticulated bones of a human skeleton to registered anatomy students. However, not all students choose to accept this set of bones for additional study. The purpose of this study was to explore anatomy students' utilisation of human bones and to determine their preferences and suggestions for alternative resources to learn osteology. This descriptive observational study entailed an opinion survey regarding resources for learning osteology amongst anatomy students at the UFS in 2014. These students included medical, occupational therapy, physiotherapy and nursing students (n = 425). Results are presented using descriptive statistics. The majority (89.9%) of students across disciplines found using human bones beneficial, irrespective of whether they chose to receive bones. The bones were most frequently used by occupational therapy students and least frequently used by medical students. Students used bones for learning bone names and specific features that included bone markings and muscle attachments. Other preferred and suggested resources included textbooks, atlases, computer software and the anatomy museum. This study reveals that students prefer to use human bones to learn osteology. The results could assist anatomy departments to develop a strategy to provide sufficient opportunities for anatomy students to use human bones to learn osteology. Alternative, suitable resources for the study of osteology could be implemented due to increasing student numbers and difficulty in obtaining human material for teaching purposes

No disponible

Monitoring preceptors' supportive role: A measuring instrument for increased accountability.

PURPOSE: This article describes the development of a measuring instrument to monitor support offered by preceptors during their accompaniment of students in clinical facilities. DESIGN: A quantitative methodological study design was used to develop the instrument. METHODS: Data were collected by means of a self-completed questionnaire. Total sampling of 192 undergraduate nursing students was done. Descriptive data analysis was conducted regarding the biographical characteristics, Cronbach's alpha was computed to determine the reliability, and an exploratory factor analysis was done to describe the construct validity of the developed instrument. RESULTS: The Cronbach's alpha of 0.98 indicates high reliability and high internal consistency. Three constructs regarding clinical support, namely cognitive-, emotional- and system support were identified by means of the exploratory factor analysis. CONCLUSION: The new conceptualisation of support gives insight into the value of the preceptor's role. The instrument designed for this study could be used to assess and monitor the support offered by preceptors while they accompany students in clinical practice. CLINICAL RELEVANCE: Considering the need to strengthen nursing and midwifery education systems, this instrument contributes to measuring and monitoring clinical accompaniment of students by preceptors.